Competition in the NHS

The marketplaceIs competition good, or bad, for services paid for out of public funds?

A lot depends on whether the competition is fair or unfair.  For example, when you go out to buy a car, the competition is generally fair.  Most people know what to expect from a car, both tangible (how many doors, comfort, performance, fuel economy) and intangible (marque, implied warranty), and most options are available to most people in most places.

Healthcare is a little different.  People don’t necessarily know whether they need a hospital visit or whether care nearer to home will actually be better for them.  Often no-one explains (in terms they can understand) what they will get for the different choices they make, and there’s no-one to ask advice – and these decisions come at a difficult and emotional time.

So this isn’t helped when people are arguing till they are blue in the face, about competition (incidentally, I suspect that a trip to hospital is NOT necessary when you are blue in the face; perhaps it’s time to stop talking and start listening?).

In PM Tony Blair’s time, everyone assumed that competition would be fair, in the sense that all healthcare was only delivered to the best possible quality.  So people (including government, I’d like to think) got a bit of a shock when the private providers came in and all sorts of distortions and unfairnesses emerged – cherry picking the easy cases but still charging the full tariff, getting paid for activity not carried out, poor quality of care with the problems then passed on to the NHS hospitals to sort out.

Managing QualityThe arguments will toss back and forth, and like any good commentator, I say “follow the money” – look at the motives behind each of the people.  For example, Mark Britnell is widely respected and is one of the key voices saying “any competition is good competition”.  Well his consultancy benefits from advising governments to change policy (well, you wouldn’t get asked in for the next job if you just said “things are fine as they are”); from implementing policy; and from clearing up the mess and designing a new policy (“well you didn’t implement it the way we said”).  Nick Clegg needs to put clear blue water between himself and David Cameron.  PM David C needs to support the international healthcare providers who funded his election campaign.  And so on.

But at the root of it all, we need good regulation.  This means clear measurement of the things that are easy to measure (Full Consultant Episodes, Outcomes, Costs, Waits), but also of the things that are less easy to measure (complexity, staff use) and of things that emerge as needing measuring.  It means teeth – a range of sanctions from fines to restricted practice before the nuclear option of removing a contract or removing a license to act. And the regulator needs to be locally accountable.

How will we get to this?  That’s a subject for another paper.

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