There has been a minor debate on the internal NHS CFH bulleting board about the role of choice and competition in the NHS. Specifically, the discussion has centred on what the evidence is to support the government's oft-repeated notion that it will drive up quality.
The reality is that such evidence is pretty thin on the ground. The theoretical underpinnings to the potential role of choice and competition in the NHS come largely from the work of Julian Le Grand, professor of social policy at LSE and one-time senior adivsor to Tony Blair. In spite of the lack of hard evidence, competition and choice have become articles of faith for the current administration. In particular, they are drawn to nudge theory as a means of manipulationg choice to bring about better outcomes.
However, the reality is that re-engineering the entire NHS in order to promote choice and competition between 'any qualified provider' is a massive experiment, based on a largely untested theory and driven forward by an ideologic faith in market mechanisms as the best way of distributing all goods and services.
The problem as I see it, is that even where the introduction of competition and choice are thought to have delivered benefits for 'consumers' the results are pretty equivocal. Also, the introduction of market mechanisms into complex sectors and natural monopolies tends to lead to both a plethora of unintended consequences and a consequent creation of a large and complex regulatory mechanism to try to manage those consequences.
To take some examples. The privatisation of public utilities in the UK was undertaken in the 1980s on the basis that it would lead to more efficient services and keep prices down for consumers. The reality is that, although it can be argued that prices have been kept down, the net result is also included the rise of 'confusion marketing' and complex tariff structures to inhibit the workings of the market. And that's in spite of the significant amount of interia in the system(s) which have seen only a small proportion of consumers switching suppliers.
On top of this, there have been significant strategic problems. Firstly, the privatisation of energy supply helped to create the 'dash for gas' and has made the UK dependent on Russia for its energy. Secondly, the privatised power companies have prioritised profits over investment with the net result that the energy infrastructure of the UK has been run down and is now likely to require government intervention and public investment to ensure it is fit for purpose for the future.
It might be argued that in the case of the railways, the problem was that privatisation was the goal, rather than the creation of mechanisms to promote choice and competition to drive benefits for the paying customer. But there is a real lesson in there about seeking to introduce market based reform into something that is a complex, multi-facetted organisation where quality and safety depend on collaboration rather than competition.
So in sum, the omens for further market based reforms to the NHS are not good. Like many people, I believe that the market based reorganisation of the NHS will at the very least lead to a host of unintended consequences that will probably have a detrimental effect on the quality of patient care and the integration of different parts of the service.
In spite of the academic credentials of Professor Le Grand and the authors of Nudge, I remain to be convinced by hard evidence. To quote US politician Richard Holbrooke: 'The smartest man in the room is not always right.'
