Competition and the NHS – reponse to Le Grand

Today on the LSE policy and politics blog, Julian Le Grand has posted a piece that is critical of our earlier blog casting doubt on the LSE team’s work claiming ‘competition saves lives’. You can read it here (

I’ve posted my reply on the LSE website, but here it is again for completeness’ sake.

I have liked and admired Julian Le Grand’s work for years, and he is on many my teaching reading lists. But I do have to wonder what is going on here.

There is a basic category error in the piece above – competition doesn’t save lives. It never can. Clinical workers save lives, hopefully with the support of managers. To simply assert (as economists are inclined to do) that competition changes incentives is to not engage with the difficult, messy, empirical work of exploring exactly what has changed and how (if anything, and the moral of reorganisation in the NHS is how little changes). So the key question here is what exactly changed after 2006, and how did it change both managerial and clinical behaviour. The answer, I’m afraid, is that we really don’t know.

Even reviews of research that consider the econometric work that Cooper and Propper favour on their own terms find there are big gaps (for example, Bevan and Skellern in the BMJ ( Most particularly, their research is based on a ‘black box’ where incentives and changes are assumed rather than being empirically demonstrated.

It is also interesting that Le Grand cites the King Fund’s work as supporting his claims. Again, that is very contestable, as David Hunter’s review of the book, again from the BMJ ( suggests. My reading of the book was that Labour’s market-based improvements were extremely modest when compared to what was achieved elsewhere. It therefore seems odd that Le Grand presents this work as supporting him, when I’m really not sure that’s what the book is saying.

Above all, it seems to me that it’s time we started being a bit more humble about our work. Le Grand and Cooper, in their FT piece, seemed to be suggesting that there is only one way to do research, and people who do other kinds of work are mere ‘intuitionists’. This reads to many of us as an intolerant and rather blinkered view of social research. In order to understand what is going on in the NHS we need a range of different methods and different types of work. To imagine we can provide some kind of definitive answer, as they appear to be suggesting, from work that doesn’t empirically examine whether the changes they believe are going on are actually happening, without actually asking anyone involved in their implementation, seems a little odd.


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