Competition and the NHS – reponse to Le Grand

Today on the LSE policy and politics blog, Julian Le Grand has posted a piece that is critical of our earlier blog casting doubt on the LSE team’s work claiming ‘competition saves lives’. You can read it here (http://blogs.lse.ac.uk/politicsandpolicy/2012/03/09/hospital-competition-le-grand/).

I’ve posted my reply on the LSE website, but here it is again for completeness’ sake.

I have liked and admired Julian Le Grand’s work for years, and he is on many my teaching reading lists. But I do have to wonder what is going on here.

There is a basic category error in the piece above – competition doesn’t save lives. It never can. Clinical workers save lives, hopefully with the support of managers. To simply assert (as economists are inclined to do) that competition changes incentives is to not engage with the difficult, messy, empirical work of exploring exactly what has changed and how (if anything, and the moral of reorganisation in the NHS is how little changes). So the key question here is what exactly changed after 2006, and how did it change both managerial and clinical behaviour. The answer, I’m afraid, is that we really don’t know.

Even reviews of research that consider the econometric work that Cooper and Propper favour on their own terms find there are big gaps (for example, Bevan and Skellern in the BMJ (http://www.bmj.com/content/343/bmj.d6470). Most particularly, their research is based on a ‘black box’ where incentives and changes are assumed rather than being empirically demonstrated.

It is also interesting that Le Grand cites the King Fund’s work as supporting his claims. Again, that is very contestable, as David Hunter’s review of the book, again from the BMJ (http://www.bmj.com/content/343/bmj.d7786) suggests. My reading of the book was that Labour’s market-based improvements were extremely modest when compared to what was achieved elsewhere. It therefore seems odd that Le Grand presents this work as supporting him, when I’m really not sure that’s what the book is saying.

Above all, it seems to me that it’s time we started being a bit more humble about our work. Le Grand and Cooper, in their FT piece, seemed to be suggesting that there is only one way to do research, and people who do other kinds of work are mere ‘intuitionists’. This reads to many of us as an intolerant and rather blinkered view of social research. In order to understand what is going on in the NHS we need a range of different methods and different types of work. To imagine we can provide some kind of definitive answer, as they appear to be suggesting, from work that doesn’t empirically examine whether the changes they believe are going on are actually happening, without actually asking anyone involved in their implementation, seems a little odd.

Conflicts of interest and the NHS bill

Let’s assume for a moment that the NHS bill passes, and that it leads, as the government want it to, to a competitive environment for care. Every thought how much conflict of interest this would lead to?

Let me say, first of all, that I like doctors, and what follows isn’t meant to be hostile, even if it reads a such.

GPs are the cornerstone of the reforms. They are meant to be getting involved in commissioning as well as acting to make sure patients make the best choices (at least they will be advising patients on choice, at most making the choices for patients if, like me, they don’t think they are qualified to be making choices).

Thing is,  most GPs have been asked to consider themselves as independent contractors in the NHS. They get paid on a really complex mix of different kinds of fees, and have increasingly invested in provision in areas of primary care outside of their own surgeries (which they may also part-own as well). If you are regarding yourself as an independent contractor in a non-competitive environment all this is at least moderately sensible (I’d prefer GPs to be salaried myself, buy hey ho).

None of these arrangements, however, are sensible in a market-based environment. Somehow we are going to have to make sure GP commissioners don’t face the situation where they have to choose between providers, some of which they have a financial interest in. That will mean potentially excluding the very large numbers of GPs who have done largely what the government asked them to, and got involved in local healthcare provision, and even then GP commissioners don’t have interests themselves, they will be in a difficult position because of their partners’ and colleagues’ financial interests. Even in advising patients about choices, GPs will have to disclose their financial interests – and what on earth are patients meant to do with this information? If you are in a collaborative environment, not driven by profit, there is greater scope for allowing GPs to refer to organizations in which they have an interest, as this is surely covered by professional ethics. If, however, we are moving to a competitive, for-profit basis, things are getting a lot more fraught. I’m not convinced the government has worked this through.

If the situation for GPs is going to get a lot more complex for hospital consultants. Consultants may work for both the NHS and private sector. In that case, they will be effectively working for organizations that are now expected to compete with one another. Surely that can’t be right? It would be like someone working for both Apple and Microsoft – far too much potential for conflict of interest through seeing information that is commercially confidential. In a competitive environment, I’m afraid, you have to choose whose side you are on, and stick to it. Professional ethics, again, don’t cover this.

Professionalism, as US sociologist Elliot Friedson suggested is a third logic – neither market, nor bureaucracy, but something else. If healthcare is going to be delivered competitively, you can’t depend on professionalism alone to prevent conflict of interest. And if you are depending on professionalism to prevent a creep of non-professional, market-based ethics into relationships, why introduce markets?

There is one more conflict of interest that has sadly become very apparent in recent weeks. Every time the NHS bill has been debated in the Lords, a running commentary on twitter has appeared explaining the financial interest many of those speaking have in relation to private medicine. That hasn’t stopped them, however, from making points entirely in favour of that interest. That is breath-taking – and to think that politicians wonder why we no longer trust them. If we can’t depend on politicians to deal with pretty obvious conflicts of interest, I wonder what the future holds for those that are tasked with implementing their reforms.