Intended for healthcare professionals


Competition in healthcare can help to save lives, study concludes

BMJ 2011; 343 doi: (Published 01 August 2011) Cite this as: BMJ 2011;343:d4898
  1. Adrian O’Dowd
  1. 1London

Competition among hospitals in England led to a 7% fall in the number of deaths from acute myocardial infarction over three years, saving around 900 lives, a new study claims.

However, academics and experts on health policy have questioned the interpretation of the study, which was published on 27 July in the Economic Journal (2011;121:F228-60, doi:10.1111/j.1468-0297.2011.02449.x), the journal of the Royal Economic Society.

Using data from hospital episodes statistics on more than 430 000 patients who had a myocardial infarction between 2002 and 2008, researchers from the London School of Economics looked at English hospitals before and after competition was introduced into the NHS and in particular at the effect of the 2006 introduction of patient choice (offering patients a choice of hospital service provider).

They found that, after the changes in 2006, mortality fell more quickly in more rather than less competitive areas of the country—those with a higher number of potential providers.

Across all areas mortality from acute myocardial infarction fell by around 7%—with 300 fewer deaths a year—during the three year period after patient choice and competition were introduced.

Zach Cooper, a health economist working at the London School of Economics and one of the study’s authors, said, “Our study suggests that creating incentives for hospitals by introducing competition alongside providing patients with publicly available information can improve patient outcomes and save lives.

“This research isn’t about public versus private; it’s about illustrating that financial incentives can have a profound impact on hospital performance.”

Allyson Pollock, professor of public health research and policy at Queen Mary, University of London, was quoted in the Guardian newspaper as saying: “This study is extremely flawed” (

She said that acute myocardial infarctions were not a measure of hospital performance and that better outcomes among patients were more likely to have been the result of better screening by GPs and new non-surgical procedures.

Anna Dixon, director of policy at the health think tank the King’s Fund, was also sceptical about the finding. She told the BMJ: “I am yet to be convinced that there is a connection between patient choice and these differential rates of improvement. Their [the researchers’] analysis is good, but the issue is the interpretation.

“We have done an evaluation of patient choice, and we came to the conclusion that the things that were really driving providers [to improve] were not patient choice or competition (BMJ 2010;340:c2971, doi:10.1136/bmj.c2971). They were still paying more attention to some of the external pressures around targets. They wanted to improve patient care based on feedback from patients.”

Dr Cooper stood by the study and told the BMJ: “You are welcome to oppose it [the research] on ideological grounds, but this isn’t ideological research. It’s rigorous and peer reviewed.

“The idea of competition in the NHS is, historically for England, a foreign idea. It is one that quite wrongly gets conflated with privatisation.”

The care services minister, Paul Burstow, welcomed the report, saying, “This shows how choice and innovation can help improve quality of care for patients—and ultimately save lives.”


Cite this as: BMJ 2011;343:d4898

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