I’m surprised to see the aphorism that competition in the NHS saves lives still being trotted out as if it is some kind of truism – most recently by John Rentoul this weekend. So let’s be clear what the LSE research actually shows us.
For the claims around competition saving lives, in my reading of the work, the following line of argument has to be true.
- Choice of provider was introduced by Labour in 2006.
- Therefore competition was introduced at the same date.
- Take a measure of competition which does not correlate to how urban an area is.
- Take a measure of mortality in an area which is not, itself subject to choice (AMI – heart attacks)
- Look to see if the measure of competition which does not correlate to how urban an area is correlates to the measure or mortality in an area, which is not, in itself, subject to choice (still with me?)
- If yes, with a range of econometric controls, say competition saves lives.
Now given all this, do you think these claims are credible?
First does choice=competition, when only half of people surveyed by various bodies say they were even offered it, and only a tiny proportion actually used any kind of information sources when making it (have a look at http://www.lancet.com/journals/lancet/article/PIIS0140-6736(11)61553-5/fulltext). In other words, even though only half of people being offered a choice remember it, and only a tiny proportion could actually have made an informed choice, that counts as competition.
Second, the measure of competition used in the study does not correlate to how urban an area is. In other words, competition is not restricted to cities (as we might intuitively expect, given that’s where most providers are), but is a measure wider than that. It’s a measure of competition which doesn’t seem to be related to how dense provision is. Does that really make any kind of sense to you?
Third, the measure of mortality is not itself, based on an area of clinical work where patients can make a choice. The authors have done this on purpose – their claim is that the effects of choice (and so competition) are so profound that they even affect areas where no choice is itself in place. Now that’s a pretty extraordinary claim – for 60 years we’ve been trying to reform the NHS, but simply introducing choice (which, remember, patients can’t remember being offered and only a tiny proportion made in any informed way) led to clinical areas which aren’t even being affected by choice improving! That’s pretty extraordinary. You’d expect some explanation of how this happened being given, but it seems, it’s simply down to the magic of choice.
Fourth, you run regressions of your measure of competition (which isn’t about how urban an area is) against your measure of mortality (which isn’t affected by choice), and you get a positive result.
Finally, you proclaim that competition saves lives. You are listened to because people don’t understand your paper as it is mostly made up of mathematical symbols, and uses methods from quantitative economics. And economists have SUCH a good record of conducting great research in their own area (financial crisis anyone?) that they are now applying their methods to areas like healthcare as well.
You may have picked up from the above that I’m rather cross about this. We need informed and careful debate about the future of the NHS. This kind of work really, really, doesn’t help.