Is care for people with rheumatoid disease better in Liverpool or Manchester?
Is care for frail elderly people better in Somerset or Devon?
Which big city has the best service for people with bipolar disorder?

After 60 years of the NHS and 20 structural reorganisations these questions, and similar questions about other health problems, still cannot be answered. Neither can they be answered in any large “developed” country, but they could be answered in England soonest because the NHS in England is the only large country with programme budgeting. We know, for example, that we spent £92m per million population on musculoskeletal disease, £117 m per million population on cancer, and £ 25m per million population on mental health services in 2009/10. Furthermore we know this by population, and by primary care trust at present. We could therefore measure the relationship between outcome and resources and the value of services for different populations, but not if we continue to focus on “providers” and “commissioners,” or “primary” and “secondary” care, or “hospital” and “community” services. These are 20th century terms, based on 19th century bureaucracies, describing aggregations of parts of systems, and it is competition between hospitals or insurance schemes that forms the basis of the recent literature on competition. (1,2,3,4, 5) It is systems that are needed, systems that compete with one another on the value they provide for patients in the population that they serve with the only incentive or reward being professional pride in a job well done. 

Although the development of hospital and primary care services has been a great achievement in the last 50 years, they are only one dimension of care. The other is the patient’s problem – pelvic pain, or breathlessness, or rheumatoid arthritis:  these are the eternal verities of healthcare whereas “commissioners,” or “foundation trusts,” or “health maintenance organisations” are ephemera. The need for the second dimension that focuses on health problems was argued many years ago, also in a time of “zero growth” (6) and there has been progress in some conditions such as cancer, but it has usually been where technology has forced some change, with people from different institutions needing to work in networks to create systems. Most healthcare in most countries resembles Brownian motion, the random movement of patients, professionals, blood samples, and documents. What is needed are systems.

A system is a set of activities with a common aim, for example “to minimise handicap in young people with severe disabilities.”  The aim is amplified in a set of objectives which define the scope of the system, for example defining whether or not a system for people with chronic obstructive pulmonary disease includes responsibilities for prevention and terminal care.  A set of objectives for an epilepsy system, prepared at a workshop, are set out below:

• To assess seizures and diagnose epilepsy quickly and accurately             
• To treat effectively and with minimal side effects
• To help the child and their family to adjust to the diagnosis and minimise handicap
• To ensure that all children with epilepsy and other problems receive prompt and comprehensive assessment
• To promote equity
• To involve children and their families, both individually and collectively in management
• To promote research
• To develop all the professionals and practitioners involved in epilepsy care
• To make the best use of resources.
• To produce an annual report for the population served

For each objective one or more criteria are identified, both process and outcome. The outcomes need to include both benefits and harms, because one aim of the system is to achieve the optimum balance of good and harm from the resources allocated. For this reason too, standards may include upper rates of testing or referral as well as lower rates to minimise overdiagnosis and overtreatment, as well as minimising underdiagnosis and undertreatment. Systems are delivered by networks. A network is a set of individuals from different bureaucracies who work together, and trust one another, and although there will be contractual relationships between the bureaucracies the key element is trust. The systems are expressed as pathways and localised care maps using internet based tools like the Map of Medicine make the usual pathway of care clear to all patients and professionals.

Competition by systems for better value

Competition, like all medical care, can do harm as well as good. Competition between “providers” on hospital criteria such as compliance with standards, appears to do more good than harm, though quality improvement too can have unintended consequences. What is needed are population based systems competing on value, on outcome, and cost. The issue of cost cannot be avoided because if resources are used and produce low, or no, value it is not the tax payer who pays but those other patients whose needs could have been met with that wasted resource, and there is evidence that this type of competition works.

Competitive screening systems
Screening is relatively, but only relatively, simple to run as a system, particularly if there is a green field site on which to design and build the system, as was the case with screening for breast cancer.  All screening programmes, like all medical care, do harm as well as good. The balance of good to harm demonstrated in the research on which the policy decision to introduce breast cancer screening is based, is best described as the efficacy of the service, when its results were performed by highly experienced experts working to protocol. To minimise harm and maximise benefit the English Breast Cancer Screening Programme developed a set of objectives and used identical criteria to measure progress, or the lack of it, and produced an annual report of how all the systems, or programmes as they were called, performed in comparison with national standards and with one another.  It took five years for the mean performance of the English programmes, about one hundred in number, to achieve the Standardised Detection Ratio (SDR) set by the research teams. That is for the effectiveness to match the efficacy to use more formal terms. It was recognised that the performance of the research terms would also have improved in that period, but the competitive system was designed to maximise benefit and minimise harm in all the programmes. Standards relating to the process of screening were set, with every programme competing to achieve a position in the top quartile and with those in the top quartile aspiring to be the best, expecting no reward other than their sense of achievement and pride. Minimal acceptable standards below which no programme should fall were also set, but programmes which were below this standard received neither humiliation nor additional resources, but help from other programmes to improve. After 10 years the worst performing programmes were also achieving the SDR of the Swedish research teams (7).

Ten years, twice as long as the Second World War, to translate efficacy to effectiveness, was this period too long, or was progress too slow?  Perhaps, but population based systems, each accountable to the population served through an annual report, and competing for pride achieved this. Cancer, cardiovascular, and end stage renal failure services have also developed this approach, but we need to do it for all health problems and patient groups.

Accountability to and engagement of the population served

The population size varies. For a common condition without the need for highly specialised interventions, asthma or the problems of frail elderly people for example, a population of 300 000 would  generate enough activity for meaningful comparison.  For other conditions a larger population base would be appropriate to measure variations in less frequent interventions, for example a population of two million for epilepsy, while there might be a need for only three or four systems in England for childhood metabolic diseases. The professionals responsible for these systems would naturally compete with one another on quality, outcome, and the use of resources.  So too would the patients and carers who are partners in the system. Their feedback offers opportunities to improve quality and safety, their suggestions offer opportunity for redesign, and they would want their service to be the best:  co-ownership is effective. The annual reports from the systems, perhaps 100 for asthma and 30 for epilepsy could be compiled by the relevant national charity, so that the system would be accountable to the population served, both nationally and locally.

Only systems competition does more good than harm

Thus it is not possible to generalise about competition. Some competition is ineffective, some does more harm than good, but competition between systems accountable to defined populations is effective.  The luminaries of the business world (8,9) have now joined the call for this approach and there is evidence to support it.  The core business of healthcare is not its institutions, which are necessary but not sufficient, but the problems borne by patients and carers. These should be the primary focus of a health service which should encourage competition to maximise value.

King Kong, Godzilla, or the ants?The King’s Fund report on competition recognised the complexity and the potential of combining integration and competition, and calling on the NHS Commissioning Board and Monitor, the big beasts, the King Kong and the Godzilla of healthcare, to bring this about, (10) but maybe this is just too complex for big bureaucracies to manage. Perhaps it is better to leave it to professionals and patients to create the  systems and the networks cooperatively, just like the ants do.

Muir Gray is visiting professor of knowledge management, Nuffield Department of Surgery, University of Oxford.

References
1. Propper C, et al. The effects of regulation and competition in the NHS internal market J Health Economics 1998;17: 645-74.

2. Cooper Z,  et al. Does hospital competition save lives? Evidence from the English NHS patient choice reforms J Health Economics 2011;121: 28-260.

3. Stevens S. Is there evidence that competition in healthcare is a good thing? Yes BMJ 2011;343:72-3.

4. Mays N. Is there evidence that competition in healthcare is a good thing? No BMJ 2011;343:72-3.

5. Okma KGH, et al. Managed competition or Medicare? Sobering lessons from the Netherlands New Engl J Med 2011;365:287-89.

6. Gray JAM. Four Box Health Care –development in a time of zero growth. Lancet 1983.

7. Gray JAM  et al. Maximising the benefit and minimising the harm  from screening  BMJ 2008;336:480. doi: 10.1136/bmj.39470.643218.94

8. Porter ME, Teisberg E. Redefining Health Care. Harvard, 2006.

9. Christensen CM, et al. The Innovator’s Prescription. McGraw-Hill, 2008.

10. Hawkins L. Can competition and integration co-exist in a reformed NHS? Kings Fund, 2011.