Competition does improve the NHS

So there.

List of peer reviewed studies showing that it does.

Then look at the comments.

This science stuff, Pah! what\’s that against me and my prejudices?

41 thoughts on “Competition does improve the NHS”

  1. First comment:

    Waseem: “Bollocks!”
    [that’s it; no evidence or analysis, just “Bollocks!”]

    184 other Guardian readers “Recommend” this.

    Says all you need to know about Guardian readers.

  2. Peer reviewing patient outcomes in an economic journal is like reviewing economic theory in the Lancet

  3. “Hello ambulance control, multiple providers will be competing to stabilize the patient. ETA? Er, I’ll let you know once we’ve compared bids… what’s that? Try ‘co-operating’? Negative boss, it’s not what the peer-reviewed economic journals say.”

    Science, my arrse.

  4. That, lost_nurse, is gently described as a fallacy of division. What is true of the whole need not necessarily be true of every constituent part.

    So, while both theory and practice tells us that introducing markets is an oblique, tiresome, distracting but curiously necessary step to optimise outcomes, it does not necessarily follow that is is true for all parts of the system. A&E being the most obvious example. I am sure there are others.

    But, despite limitations to the findings, the findings are still true across the system.

  5. john,
    I’m not saying you are wrong, I’m just asking the question – what is so exceptional about a statistical analysis of patient outcomes, controlling for specific variables, that makes it beyond the juristiction of people who are experts at performing statistical analyses of outcomes controlling for specific variables?

  6. John,

    I think we are hoping the ‘science’ answers different questions.

    A Lancet question: for a given condition, physician skill set and delivery model, what drugs optimise patient outcomes?

    An economist question: for a given set of physicians skills and drug portfolio, what delivery model optimises patient outcomes?

    You need double bind trials. I don’t. I have a different question, a different problem type and a different methodology.

  7. Not entirely sure how well the ‘peer reviewed’ claim stacks up when a paper by an LSE academic gets published in one of the LSE’s own journals.

    Seems a tad incestuous…

  8. “Hello ambulance control, multiple providers will be competing to stabilize the patient. ETA? Er, I’ll let you know once we’ve compared bids… what’s that?

    Is this what NHS staff think competition is? Seriously? I mean, is the idea that you can have a single provider resulting from a competitive tender process really unknown to them?

  9. Surreptitious Evil

    Is this what NHS staff think competition is? Seriously?

    Yup. Not necessarily their fault, of course. They are (mostly) dedicated people with a busy professional job to do. And the propaganda from the post-professional weasels who would lose out is both incessant and, as you have seen, insane.

  10. John,

    Yes that is what I’m saying. You need evidence I don’t (double bind trials).

    Equally, I need evidence you don’t (time series outcome data straddling multiple geographies and delivery structures).

    Not better, not worse. Just appropriate.

  11. I am sure there are others

    Precisely – and if commentators are unable to grasp how hiving off, say, elective surgery has serious implications for A+E capacity, then it’s simply not good enough to waffle platitudes about the “market”. It boils my piss.

    Le Grand has yet to explain why the outcomes attributed to the use of ISTCs etc are not better/simply explained by increased investment & capacity. IME, the competitive relationships he specifies just don’t exist. Now, I’m all for informed patient choice- but if you talk up the role of competition, then it is beholden upon you to acknowledge how much is achieved via co-operation (between staff, units, specialties, hospitals) – and how this is potentially threatened.

    Is this what NHS staff think competition is?

    All manner of stupid shit is being proposed in the name of ‘competition’. You may envisage a glorious future of competitive tendering – I see Crapita writ large. I don’t want ’em running my local hospital.

  12. n.b. to clarify, Zack Cooper (the article author) is straight out of the Le Grand stable. Personally, I don’t care much for health economists who look/write like they’ve never handled a bedpan in their life.

  13. “if you talk up the role of competition, then it is beholden upon you to acknowledge how much is achieved via co-operation (between staff, units, specialties, hospitals) – and how this is potentially threatened.”

    One would need to explain all that and a lot more beside if the objective was to explain *why* non-price based competition worked.

    But that’s not the issue at hand. Rather the issue in the research is that, in practice, non-price based competition *does* work already. Out in the wild. It doesn’t need to explain why. It just records what *is*. And what is true is that:

    1) Price-based competition erodes patient outcomes
    2) non-price based competition improves patient outcomes

    Not “we want it to improve outcomes”, not “we think it probably should improve outcomes”, not “here is why it improves patient outcomes”. Just “It does improve patient outcomes”.

  14. All manner of stupid shit is being proposed in the name of ‘competition’.

    So why do you need to make up even more stupid shit to prove your point?

  15. You may envisage a glorious future of competitive tendering – I see Crapita writ large.

    I can sympathise with this. However, the problem is not that competition does not work, it is that dickheads in government – and the NHS – do not know how to run a tender process, write a scope of work, and manage a contractor.

  16. In any case, it should be understood that competition is a means to an end, not an end in itself. What is missing in the NHS is a feedback mechanism to punish the poor performers and reward the good performers. In theory, competition should provide this to some extent, and it has been shown to work elsewhere. However, if it doesn’t work, the problem of there being no feedback mechanism still remains, and another solution will have to be found. What nobody should put up with is whining staff who reject any proposal for feedback of their own work reaching them.

  17. Just “It does improve patient outcomes”.

    As far as Le Grand et al are concerned, I remain to be convinced that non-price competition is improving the outcomes in the way they envisage. I know full well how local ISTC capacity is being utilised (not least because I was referred there as a patient). They do the *simple stuff, we do the *messy stuff (even though our capacity to do the latter has been hampered by outsourcing the bread n’ butter cases). Again, there’s no competition involved – at least not in the way that politicos/health economists seem to imagine it, and certainly not in the way that propagandists for “choose n’ book” would have you believe. Linking patient survival data to the number of accessible hospitals (crudely put, more hospitals=better outcomes) is up there with the observation that bears shit in the woods. Pollock’s Grauniad article was badly titled (“THE FEAR!”), but her criticism of Cooper’s paper was bang on.

  18. it is that dickheads in government – and the NHS

    The dickheads in question tend to be seconded from McKinsey & co, etc. I’m rather tired of “the public sector” being blamed for procurement strategies that stem from a greasy revolving door. See also MOD.

    why do you need to make up even more stupid shit

    Because when I see path labs being outsourced to Serco and The Times doing PR puff jobs for ex-Goldman Sachs investment punts (Circle healthcare), it makes me spit. None of this is going to improve the kind of thing seen at Mid-Staffs.

  19. lost_nurse,
    “I remain to be convinced that non-price competition is improving the outcomes in the way they envisage”

    Help us out then. The LSE paper points to a number of sources concluding that non-price based competitions improve outcomes. Is there another body of evidence with another conclusion (for non price based, not for price based competition)?

  20. Help us out then

    If you asking for a huuge corpus of JSTOR stuff showing the opposite, then no, I don’t have it. I take it that you deal with stats on a professional basis – and I’m afraid I can only offer gut feelings & anecdote… and my gut feeling is that using data for survival following myocardial infarction is a pretty odd way of espousing the value of competition in, say, elective procedures – i.e. in simple terms, you are “choosing” (or more likely, being allocated) where to have your tickbox hernia op done – not where you envisage having a bloody great big unplanned heart attack (for which the proximity of big teaching hospital might be useful)! And based upon what I see in emergency surgical admissions, I simply don’t believe what Le Grand says – IMO, improvements in outcomes are better explained by the simple expedient of having more capacity to play with. Not much in the way of an evidence base, I know. 🙁

    There’s no doubt that financial penalties of any kind (including losing potential income/market share) focus the mind, but I’d prefer a more rounded take on “competitiveness” , as expressed on ConservativeHome – of all places.

    http://conservativehome.blogs.com/platform/2011/06/teck-khong-.html

  21. lost_nurse,
    I am not reading that paper (or the studies it references) as disputing your claim that “improvements in outcomes are better explained by the simple expedient of having more capacity to play with.” I reckon that assertion is self-evident (subject to diminishing returns of course).

    But the LSE paper is concluding that *holding other variables such as capacity constant* then non-price based competition improves outcomes.

    It’s not the only answer, but *for that variable*, this is the best answer we know right now.

    You might also want to investigate your preferred variable (capacity) to see how that impacts outcomes and where diminishing returns kick in, but that is a different variable from the one being researched by LSE.

    Each party needs to optimise each variable. You can go figure out the capacity variable. John can figure out the drugs variable. But regardless of the answer for those variables, the right answer for the delivery model variable will be ‘non-price based competition’.

    Until new evidence comes to light.

  22. Gary,

    Thanks for your reply. I would simply question Cooper’s view of non-price competition as a driver. IME, it doesn’t reflect how capacity is actually being used. In other words, how much competition is really going on (especially given the bloc contract management of high volume/low risk cases)? How do you isolate that from the various other sticks/carrots ? There are all kinds of agonising provision debates at the moment (paediatric cardiac surgery being the classic). And the mortality data for high risk interventions doesn’t really make for simple soundbites – which, I suppose, is my real beef with competition mantras.

    You might also want to investigate your preferred variable

    Only if somebody gives me some paid study leave. 🙂

  23. Hi Gary

    Sorry about the silence but I was working in the non competitive world of NHS land.

    Seriously is the data to which you refer available? I certainly haven’t seen it.

    The only Healthcare markets I have witnessed are Australia and USA. One has dispensed with price as the competitive driver and replaced it with quality OK but only one provider usually so once contract is placed no choice.

    The other provides healthcare for 85% of its’ population leaving 50 million without cover at a cost of 18% GDP leading to 45000 unnecessary deaths (Harvard).

    Not my idea of good value or improved outcomes or choice?

  24. The dickheads in question tend to be seconded from McKinsey & co, etc.

    Well, quite. Why are McKinsey hired to manage tenders, usually being thrust into a conflict of interest from the word go? Because nobody in the public sector has the faintest idea how to write a scope of work or tender a job. Few private companies get fleeced in such a manner, and those that do rarely survive. The NHS and MOD just demand enough slug of taxpayer money and carries on like before.

  25. Because nobody in the public sector has the faintest idea how to write a scope of work or tender a job

    I’m not sure that’s an entirely accurate picture & it’s certainly not fair on the likes of NHS Logistics (who ran a tight ship across a whole bunch of different lines). How funny, then, that DHL should have been so desperate to go into “partnership” (read: asset grab) with them. There was, furthermore, no end of opposition among both NHS clinical & beancounting staff to the monstrous fcuk-up that is PFI (& see also LIFT) – they could see what was coming & said asmuch. Indeed, NuLav used some pretty dodgy financial comparators when trying to force the issue (and the ConDems appear equally happy to sign off such projects). IMO, what you allude to is a cultural & political malaise that goes far beyond clichés about public/private/good/bad – vested interests lord it, whilst Toms go short of kit in Helmand & the elderly get crated up on understaffed wards. My own preferred solution would involve a rifle and a wall.

  26. How funny, then, that DHL should have been so desperate to go into “partnership” (read: asset grab) with them.

    No, it’s what is to be expected: getting a government or NHS contract is money for old rope for most private companies because, as I have said, they have no idea how to manage contracts properly.

    There was, furthermore, no end of opposition among both NHS clinical & beancounting staff to the monstrous fcuk-up that is PFI (& see also LIFT) – they could see what was coming & said asmuch.

    From what I remember, they were protesting to protect their own narrow personal interests, not scrutinising the details of PFI.

  27. From what I remember, they were protesting to protect their own narrow personal interests, not scrutinising the details of PFI.

    Utter bollox. I was actually there, but suit yourself.

    No, it’s what is to be expected

    Really? Well, duh, knock me down with a feather. And nobody in the NHS could see this coming, you say? Nulav’s insistence that it was “PFI or bust” was itself predicated on the soundbite basis that public procurement is always bad, M’kay – despite evidence to the contrary.

  28. Utter bollox. I was actually there, but suit yourself.

    Well, lessee. In all your postings thus far on the subject, you have said a lot about what you – as an employee – wants, but nothing about what might be best for those who actually use the service.

  29. you have said a lot about what you – as an employee – wants

    I tell you what I want: wards that are properly staffed, so that we can look after people with the kind of dignity & care they deserve. I have a pretty clear-eyed view of what is & isn’t going well – and if I think somebody is talking spurious nonsense about acute care, I will say so. FFS, I am also a “service user”!

  30. I tell you what I want: wards that are properly staffed, so that we can look after people with the kind of dignity & care they deserve

    Right, but the NHS is utterly failing to provide that, and it has a lot – nay everything – to do with how it is structured, in particular the monolithic nature of the organisation and the lack of feedback mechanisms. Even though evidence abounds that systems with competing providers result in a better overall standard of care, you dismiss the concept of competition out of hand. Really, whose interests are you championing here?

  31. Right, but the NHS is utterly failing to provide that

    Not on my ward, it ain’t. Not least due to a senior sister who runs emergency admissions with the severity of an RSM. My concern isn’t a blanket defence of the NHS – I am more than aware of how & where it falls down (especially when it comes to feedback) . My concern is that we don’t fcuk things up even more. And Cooper’s paper will now be cited by politico as support for all kinds of things that (I’m willing to bet) will do little to improve standards of care. As for plurality of providers & competition: we could play this game all night – it hasn’t necessarily done wonders for residential care. ..

    I am pretty familiar with Spain

    Very different attitude towards next-of-kin/family involvement in nursing care, or so a Spanish ITU friend tells me. Something else we could probably learn from.

  32. [email protected],
    “how much competition is really going on (especially given the bloc contract management of high volume/low risk cases)? How do you isolate that from the various other sticks/carrots ? ”

    Sticks and carrots are collectively called ‘incentives’ in economics. If you can’t trust economists to tease out incentives, we’re fcuked. Like if we couldn’t trust doctors to do double blind trials.

    But even if you want to discount the LSE report, it does point to a whole host of other research in the lit review, conducted by all sorts of different people from different countries with different prejudices using different methodologies. They all get to very similar results. The cumulative consensus is less likely to be wrong, even if you don’t wont to include the LSE.

    By “you might also want to investigate your preferred variable”, I should have more correctly written: “You might prefer to see more reasearch on your pet variable.” I’m not trying to instruct you on how to spend your time!

  33. we’re fcuked

    We are already fcuked, surely? I thought that was the general consensus… 🙂

    Anyway, thanks all for the debate – I’m off to bed, before my own pet variable gets too mad at me.

  34. yes we are, but we do know the service delivery model with the highest chance of getting us out of here.

  35. but we do know

    Just quickly, because I have to go to work… I’m not disputing the value of genuine patient choice where services are amenable to competition. But, speaking from the coalface, I have big problems with what Cooper thinks he is measuring (specifically the use of AMI data) – and, more to the point, what is going to be extrapolated from it by all and sundry (e.g. see this NuLav blog here http://labour-uncut.co.uk/2011/06/27/nhs-reforms-a-pyrrhic-victory/ – which treats the article as a ringing endorsement of Blair/Milburn policies, and then fails to address various frontline concerns). My key fear is that core services in acute care are going to be needlessly fragmented, for the sake of a political mantra. If you don’t believe me, walk into the nearest A+E/ITU and ask about multi-specialty surgical cover. The present debate is pretty skewed, imo, e.g. baldly stating that “the French system is better because of competition” – without mentioning the increased levels of investment, tightly regulated insurance requirements and (not least) the frogs’ chronic hypochondria!

    Anyway, till the next round…

  36. “and, more to the point, what is going to be extrapolated from it by all and sundry”

    Sure, there is no end to how evidence can be bastdardised by the political classes, but to shy away from/ignore/dispute the evidence makes us as bad as them.

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