Competition: the solution to the NHS's problems?

19 February 2008, House of Commons

• Mr Nick Boyle, Circle


• Professor Parveen Kumar, Barts and the London School of Medicine and Dentistry, Barts and the London NHS Trust and Homerton Hospital Foundation NHS Trust


• Nick Seddon, Author 'Quite like heaven? Options for the NHS in a consumer age'


• Professor Chris Ham, University of Birmingham

This is the first in Civitas's series of debates, chaired by Professor Aidan Halligan, that look at some of the key themes, drivers and milestones in the Next Stage Review of the NHS currently being conducted by Lord Darzi.

Background:

Since the publication of the NHS Plan in 2000, health reform in England - at least for planned hospital care - has broadly focused on creating the conditions necessary for competition between providers: choice for patients, greater diversity in provision, payment-by-results and a proper regulatory framework. The NHS Operating Framework for 2008/09 confirms this is very much here to stay, but is it the best way forward?

Resources from the debate:

• Online summary


• Full summary text(.pdf)


• Listen again: Mr Nick Boyle(.mp3)


• Listen again: Professor Parveen Kumar (.mp3)


• Listen again: Nick Seddon (.mp3)


• Listen again: Professor Chris Ham (.mp3)


• Blog: Any thoughts on the debate? Post them here.

Online Summary:

Issues raised:

The delegates 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 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 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.'

More effective competition?

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.

Rephrasing the question?

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.'

A full summary text of the debate, with comments made in discussion from Professor Nick Bosanquet, Massoud Faloudi, Mr Christoph Lees, Norman Lamb MP, Philip Brown, Professor Steve Smith, Dr Rodney Burnham and Andy Cowper can be viewed here.

We are also hosting an online discussion forum on our blog - please feel free to add your comments on any of the issues raised. We will be considering them carefully in a working group over the next few months.