We should scrap the internal market
The recent BMA Annual Representative Meeting passed a motion for the repeal of competition rules introduced by Lansley's Health and Social Care Act 2012, criticising it for accelerating private sector provision in the NHS.1 That is absolutely correct. But NHS privatisation is a secondary cancer. The primary cancer is the internal market.
The internal market has turned our public hospitals into businesses in which, when there is a conflict between financial health and patients' health, financial health trumps. The Mid Staffs scandal was only the tip of the iceberg. All NHS hospitals are affected, as can be seen with increasing clarity in today's austerity climate, in which quality of care is sacrificed across the board on the altar of 'efficiency savings' – all too often a euphemism for budget cuts.
The internal market was created by Kenneth Clarke under Thatcher to introduce competition in the NHS to increase efficiency. The mechanism was to effect a 'purchaser-provider split', which created bodies for health service commissioning separated from those responsible for health care provision.
The internal market has resulted in high regulatory and transaction costs, health service fragmentation and bureaucracy, and opening the door to privatisation. Yet it has not demonstrably improved NHS performance and has thus not worked in its own terms. Even a centrist health economist like Alan Maynard came to the conclusion that the internal market is neither effective nor cost-effective and should be abandoned.2 The considerable savings could be devoted to patient care. And even the previous NHS Chief Executive David Nicholson on stepping down questioned the appropriateness of the purchaser-provider split and said he was 'interested' to see the reintegration of service commissioning and provision.3 And even still, scrapping the internal market may now be acceptable to the Conservative government.4
During the neoliberal heyday of the 1980s and 1990s market ideologues in international agencies promoted marketisation and privatisation of health systems.5 But the experience has been that competition in health care does not work for the public good and policy is reverting to the need for cooperation and integration. The purchaser-provider split has been abolished in New Zealand, as well as in Scotland and Wales.
In England the internal market has accentuated the fragmentation between primary and secondary NHS care and between health and social care. The potential savings from scrapping the market could be invested in integrated health and social care.
1. Moberly T. Scrap Lansley's competition regulations. BMJ 2018;361:k2791
2. Maynard A. Head to head: should the NHS abolish the purchaser-provider split? Yes. BMJ 2016;354:i3825
3. Nunns A. Sir David Nicholson's latest bright idea for the English NHS. www.opendemocracy.net accessed 31/12/2017
4. Ham C. Editorial: a funding boost for NHS in England. BMJ 2018;361:k2741
5. Segall M. From cooperation to competition in national health systems – and back?: impact on professional ethics and quality of care. Int J Health Plann Mgmt 2000;15:61-79
Competing interests: No competing interests