Competition: the solution to the NHS’s problems?
James Gubb, 19 March 2008
Disagreement is still evident over the exact role of competition in healthcare, but a consensus is emerging that the ‘type’ of competition being pursued in the NHS is too narrowly focused and must facilitate greater service integration and clinical leadership.
That was the finding of a high-profile seminar organised by Civitas last month, which debated one of the key drivers of system reform in the NHS: competition.
Chaired by Professor Aidan Halligan, former deputy chief medical officer, the event explored the impact competition has had on the NHS and the extent to which it should be pushed to drive performance in the future.
It found competition has been too focused on:
– Activity rather than quality. Andy Cowper, editor of the BJHM, raised the issue: ‘I don’t want competition based on providers who can bang them out, but leave people worse off afterwards’. Yet there is no account of quality in payment-by-results.
As Nick Seddon, author of ‘Quite Like Heaven?’, pointed out ‘both purchasers and providers should stop thinking of a procedure and instead look at the patient’s health as the product of health care’.
– ‘Reputation’ rather than accurate information. Mr Nick Boyle, a partner at Circle, put this starkly: ‘…people have reputations for all sorts of reasons; it could be because they’re a great clinician or because they happen to play golf at the weekend with the local GP. That’s not good enough.
‘One of the reasons why the poor have such bad access to the NHS is because they don’t have access to a clinician’s ‘reputation’’, he said in calling for clinicians to publish data on their performance. Systematic measurement drives systematic improvement, he argued.
– Episodes of care rather than cycles of care, including prevention and rehabilitation. Chris Ham, professor of health policy and management at Birmingham University, drew on the implications of this: ‘…there are no incentives to encourage people to come together in networks and integrate care.’
The point was echoed by Professor Parveen Kumar, Hon. Consultant Physician and Gastroenterologist at St. Bartholomews, The Royal London & Homerton Hospitals: ‘Foundation Trusts may choose to do some procedures and not others…and private providers may cherry-pick and leave the complicated patients with co-morbidities, heart conditions and diabetes to the NHS.’
The implications of these failings were hotly debated. Pretty much all agreed on the ‘end goal’ of having more clinically integrated systems, the importance of clinical leadership and the importance of developing accurate comparative data, but there was less agreement on what the driver(s) should be.
Professor Kumar argued against a reliance on competition: ‘…the real problem is not a lack of competition, rather that the health care we provide is just not joined-up enough. We need an integrated system, led from the ground, by clinicians, with the focus on the patient. [The medical profession] have been fettered into immobility.’
But competition, Mr Nick Boyle put forward, ‘is a principle that in all other facets of human life leads to better value and better quality’. Surgeons, he argued, compete with each other all the time to provide the best care – and similar motivations could apply across health systems.
However Chris Ham was sceptical that such conceptual benefits could be realised in practice, even in the field of electives: ‘if the government isn’t prepared to let a private bank [Northern Rock] go bankrupt, what will it do when a hospital gets into difficulty?’ he asked.
With ‘world-class commissioning’ yet to be realised anywhere in the world, he argued instead for a move towards integrated systems, along the lines of Kaiser Permanente in the US. Choice between such systems could then be offered in the long-run.
Nick Seddon concurred, but asked for the question to be rephrased. The debate, he argued, ‘is not whether competition will improve performance, but how to organise systems to make it more effective’.
Effective integrated systems, in his view, would require fundamentally reforming the NHS; by promoting the independence of the service from government and changing finance towards universal insurance in order to make it more pluralistic and responsive.
‘Competition’, he said ‘need not come at the expense of collaboration, and should make integration of care financially, as well as clinically, desirable.’
You can listen again, or read a summarised transcript of this debate along with all the observations made by the audience at: http://www.civitas.org.uk/nhs/seminars.php.