Choice, competition and markets within the NHS

By Martin Scott

The plans put forward by the Health Secretary, Andrew Lansley, mark a major shake up of the NHS. This shake up has been interpreted by many as pro-market and, as a result, has come under much criticism.

On the surface, the plans seem rather democratic. Foundation Trusts are the embodiment of the Government’s commitment to devolution and decentralisation in the public services, and are at the heart of a patient led NHS. By 2014, every hospital will be a foundation trust. Foundation Trusts seem to embody all the values that a democracy holds dear: accountability, community driven, sense of ownership, and, most importantly, ‘they have a primary purpose of providing NHS care to NHS patients according to NHS quality standards and principles – free care based on need, not ability to pay’. Surely a National Health Service consisting of Foundation Trusts can only mark a step forward for creating a more efficient and more democratic system.

This is not necessarily the case, – the reforms proposed by Lansley are not based on bringing the NHS to the people, they are motivated by a desire to inject the virtues of the market into the NHS in the hope that this will raise efficiency and keep costs down. Foundation Trusts will be run like small businesses, run and owned by the staff and competing against their local ‘rivals’. Devolution is therefore a rather optimistic way of looking at it; rather, the government is keen to take the burden of failing practices off their hands and blame their inevitable dissolution on the forces of the market.

Lansley believes that the NHS is suffering because it has not been kept on its toes by the invisible hand of the market. It has been complacent and there is a need for the government to use the market to whip it back into shape. He is therefore planning to implement market forces into hospitals. As mentioned above, all hospitals will be Foundation Trusts by 2014. As a result, they will be given the option to become mutuals, a system based on the principle that the staff own the service. This has damaging implications for equity among staff; new employees could be shut out of the NHS pension scheme and the plan would also introduce variable pay schemes across the NHS. In addition to this, Lansley has suggested that there will be no bailouts for failing hospitals. Failing hospitals that overspend will be allowed to go bust. Implementing such a strict sentiment of market driven principles into an institution that is state owned and was founded on the principle of providing a national standard of care for all seems slightly unfair.

How does this impact on the patient? This new pro-market agenda has been focused on a ‘patient-led NHS’. The coalition’s plans are driven towards empowering the patient (or consumer) with the ability to choose the practice they prefer based on information that they are provided or on the advice of their GP. The constitution states that “You have the right to make choices about your NHS care and to information to support these choices. The options available to you will develop over time and depend on your individual needs”. Based on this, the plans seem rather empowering. They appear to be driven towards the patient’s needs and preferences and are very much in line with the pledge to make the NHS patient-led. However, yet again, there is a catch. It has been argued that ‘choice’ is a reflector of class. Writing for the Guardian, Yvonne Roberts has suggested that choice is relative and will be exercised most effectively by “those with the greatest confidence, eloquence, and sense of entitlement”. It is believed that ‘choice’ is primarily beneficial to the white middle class. Other patients, such as the old and those whose first language is not English are thought to depend much more on the advice of their GP.

It is important that people see Andrew Lansley’s plans for what they are, an injection of market forces into public services in the hope that this will drive costs down, rather than for what it appears to be on the surface, a democratisation of the NHS to promote efficiency and greater patient control. The plans put forward by Lansley are detrimental for the provision of a national standard of care. Competition among practices will arouse a pressure to dominate rather than collaborate which could bring new tensions to inter-organisational relationships, a distraction that is damaging and unnecessary. The patient will slowly become the consumer and will ‘shop around’ for the most appropriate choice. This could lead to providers becoming commercially unviable and, as a result, the services are limited or stopped, while another provider becomes commercially viable with its services being stepped up. For me, there is only one way this is heading and the marketisation can only feed and strengthen a two-tier system which represents anything but a national standard of care which promotes equitable treatment among its patients, regardless of location, income or nationality.