Do Markets Kill Patients?

With another care scandal across our media we now have some suggesting that the root cause was the introduction of the market[1] into the NHS.  There does not appear to be any actual evidence to support the assertion; it fits into a general category of argument from anecdote.  The market is bad; some care was bad therefore the market must be to blame for the bad care.  Or the culture was to blame and the market made the culture.

The evidence on whether or not market competition in health care (in our system) improves quality is contested.  Some claim there is evidence that where competition applied then outcomes improved, so is there any evidence of the opposite?  To be fair advocates of the market-kills-people argument also claim that the evidence is there but ignored.

There are no comparative studies of quality generally or unnecessary deaths in particular looking at the pre-market NHS compared to the current version.  Neutral observers might suggest there were as many, if not more, examples of poor care in the good old (pre market, pre management) days, but evidence is not available.

It is probably accepted that a management put under pressure to achieve targets, especially financial targets, may pay less attention to quality.  How that pressure on senior managers translates into poor clinical practice and so to unnecessary deaths is hard to prove and appears to denigrate the professionals who deliver care.  But there will presumably be pressure to perform in any system with or without a market – organisations have to balance the books in some way.

Proper case notes based studies, as opposed to league tables of death rates, have repeatedly shown the main causes of unnecessary deaths[2]; late or incorrect diagnosis, prescribing errors, poor observation as three.  The level of resources is clearly important to some degree in each factor but so too are many other factors.

We do appear to have some evidence that those organisations that have higher death rates have a lower (comparative) level of resources – less doctors, less nurses, less cleaners.  The market obviously distributes resources in an uneven way but then so does any bureaucratic process of allocation.

Finally there is the net effect argument.  Management pressure (market or otherwise) such as imposed wait targets may distort care and have some consequences that are bad (even lives lost.  But it is also argued and some evidence supports the claim that lower waiting times, which were a result of imposing targets, saved lives.  Some bad affects but overall a gain.

In the end the quality of the local management must the key to care quality in our devolved and semi-autonomous system.  Does a market system make management worse or better?

Where is the evidence?

[1] The SHA is clear that our NHS should not be a market and we have set out our clear alternative to a market/competition model.

[2] A death where a significant contributory factor was that something was done that should not have been done or something that should have been done was not done.