Without wanting to create scare stories, I think it sensible to try and explain the reasons why I think it will lead to problems later on. I’m not alone in foreseeing problems – several other commentators have written about this as well. What I can do is explain my perspective on this, and to try and justify my fears.
I’ve organised the following under three headings: problems about the market; problems about provider failure; and problems about responsibility for the system. I can then end by explaining briefly a different way of thinking about the problem of NHS reform than is in the Bill.
Problems about the proposed market
We seem completely in thrall to the idea that there must be some kind of market for healthcare reform to work. However, I’m not convinced about this at all. I’m very much of the view that the problems of putting in place a viable market in the NHS are insurmountable. Three problems immediately come to mind, although I’ve written about this extensively elsewhere in this blog.
First, what we are talking about here isn’t any kind of sensible market with lots of competition, but instead, for the most part, for most locations, very limited competition amongst a small number (say, less than five) possible providers. Economists call this market structure an oligopoly, and it is rife with informal agreements between firms not to compete, but instead to divvy the market up between themselves. If the aim of these reforms is competition, it must be real. It won’t be.
Second, even assuming we can get competition, we won’t be able to make the right choices, if it is patients that are meant to be making choices, it isn’t at all clear whether they have the information or capacity to choose well. Under these circumstances, in line with Daniel Kahneman’s ideas, we would expect patients to substitute what they do know into the choice, and to pick providers which have lots of car parking, or the newest facilities, or where patients happen to know and like someone who works there. Some groups, such as those with long-term conditions, can make these kind of choices with adequate support. For most other groups, however, the information (and please don’t point me to NHS Choices) or the means by which choices are meant to be made is not at all clear. The best providers won’t necessarily be chosen because patients don’t know how to choose them. And that makes a nonsense of the market.
If it is GPs that are meant to be making the choices (and indeed commissioning decisions) then I’m afraid things won’t necessary fare better. There is good research that GPs don’t have the skills or the information to refer patients to the best providers (I won’t cite it here, but my SDO report on health organisational reform available at http://www.sdo.nihr.ac.uk/projdetails.php?ref=08-1808-245 went into this in some detail). I don’t think this is a slur. I’m rather keen on GPs being good at diagnosing illness and looking after their patients rather than being care commissioners.
If you think about it, putting GPs as commissioners of care is madness. Why on earth put someone through seven years of medical training only to do a job which doesn’t really require it? I think this is likely to lead to an enactment of either the Peter Principle of the Dilbert Principle. In the first, we’ll get really good GPs to do commissioning, asking them to do a job for which they aren’t really trained, and taking them away from looking after patients. We’ll take them away from a job they are good at, in order to do another one. If we use the Dilbert Principle, we’ll get GPs who aren’t very good at being a doctor to do the job as they won’t be missed. However, being poor at being a GP isn’t a very good predictor of being good as a commissioner either. On either basis it isn’t clear to me that GPs spending less time with patients and more as commissioners is a good idea.
In al then, I can see just about no way the new market for care will work – we won’t have much competition, and even if we do, I don’t know how the best providers would be chosen either by or for patients.
Provider failure problems:
A second category of problem is based on the thorny problem of failure (again I’ve written about this earlier in the blog, but can add some new bits here). The main problem here is that we still don’t know what to do with either private or public provider failure. There is no guarantee we can find another provider to pick up patients where this happens, never mind dealing with the disruption it will mean for patients, and the problems it could lead to for medical training.
A first point here is that the private sector (collectively) has no means of taking responsibility if a single provider goes bust. The issues we’ve had about breast implants have shown this problem starkly – the industry as a whole have simply failed to take responsibility for fitting what we can see is a faulty product. While politicians and private providers blame one another, women have been left with all the insecurity of knowing they have a substandard product within them. This is dreadful. Imagine that occurring in any one of the treatments now being provided by the private sector (hip replacements, knee replacements etc….).
What seems to be the case is that it is the public sector that will have to pick up the tab, in the end, for provider failure (privatisation of profits, socialisation of losses, once again).
However, it is also the case that many public providers will be in considerable financial danger in the new structure as well. If new providers enter the market, and get any referrals at all, this undermines the cost base of large NHS providers, who have large fixed costs (especially if they have PFI builds) and so need large volumes to cover them. The combination of budgets effectively freezing in real terms, and more providers in a geographic area, means that public providers potentially face real financial problems.
However, as noted above, we can’t let public providers fail as we will need them to pick up the pieces if private failures occur. This makes a nonsense of the whole market-based logic again.
So in sum, if private providers go bust, the NHS will have to pick up the patients. If private providers mess up and leave the market, the NHS will have to pick up the pieces. If public providers fail, we’ll end up having to bail them out as we can’t afford to be without them.
Finally, there is the problem of responsibility for the new system as a whole. The logic of Lansley’s reforms is that no-one should be – we are letting a market do its magic. However, this isn’t really much of a market. Equally, in most markets we aren’t dealing in services that, if they go wrong, can kill people, and which involve the spending of £100bn+ a year of public money. It seems to me that there has to be someone prepared to say ‘the buck stops here’.
For me though, this highlights the tenuous relationship between democracy and the NHS. The public don’t want these reforms, the clinicians don’t want it, most of the sane experts don’t want it. And yet we have to wait until the next General Election to do something about it.
Isn’t it about time we took democracy a bit more seriously? I firmly think we need to move the NHS into the remit of local government, and to seek a far closer relationship between the public and the NHS. This will not only prevent central government from putting in place bonkers top-down reforms, but mean it is easier to find ways of integrating health and social care. But that’s another story. The main point here is that the present reforms are a mess. They need to be stopped.