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