David Payne: Competition and the NHS reforms

David Payne With the pause button still firmly pressed on the NHS reforms in England, one former Tory health secretary claims this week that the debate is losing touch with reality.

Stephen Dorrell, who now chairs the Commons health select committee, says the row about competition is nonsensical and could harm patients because it’s already happening in the NHS and has been for years, most recently to drive down waiting lists.

I wonder what Mr Dorrell would make of the reality check and historical context provided by Allyson Pollock this week when she argued in a lecture that trust in public health research is being jeopardised by the marketisation of the health service.

Markets are a problem for public health, she said, because they rely on risk selection. Also, private sector providers are often reluctant to provide data, so public health researchers often have to rely on freedom of information requests, which are resource intensive.

According to Pollock, professor of public health research and policy at Barts and the London School of Medicine and Dentistry, market forces, with their focus on risk selection, gathered pace following the publication of a BMJ paper in 2002. It compared costs and performance of the NHS with US private provider Kaiser Permanente (currently busy advising the department of health, she claimed).

The paper found that “Kaiser’s superior performance is mainly in prompt and appropriate diagnosis and treatment. These findings challenge the widely held view that the NHS is efficient and that its inadequacies are mainly due to underinvestment.”

It concluded  that Kaiser Permanente was more efficient than the NHS. And according to Pollock, the paper has been used  by the UK government to justify changes to the NHS, featuring in subsequent white papers and Derek Wanless’ review of future resource requirements. The paper attracted dozens of responses critical of the data, she added.

When the BMJ paper was published,55m US citizens had no access to health care. Kaiser provided care for only 8.1m people, 2.8% of the population, excluding chronic mental illness, long term and elderly care. Each primary care visits costs $50, $85 for an A&E appointment, $500 to have a baby.

The NHS, on the other hand, offers lifelong coverage, even if you’re unemployed, and foots the bill for training and educating health care professionals, and public health.

A colleague joked that I’d come back a communist after the lecture. I didn’t, but those of us who share Professor Pollock’s concerns might derive some comfort from BBC political editor Nick Robinson.

Earlier this week he suspected that both the prime minister and his deputy are “competing publicly for the credit in undoing the reforms that they themselves proposed”.

But that was before Mr Dorrell’s intervention.

David Payne is editor, bmj.com

  • Steve Black

    It is hard to take Allyson Pollock's views as disinterested comment on the debate about the NHS. She seems to oppose profits and markets wherever they appear not just when they appear in health systems. 

    This, I expect, is what drives her to try to undermine the NHS to Kaiser comparison. But the logic of mixing in the faults of the broader US system to the specific efficiency of Kaiser makes no sense and the idea that all markets are based on risk selection is merely a slur on markets in addition to being obviously untrue if you look outside the US health system. 

    Kaiser is particularly good at balancing primary care and hospital care investment and intervention and does a much better job than the NHS at keeping its people out of hospital (it is much ore joined up than the NHS). It clearly uses far fewer beds then the NHS on a population adjusted basis. But this comparison cannot be allowed to stand for those who believe that state provision is always the best way to do health.

    Besides, the best arguments that the NHS is not as good as it should be are not based on external comparisons which are always imperfect and can always be challenged (even if the challenges don't stand up). The NHS Atlas of Variation and the recent Kings Fund report on variation show that there are large and persistent variations in the clinical thresholds and practices across the NHS. These are not justified by any clinical or demographic need and suggest that the NHS has a serious problem learning from experience and propagating best practice. 

    This evidence is systematically ignored by the believers in the superiority of a monolithic state-run NHS. Those of who prepared to take a less ideological line can see that it might actually be possible to harness the good parts of markets in a carefully regulated system that retains universal government funding and health coverage but creates some incentives for improvement.