What kind of market is the NHS market?

This week a merger between two hospitals in Dorset was blocked by the competition commission, on the grounds that the move would be anti-competitive (http://www.bbc.co.uk/news/uk-england-dorset-24559766). The two hospitals aren’t happy, especially Poole hospital which is apparently in a pretty bad financial state, and was depending upon the merger acting as a kind of financial bail-out for it. What are we to make of this? What can it tell us about the emergent NHS market?

Well, as I keep on complaining, the NHS is not a market. Using the term ‘market’ suggests that we are talking about something like perfect competition, a theoretical model never observed in the real world, in which there are lots of small purchasers, lots of small providers, freedom of entry and exit from the market from both purchasers and providers, and it is cheap and easy to get in and out. There is also perfect information about what is going on, and participants that make highly rational decisions.

Now others (Alan Maynard especially) like to remind me that expecting the world to be this way is unrealistic. And that’s right. But in talking about ‘markets’ we are using the legitimacy of an idea (the perfect market) to underwrite a bunch of arrangements that are nothing like this.

Because over here in the real world, the NHS isn’t like this. We have large providers (both public and private) where we can’t let the public providers exit or go bust (although we might let private managers or even private providers take them over). We have private providers who can duck out, but we’ve still got to provide care so public providers will end up having to take their place (breast implants, for example). We have lots of small purchasers, but when they are up against big providers they will appear weak and disjointed and have little power. And where we have to pay for something complicated, like care, we may need planning and co-ordination – whether it is long-term care for the elderly (which is especially worrying given this (http://www.bbc.co.uk/news/uk-england-sussex-24579496)) or for cancer care.

Now look, I like competition in markets where I think I can make sensible choices. I like it that Samsung and Apple are driving each other on to make me better gadgets. But I still have no idea how I’m supposed to make choices in the healthcare market, and I don’t think my GP does either (and s/he is meant to be doing the commissioning on my behalf). We have put in place a system of buying and selling care that labels some providers as being effectively bankrupt when they may actually be providing really good care, and little or no sensible evidence showing all the effort and expense of having the market mechanism in place actually justified its costs.

So – back to Dorset. Should the merger have been blocked? Well, there’s very little evidence showing that mergers work, anytime, ever. They take years to get over, and just about never live up to the claims made to justify them. Mergers are generally a bad idea. But equally it is ridiculous to force hospitals to merge because they are in financial trouble. Surely the question we should be asking is whether they are providing a good service to their local people? Are they providing high standards of treatment? Are they giving good care? If they are, shouldn’t we be paying for their services rather than forcing them into dubious merger manoeuvres on the grounds of market legitimacies that are based on a theoretical model rather than anything in the real world? And if they aren’t, shouldn’t we be finding ways of driving up their standards rather than assuming somehow that better management can fix it?

The NHS ‘market’ isn’t a market in any kind of sense by which we usually use the term. To use the term market is to confer dynamism and innovation upon institutional arrangements that run directly contrary to providing the long-term, stable, and open-ended care that we need. More importantly, pretending the NHS is a market conceals the need to think very differently about how we can support care by organising things differently, and how we can arrange finances to support good care, rather than forcing hospitals to try and merge to avoid running out of money and being forced into private hands. That way madness lies.

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Confronting obesity – a response to Max Pemberton

In this week’s Spectator (12^th October) Max Pemberton makes the case that Britain must urgently confront its growing obesity problem. He takes us through an anecdote about a patient in a GP surgery demanding a pill that will allow her to not digest fat along with a range of alarming statistics (£5bn a year additional costs to the NHS with 300 hospital admissions a year due to obesity). He writes about other costs – Ambulance services having to replace their fleets to deal with obese patients and hospitals having to buy new operating tables, trollies and scanners. Max points to the failure of public health policy in terms of eating five fruit and veg a day, and suggests we now plan around obesity – assuming it to the both norm – rather than confronting it.

So what should we do? Max suggests we need to confront patients about their weight to get them to confront the reality that they are eating too much and moving too little. He accepts that some people may be genetically predisposed to weight gain, but that changing lifestyle can deal with this. The problem, he writes, is that we aren’t trying to lose weight any more – it’s an attitude problem. We treat patients as consumers (literally here, I guess) and then we are surprised that they won’t take responsibility for their weight any more. Obesity is not a disease, Max writes, – it’s a mindset.

I hope I’ve represented Max’s piece reasonably above. Is he right?

On one level, I think he is. Clearly we can control our weight by eating less and moving more. But it may not be as simple as that. Obesity is important because it is a growing and expensive problem. But it also challenges the way we think about our environments and what it means to be human in a fundamental way. Where we locate the blame for obesity tells us a lot about how we see the world.

We can locate obesity as not being our fault as individuals through two strategies. First, we can say it is down to the toxic food and drink environment we have created for ourselves. It is sometimes hard to move in supermarkets or corner shops for booze and crisp deals, and then you get to the counter and they try and sell you cheap chocolate as well (even WH Smith do this at present – I can’t buy a newspaper without being offered a family-size bar of Cadbury’s). There are studies from the US showing that many local shops offer their local populations huge deals on cheap but largely nutrition-free food and drink, and so little wonder they get fat. Suppliers of sugary drinks and convenience foods pay shops to take their products and display them prominently, crowding out more healthy alternatives. On this view we are having obesity foisted upon us by the food and drinks industry and government turning a blind eye.

Equally, we can blame our genes. Max talks about this in his piece – and no doubt some people do have a higher propensity to store fat than others. Hey – this would have been a genetic advantage not that long ago when food was scarce, but now it’s everywhere (see above), we get fat because our bodies are super-efficient at storing fat for the famine that now never comes (for us in the West, at least). Again then, not our fault.

But these two explanations, as Max points out, take choice and responsibility away from us. But we don’t all deal with choice and responsibility in the same way. Talking about personality types is always a simplification – but work done by Margaret Archer and more recently Graham Scambler points to some of us being autonomous in the way Max describes, some of us depending on others for validation more, and some of us having such jumbled and chaotic personal narratives that we struggle to make and carry through good decisions. Now if I’m autonomous I make my own judgements, and presumably can be held accountable for what I do in the way Max describes. But if I’m more likely to be looking for validation from others, then their views and lifestyles will impinge much more upon me. It’s no wonder that people with weight problems may live with other people with weight problems (be them family or friends). We want to fit in. We don’t want to be the ones not eating crisps or puddings, or seem fussy about what we have for dinner. Equally, for those with chaotic life narratives, who struggle to be consistent or make good decisions, it’s easy to see how eating convenience foods or buying the chocolate when it’s on offer to you, become the everyday decisions. Especially when you are trying to down work (possibly across several jobs).

The key thing is that what we eat and how much we move is a complex mix of the above. I’m lucky in having a job that means that most days I can arrange time to eat reasonably well, as well as being able to afford my own exercise equipment, so I can get up early and try and keep my weight under control. I live somewhere where I can access a decent range of foods without too many problems. I’m also lucky in that my wife is an excellent cook, and so much of the food preparation falls to her (I try and do childcare to balance this up a bit). All of these things mean that I can be held to account in the way Max describes. But many (most?) people aren’t.

Yes, we need to do more on obesity, and adverts with cute plasticine characters aren’t going to fix it. We need to hold those marketing and selling us nutrition-free food and drink to account – hell, let’s tax stuff that is making us fat as we should be eating less of it anyway. But we also need to make sure that better alternative are available, and educating kids better about food at school (I’m appalled at the rubbish they get taught there about nutrition). And parents, yes, need to do more as well about helping their kids be healthier, in terms of both diet and lifestyle more generally. And so do doctors.

So Max is partially right. But in simplifying this down to choice and responsibility, he’s missing out large parts of the story, as well as not questioning how why our health services are treating us as consumers, or asking our governments to act in the better interests either. We need a bigger and more encompassing strategy – leaving all this to markets will just keep making us fatter and more unhealthy where we allow money to be made in that way. But we, and our governments can change the rules to move us more towards the right direction, and to more effectively help those that need more support.