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Competition in the NHS

In NHS, Politics on January 3, 2012 at 7:43 am

This is a slightly edited version of an article that was first published by Now Then Magazine in December 2011.

Andrew Lansley’s Health and Social Care Bill has been attacked on many grounds. I’ll summarise these objections before adding my own.

  • Neither the Conservative Party nor the Liberal Democrat Party mentioned wholesale reforms of the NHS in their manifestos. David Cameron expressly promised there would be no top-down reorganisations.

  • Questions regarding the influence of donations to Andrew Lansley’s political office by private healthcare providers remain unanswered. In January 2010, The Daily Telegraph revealed John Nash, chairman of Care UK, had donated £21,000 to Lansley’s private office.

  • General practitioners currently receive no training in the commissioning of services and have no expertise in the management of large budgets.

  • The administration of these large sums of money by the same people who provide care will create conflicts of interest and affect the trust that patients place in their doctors.

  • The provision of services by ‘any willing provider’ will lead to fragmentation of services, which will make the co-ordination of care more difficult. Currently, the management of patients with complex medical conditions, e.g. children with multiple related but separate diagnoses (cerebral palsy, epilepsy, learning disability, psychiatric illness) require the GPs and specialists to collaborate to provide a delicate, customised, evolving package of care. If the service providers are seeking to compete with and therefore antagonise one another, the smooth provision of such a package will become more challenging.

  • Similarly, junior doctors require exposure to many environments and specialties during their training. This will become increasingly haphazard.

  • It will lead to duplication of services, rather than the streamlining that one would associate with economic efficiency. The evidence that competition within healthcare improves efficiency is sparse and mixed.

  • The duty of care of the secretary of state to provide or secure health services will be removed.

I wish to add one more reason to oppose the bill. It will make the NHS less beautiful.

Yesterday, I stood at a urinal in an airport in another country. In front of me, there was an advertisement for earplugs. Below the name of the brand and a picture of what one was being led to assume was a satisfied user, it read, ‘Ask for them by name and beware of imitators.’ In other words, buy our earplugs, not our competitors’. We won’t deign to explicitly say that ours are better, but we will imply as much by describing our rivals as ‘imitators’.

Of course, that’s all they can do, because they are just earplugs. How much better can one brand be than any other? But in order to ‘compete,’ they must cast aspersions. They must secure the custom and loyalty of the public. In order to do this, they do not need to provide a better product. They just need to convince the public that they are providing a better product. They need to devote time and money to doing so.

Is this what we want in healthcare? Apart from the vulgarity of describing health services as products, is the way to deliver the best, safest and most efficient care by opening it up to a system in which each provider will have to budget for advertising as much as they do for the actual care they provide? I not only contest the evidence that this will lead to greater efficiency or better health, but I also object on aesthetic grounds.

The tone of the earplugs advertisement was bullying. It was mean-spirited. It aimed to hector me and to denigrate its competitors. It was ugly. But it was a necessary component of the market. And the principles of the earplug market will apply to the healthcare market as well. Providers will vie to convince those who commission services that their product is better. But the cheapest way to do this will not always be to actually provide a better, safer service. Mr Lansley’s hopes that forcing competition on the NHS will also force increased efficiency are misguided. They may lead to increased efficiency in some cases. In others, they will lead to cost-shaving corner-cutting, and the expert concealment of this by companies whose key purpose is to turn over a profit.

I would like to think that I am wrong. I would like to think that in ten years time, I will look back at these opinions and see them as quaint, as a conservative appeal to keep things as they are. Simple resistance to change. But to force myself to think that now would be disingenuous. I believe we are throwing away something great.

If you would like to review the evidence upon which I have based my views, please follow the hyperlinks.

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