Just because I oppose the NHS bill, it doesn’t make me a lefty.

As I write this it seems like the default attack on those who oppose the NHS bill is that we are trying to undermine the coalition government, and that we are, as a consequence, lefties.

Well, it’s good to see that government continue not to allow evidence to get in the way of their arguments.

Other can make their own arguments. I spent most of the 2000s arguing that Labour’s approach to the NHS was wrong – I was pleased additional funding had at last appeared, but depressed that they thought that, as the decade wore on, trying to create some kind of marketplace was the answer. I wrote at least an article a year on this and so hope to be able to show at least some kind of track record here.

Now I’m criticising the coalition government for making the same mistake. I think both Labour and the coalition are wrong – this direction for health reorganisation is a mistake.

Ah (the coalition, or perhaps Alan Milburn might say) – the reason you don’t like either Labour or coalition health policy is that you are a proper lefty – you don’t believe in markets, and you want the government to control everything.

Er. No.

The reason why I don’t believe markets work in healthcare is that I like my markets to be competitive.

For markets to work, there has to be competition. Those working in competitive environments have to fear consumers going elsewhere, with the potential loss of income being important.  Those in charge need to be able to change what’s going on in their organizations to prevent their customers going elsewhere. But in the NHS as comprehensive providers of care can’t and won’t be allowed to go bust. Equally I’m not clear exactly what health managers can do to prevent patients choosing to go elsewhere. That’s down to clinicians. Clinicians are generally in short-supply, and so suggesting they are threatened by patient choice seems odd. Without competition, markets are pointless.

Equally, offering patients choice does not mean you have made a market. Offering me a choice between two local hospitals doesn’t mean they are in a competitive relationship. There might be enough patients for them both (that’s why we have waiting lists). A few might change from the referral their doctor might have given them at the margins, but that’s hard signals the outbreak of competition. Even if there were some benchmark that allowed patients to choose the ‘best’ hospital, we couldn’t allow every patient to choose it as that would drive up waiting lists and put the other one out of business. And we can’t allow comprehensive providers of care to go bust – we don’t have the capacity to survive without them. Patient choice is not the same as competition.

The reason why market don’t work in healthcare is that there isn’t enough competition, patients lack the information to be able to choose, patients may not actually want to make choices (surveys tell us they would prefer their local healthcare organizations simply to be good), and there is little incentive for comprehensive hospital providers to improve through competitive forces as they can’t be allowed to go bust.

Where we introduce market mechanisms where they cannot work, all we get is abuse. We give healthcare managers big pay rises to pretend they are running competitive business enterprises when they are not, but ask them largely to do the same job as before. We end up bailing out hospitals when they run out of money (as, for example, with the £1.5bn PFI bailout). We give private providers access to public money to the point where they depend upon it for 25% of their revenues but still pretend to be dynamic, independent companies. What nonsense.

Above all, all this nonsense distracts us from the serious business of marking healthcare better. How much money do we have to waste on the purchaser-provider split before we consider whether any real benefits are accruing from it? How much extra healthcare could we have bought with all the money poured away on pointless reorganizations since the 1980s? Making healthcare better involves time and effort and evidence. Imagining you can reorganize for it is nonsense.

Both Labour and Conservative politicians who have spent billions on trying to force markets upon healthcare should hang their heads in shame. You don’t need to be a lefty to see that markets don’t work in healthcare. Taking a couple of basic courses in economics, sociology, politics and the history of healthcare should do the job.

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8 Responses to “Just because I oppose the NHS bill, it doesn’t make me a lefty.”

  1. tim Says:

    Seems to me that markets only work for the businesses selling goods and services….not for the customers….see cost to the individual of Gas and Electricity….as compared to profits…

  2. marknewboldMark Newbold Says:

    Good blog Ian. Do you not think competition is inevitable as more and more clinical outcomes are published? Indeed, is it not unethical to withhold data that is clinically important from the general public, leaving just those who are ‘in the know’ free to choose the best doctors / services / hospitals?

    It seems to me that, following principles of openness, more and more outcome data will be published, which must surely drive choice and therefore competition as people realise that, frankly, some services are better than others?

    • Ian Greener Says:

      Mark I’m afraid I don’t think most patients are remotely interested in outcome data. They just want to know their doctors are good. Some services are better than others. For me we ought to be using outcome data to drive up clinical standards rather than relying on patient choices – it’s unethical for doctors to be running services that appear to be bad outliers – we can use outcome data to drive up the standard of service without any need for patients to be making choices. Indeed, patients making choices based upon them seems about the daftest use of that data I can think of!

      • marknewboldMark Newbold Says:

        They aren’t interested at the moment Ian, because they tend to assume that all outcomes are similar. I think that will change – we mustn’t underestimate people.

        We should use outcome data to drive up standards, I completely agree. However, once the data exists (and it is scanty at the moment) I feel it must be made available to potential service users. Currently, people do ask their GP for recommendations, particularly for planned / specialist care, which is exercising choice albeit through a proxy?

        Unless you keep the data secret, how can it not drive choice? Why would anyone choose a service or hospital with higher mortality, or worse success rates, if they were aware? Far better to have choice based on outcomes than on speed of access or car parking charges as we have had thus far!

      • Ian Greener Says:

        Question is, Mark, whether putting more data out there is only going to benefit some kinds of patients (typically the vocal middle classes). We can’t close hospitals because we don’t have the capacity to do so. We need all to get better – danger of the most articulate all going to what looks like best providers creates huge problems if that leaves other hospitals with the poorest, and possibly the sickest. This is a public service – we need to drive improvements, but doing that one patient at a time with the poorest being left with the worse outcomes (as in education) no kind of answer. We are in this together!

      • marknewboldMark Newbold Says:

        I share your concerns Ian but I just don’t feel it can be right to withhold data from people, once it is known, for these or any other reasons. It goes against all the current views on transparency and openness in public life.

        Indeed, if we do not publish, the ‘vocal middle classes’ will still find out and exercise choice (just as they do with education). So it will be choice, and best outcomes, for the privileged few only.

        The cardiothoracic surgeons have been publishing outcomes, by surgeon, for some years now. They have found that it has driven up standards across the board, without causing untoward consequences such as service closure.

        As I said in my last blog, openness can be an uncomfortable policy to follow at times, but we have to deal with the consequences because it is fundamentally the right and proper thing to do!

  3. theputneydebates Says:

    Mark, it is unreasonable to expect people to interpret outcomes information (assuming that it is presented without framing and bias in the first place). Being open with insufficient or biased data is worse than providing no information.

    And I am not being patronising in this view: I am a professional in the IT sector where logical and critical thinking is necessary; someone with an honours degree who is a practising sceptic. I do not want to exercise what will be illusory false choice in health any more than in education. I want to be able to trust the judgments and advice of my clinicians.

    As in education, choice will not be fair or equal because of existing provision and geography; and competition, assuming competition actually did drive out weaker performers to leave best-in-breed (something which only happens in neoclassical economics textbooks, where reality is dismissed) such inequalities would be made more significant.

    Trying to make people improve through competition is irresponsible in the sense that it is a derogation of ones own responsibility to set high standards and make sure they are attained.

    There is a desperate need for openness in public service; but the openness of evidence-based decision-making not the publishing of league tables and targets. Targets make organisations witless, and in a health service that will kill people.

  4. syzygysue Says:

    If a ‘something’ doesn’t make any sense, it is a good idea to think whether there is another agenda which is being hidden… following the money usually provides an answer.

    Your blog amply evidences ‘non-sense’:

    ‘The reason why market don’t work in healthcare is that there isn’t enough competition, patients lack the information to be able to choose, patients may not actually want to make choices (surveys tell us they would prefer their local healthcare organizations simply to be good), and there is little incentive for comprehensive hospital providers to improve through competitive forces as they can’t be allowed to go bust.’

    and then you indicate some of the probable real agenda… which is to open up the lucrative budget of the NHS to private corporations as detailed under the 1994 GATTs treaty and the WTO:

    ‘Where we introduce market mechanisms where they cannot work, all we get is abuse. We give healthcare managers big pay rises to pretend they are running competitive business enterprises when they are not, but ask them largely to do the same job as before. We end up bailing out hospitals when they run out of money (as, for example, with the £1.5bn PFI bailout). We give private providers access to public money to the point where they depend upon it for 25% of their revenues but still pretend to be dynamic, independent companies. ‘

    Arguments about the merits of ‘competition’/ ‘choice’ are part of the propaganda technique of ‘distraction’. The ‘media and his wife’ can argue the merits of this, without any thought being given to the real agenda. Health, like food, is seen as a stable commodity where there will always be a demand and has a secure funding stream. It is ripe for exploitation by commercial interests but first the inconvenience of public ownership must be dismantled and discredited.

    http://think-left.org/2012/03/05/transnational-corporations-have-not-let-a-good-crisis-go-to-waste/

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