Odd isn't it that after ten years of policies to encourage competition and choice and ten years of an increasing share of NHS cash spent on non-NHS providers, the evidence base supporting the benefits of competition in health care is too thin to make a sound judgement.
Odd, until you think of the evidence base to support integrated care, which is equally thin.
No wonder there is such room for howls of protest and undisciplined debate which doesn't get us much further forward. No wonder existing regulations and guidance raise as many questions as they answer.
What does it take to improve the evidence? Data (yes, we have and can generate it); research capability (patchy but probably enough to produce some useful findings); research interest (not much among the academic community); a high priority for research funding from the Department of Health or other funders (no).
The latter is surprising considering the ferocity of debate – maybe it is thought that competition is such a totemic policy that evidence as to its benefits would be at best immaterial, and at worst get in the way.
In fact, the best study I’ve seen comparing the quality of care in independent sector treatment centres (ISTCs) and NHS facilities – showing quality the same or slightly better in ISTCs – I have also never heard referred to in SW1.
Of the, as yet, two main studies which show an association between more conducive conditions for competition and lower mortality rates from hospital care, these studies raise more questions than they answer.
What does it take for research evidence to influence policy? No magic here, just more of it and well communicated so it can't be ignored.
Unless there is a sudden reorientation of research funding and effort, perhaps we should pin some hope on Monitor and NHS England which have both signalled a commitment to strengthen the evidence. Let's hold them to it over the next two years.
But in the scheme of things, far from a tsumami breaking over the NHS, over the next few years my bet is that competition will cause only a few ripples at the edges. Our recent publication on primary care, Mark Newbold's blog on emergency care, our series of interactive charts: NHS in numbers, and our updated reforms timeline and ‘new NHS structures’ slideshow show why.
Basically, there are the far more important preoccupations of making the system work and living within means, leading NHS types towards the planning end of the spectrum rather than competition.
Call it reconfiguration, merger whatever you like – it’s strategic planning. And as argued in an earlier blog, what will help here is intelligent use of data to understand options, as well as a clearer steer from Monitor and the Cooperation and Competition Panel.
Last Friday’s Caldicott Review may create a far bigger risk to the pursuit of higher quality for lower cost if it restricts basic analysis by clinical commissioning groups (e.g. not being able to risk stratify patients to spot who is at high risk of admission, or having incomplete data because of patients not allowing data held about them in their GP record to be shared). Check back in with us next month for more on this.
Finally if you haven’t seen it, have a look at Nick Timmins’ short video interview with Andy McKeon – a seasoned former insider who has carefully reflected on the NHS for many years.
In Andy’s view, incentives particularly for hospitals have not worked as intended. His basic message: don’t waste time fiddling with incentives, just work with what you have.
Mark Pearson from the Organisation for Economic Co-operation and Development said similar at our recent Summit. Check out the key slides, 2 and 3, of this slideshow. However your health system is broadly financed and organised, there is more variation between system archetypes than across.
So, in times of stress, as now, make what you have work. For the NHS, surely this must be to sweat the single payer inheritance far more: data; mission; planning. Sure, a bit more competition, but don’t bet the farm on it to reach 2017 in better shape.
Dixon J (2013) ‘Bet the farm on information over competition’. Nuffield Trust comment, 30 April 2013. https://www.nuffieldtrust.org.uk/news-item/bet-the-farm-on-information-over-competition