In this recent BMJ blog (http://blogs.bmj.com/bmj/2011/08/19/muir-gray-competition-between-systems-for-pride-is-effective-and-essential/) Muir Gray suggests that, instead of using market-based competition, we need instead pride-based competition ‘between systems accountable to defined populations. The luminaries of the business world have now joined the call for this approach, and there is evidence to support it…..Perhaps it is better to leave it to the professionals and patients to create the system and the networks cooperatively, just like the ants do’.
Using screening as an example, he shows how professionals responsible for those systems will ‘naturally compete with one another on quality, outcome, and the use of resources. Their feedback offers opportunities to improve quality and safety, their suggestions offer opportunity for redesign, and they would want their system to be the best: co-ownership is effective’.
I think this approach is a key intervention in the debate around the use of markets and competition in healthcare, and I encourage everyone who is interested in this debate to read it in the original. I’ve tried my best to represent it above, but necessarily can’t for length reasons.
However, I’m not sure Muir Gray is quite right. First, in terms of the presumption that we can come up with an indicator that can be universally agreed and competed upon (such as standardised detection rate in his screening example), and second in terms of the unintended outcomes I see resulting from his suggestion. I want to suggest, however, that he is going in a far better direction in terms of reform, however, than market-based competition.
What Muir Gray is suggesting is a different form of competition than market-based competition, and using the world ‘competition’ tends to conceal that. This matters because suggesting that clinical systems foster internal pride-based competition has a lot to commend it, but can only work if those system work in a very different way to those where those clinical networks are competing in markets. In markets, sources of advantage quickly turn into commercially confidential secrets, the collaborative ethos he has in mind is in danger of quickly being undermined.
Equally, his example works because of its deliberate use of a fairly straightforward (relatively) clinical system. However, most clinical systems can’t be reduced to a single indicator in the way his example appears to be, but that won’t stop health economists from trying.
I’d like to make a few amendments.
First of all, what Muir Gray is referring to shouldn’t be called competition – that term is now to associated with market-based logic. Let’s call it something else. Quality bechmarking – anything but competition.
Second, let’s put in place a system where clinicians agree appropriate measures of clinical systems from the bottom-up. The QOF seems to have worked because GPs bought into the measures, and a large part of this is that they had a voice in deciding them. What we need are evidence-based measures against which the professions are prepared to work with, and which are themselves reviewed and set against the best practice in the world.
Third, achievement against the measures needs to be accountable to outside the system, and there needs to be a link between those overseeing the system and democratic bodies. I’m concerned about how ‘insider’ his model presently appears to be. If all clinicians are so committed to improving things, how come they all aren’t using the best practices? I’m not as hard as Alan Maynard on this, but he does have some good points about how poor clinical practices are often far too tolerated.
Fourth, we need to make a big deal out of those that perform the best on the range of clinical measures. Most importantly, we need to learn from them to raise the bar for those that aren’t as good. We also need to look at the poorest performers and be clear about what the problems are and what we are going to do about them.
I’m not wild about the potential for league-table creation that will come from the creation of these measures, preferring instead to think about creating mechanisms for what we can learn from the best. However, it is imperative that health organisations are held democratically to account and these measures necessarily will form a part of that process. I favour local health organisations being far more accountable to local authorities as trying to deal with this problem nationally breaks the link between democratic accountability and the specific organisations we need to explain themselves. But we will need to achieve a far higher level of local debate around healthcare to achieve this.
We will need to make sure that health systems are held to account for driving up the standards in their areas as a whole – this would be the job of national government. National government, in turn, would be accountable to the public for resourcing that system and for its overall performance.
My concern with the Muir Gray approach then, is that I’m worried it will create the room for more market-based competition because of its use of the term ‘competition’ (and words do matter), with this single measure approach potentially being subverted into a proxy which could be used in a marketplace instead, and I’ve made clear elsewhere in this blog why I think that is a bad idea. I’m also concerned because it doesn’t link into democratic institutions in any obvious way.
However, I think this intervention is amongst the most sensible and workable we’ve seen in the debate. As such, we have a great deal to thank him for.