Another question which proposals for market-based reform raise is often not deal with, but is certainly worth airing. What are these reforms meant to achieve that can’t be done through other means? For me, they represent the failure of senior clinicians and NHS managers to do their jobs well.
The logic of the market is that, only by the threat of resources being taken away, will clinicians and managers get their act together, look after their patients, and so innovate and work well together. This is a pretty scary idea. It suggests that, at the moment, those working in our health service aren’t giving us their best, and that they have to be threatened with their organisations losing resources, and possibly even closing, to do so. Is this really the case?
Well there is certainly some evidence pointing this way. Only yesterday (25th July) I read a short response by a GP who complained that he would love to engage in more private practice from his surgery in order to serve his patients better, but was prevented from doing so by ‘NHS red tape’. That would certainly equate with a logic of, ‘if you pay me, I’ll work harder.’ Now I guess we all have an element of this in our lives – we like getting paid more. However, I’m not really convinced that paying people more to do the same job is going to lead to much in the way of improvement. Even if I’m working at, say, 80% of my potential at the moment (no sniggering at the back), then pretty soon paying me more is going to get me pretty close to 100%. Unless we enter the language the professional footballing world where it is possible to give more than 100%, I’m not sure where we go from there. It seems to me that paying me more makes me happy for a short while, but to be honest, I quickly forget about it and I can’t say paying me more makes me work any harder for any longer. Of course, if I think you’re paying me too little I’m likely to get resentful, but it doesn’t seem likely that markets are going to deal with that problem – it’s a managerial one.
We might argue, on a different tack, that only when our backs are against the wall will we be forced to innovate. This is also a pretty sad state of affairs – our clinicians are well-educated and (usually) pretty committed people. Do we really have to threaten them for them to try new things? I find that hard to believe. Surely innovation occurs in environments where experimentation and trust are high, and is more likely to lead to improvements than threat? It will always be the case that some organisations will be statically the lowest-performing, but is the threat of closure from the market the only way we can galvanise staff to work together? Really?
What all this points to, for me, is that the use of market-type mechanisms are primarily there as a threat to drive improvements. But that sort of threat is likely to lead to an environment less likely to generate innovation – which is more likely to thrive when combined with trust and experimentation. But it is the job of senior clinicians and managers to create such an environment – there is little that government or policymakers can do about that. We might argue that continual attempts at reform undermine trust and experimentation, and I think they probably do. But at the local trust level, it is for senior clinicians and managers to create an environment where things can get better, and it is their failing if this isn’t occurring. Introducing markets isn’t going to deal with the problem that, in the end, the quality of our NHS depends upon the staff we encounter there. Usually they are doing a pretty good job. But where they are not, it is down to senior clinicians and managers to deal with their problems more forcefully than perhaps they have often been prepared to in the past.