The Great Game

Last week, the British Government’s Health and Social Care Bill finally completed what has been one of the most tortuous passages through Parliament of any piece of legislation in recent memory.

The bill has been the subject of 15 months of intense political wrangling and more than a thousand amendments – many focused on its provisions for greater competition in the National Health Service (NHS).

Competition is a fact of life in most areas of UK society, but as soon as it is proposed within the sphere of the state-funded NHS, many people here start to get very jittery about it.

The key concern among critics is that competition between multiple providers will fragment the NHS and remove one of its big potential advantages – its ability to get different elements of healthcare working together within a single, integrated system.

On the other hand, proponents of competition argue that state monopolies like the NHS can become sluggish and unproductive, and that an injection of competition is just what is needed to drive efficiency and push up quality.

So who’s right? Well, any argument needs to begin with an acknowledgement that the NHS isn’t actually the competition-free zone that both its fans and its critics tend to suggest.

Patients have always been able to choose between neighbouring family doctors’ practices, a split has existed between purchasers and providers of care since the early 1990s, hospitals have been competing for patients’ custom since 2002, and up to 5% of primary care, and a little less of outpatient secondary care, is delivered by private companies.

Similarly, the NHS is not nearly as integrated as it might be. Family doctors, known here as GPs, run their own independent practices, and these only integrate relatively loosely with hospital services.

But efforts to significantly ramp up competition within a state system are tricky, and evidence of whether or not it works to drive up quality and efficiency is highly patchy.

The Government has already been forced to rule out any competition between providers by price – barring providers from offering cut-price deals to win custom.

That’s because the sparse amount of evidence that does exist – mostly from the very different US system – suggests that price competition, while successful at reducing costs, can also bring down quality.

So providers will only be able to compete in the NHS by demonstrating they can offer a better quality of service than their competitors – with the price paid for that service to be fixed by regulators nationally or in some cases locally.

That removes one potential danger of competition – lowering quality – but in doing so makes it much harder for competition to bring financial benefits.

A lot rests on the ability of competition to drive up the overall quality of care – which enthusiasts hope might also reduce costs in the longer term.

A review published in January by the Office of Health Economics could only find two studies that had ever looked at whether competition within the NHS has had any benefits for quality.

Both found that in areas where patients had had a choice of several neighbouring hospitals, quality had improved faster than where the local hospital had few nearby competitors.

But the studies had a common drawback – they both used as a marker of quality the 30-day mortality rate from acute myocardial infarction.

That happens to be easy data to get hold of, but it’s a slightly odd measure to use in the context of patient choice – since no one in this country chooses which hospital to go to when they’re admitted with a heart attack.

And elsewhere among the NHS’s experiences with competition, there are some reasons to be queasy.

The last Labour government experimented with drafting in a series of private providers to deliver aspects of elective hospital care, through new organisations called independent sector treatment centres.

The contracts weren’t well drawn up though, and there is evidence some private providers routinely cherry picked those patients who were easier and cheaper to treat – by applying strict clinical eligibility criteria.

The current Government is desperate not to make the same mistake, and has pledged to forbid cherry picking by insisting new providers must offer services to the same range of patients as the existing NHS.

But that only prevents cherry picking of patients within a service. The real risk is surely that private providers will cherry pick which services to provide – and compete for the chance to deliver care only where the regulated tariff price appears attractive and profitable.

That would leave the NHS facing competition wherever tariffs looked lucrative, but as the single monopoly provider of those parts of the system no private provider would touch with a barge-pole – most glaringly, expensive, loss-making services like accident and emergency.

These are the complications of attempting to draft in competition to a universal, state-funded healthcare system (and there are many others besides).

The health bill has taken more than a year to get to its current stage, on the verge of entering the statute book.

But it feels like it will take much longer still before the arguments over how to marry state security with private enterprise die down.

Richard Hoey is editor of Pulse, a weekly magazine for UK primary care professionals and physicians. He writes Pulse’s editorials and muses on general practice in his weekly blog. You can follow him and read other news about the NHS at pulsetoday.co.uk.