Choice Markets Competition in the NHS

2006   Five seminars:

  • Ipswich Wednesday 25th January,
  • Bristol Saturday 28th January,
  • Liverpool Friday 3rd February,
  • York Friday 17th February,
  • London Tuesday 28th February

Main speakers:

Julian Le Grand Richard Titmuss Professor of Social Policy London School of Economics:

Prof Dave Gordon Centre for the Study of Poverty and Social Justice Bristol:

Pat Taylor – Non-Executive Director Bristol South and West PCT
Dr Tony Jewell, President of the UK Association of Directors of Public Health. Notes of his talk.

Dr Sally Ruane Deputy Director – Health Policy Research Unit De Montfort University Leicester. Sally’s presentation

Melanie Johnson, former Minister for Public Health

Emily Sparks, Experian Mosaic UK

Rt. Hon. Jane Kennedy MP former Minister of State for Quality and Patient Safety

Dr Katy Gardner Princes Park Health Centre. Katy’s presentation

Dr Ruth McDonald Manchester School of Medicine. Ruth’s presentation

Fay Selvan, Chief Executive, the Big Life Company. Fay’s presentation.

Hugh Bayley MP

Prof Steve Harrison, Department of Applied Social Science, University of Manchester. Steve’s presentation.

Tina Funnell, General Secretary of the SHA

Dr Paul Walker, Chair of the Socialist Health Association

SHA key planks for evaluating marketisation policy are fivefold:

  • Impact on inequalities
  • Integrated care
  • Impact on user charges
  • Impact on level of “publicly provided” services
  • Impact on total funding available to the NHS

With impact on inequalities being the most important.

Frances Blunden Principal Policy Adviser Which?

Jessica Allen IPPR – joint author of Equitable Choices for Health.

Prof Chris Drinkwater President and Public Health Lead for the NHS Alliance: Threats and Opportunities – a primary care perspective

Jon Trickett MP Secretary of the Parliamentary Labour Party Health Committee

Prof Wendy SavageIs a patient-led NHS possible?

Account of proceedings at the London meeting:

Health inequalities have increased under this government, that is the difference in life expectancy between the higher and lower social classes has widened, although there have been overall improvements. The inverse care law seemed to apply to the provision of primary and secondary care, the poorest health care could usually be found in the most socially disadvantaged areas.

Choice requires additional capacity in the NHS – which is an unrealistic assumption, unless it means that the private/independent sector is included, which it is. Most rural health economies have no spare capacity.

Transport is a key constraint in regard to choice. Access is restricted for poorer and for disabled people.

The “marketisation” of the NHS, that is the introduction of the independent sector, will reduce NHS capacity through draining NHS staff, high PFI costs and through cherry-picking easy cases.

Concern was expressed about GP led Practice Based Commissioning, since GPs had poor community links and almost no relationships with the voluntary sector. The market oriented government initiated changes were based on the premise that competition/contestability would lead to better services. Patients opting with their feet would drive up quality in the poorer services. This could probably lead to longer waiting times in the higher performing services. There was also the view that the poor providers would not be allowed to go out of business because of the political fall out (e.g. Kidderminster hospital closure).

The government’s proposals are particularly weak in regard to patient voice and real local accountability. The basic question was whether quality would be driven up by exit or voice. Most patients and other surveys have clearly indicated that most people are looking to local services of good quality over which they have some say.

Frances Blunden from Which spoke about choice in the NHS. Her view was that choice was fundamental to health care, shown in consent and in the fact that health care is a very personal matter and that people want some control over their own health care/treatment options. The government’s choice policy was currently limited to elective care, planned non-emergency operations.

There were huge health information asymmetries between providers and users and between different users. “Which” had undertaken a detailed survey of consumer issues in health (2005). The key issues for health consumers according to the survey are:

  • access,
  • waiting times,
  • quality,
  • relationships with health care personnel,
  • information,
  • length of consultation.

Opportunities to exercise choice are limited for some groups, due to communication difficulties and/or long term mental health needs.

Choice will lead to more choices being desired. Since many consumers lack confidence and information to make choices, it will lead to more inequalities in health and will exacerbate existing health inequalities. What is needed is better support for patients who need support, better information, a strategic policy framework and communities ensuring that wide choices are available locally. Measures to address inequalities are needed, such as Patient Care Advisors, help with travel and more time with the GP (as the London Choice pilot had set up.) Regrettably these measures had not been “rolled out” nationally with the introduction of Choose and Book.

Doubts were expressed whether there could ever be a patient led NHS unless the democratic deficit was addressed. There was no evidence that the public really wanted to get involved and lead the NHS. Nonetheless a NHS that was responsive to patients was important. Any planning presupposed public health input, but the role of the public health specialist was unclear in the latest reorganisations.

The Soc Health Association seemed to be of the view that the most recent spate of reforms was clearly designed to enable a stronger role of the private and independent sectors. There was no longer a level playing field, in that private providers were paid a more advantageous tariff for their work than NHS providers. There was the view that the White Paper was an open door for the private sector, especially for multinational companies to move into community care. The future was Tesco’s. The local partnerships advocated in the White Paper were not partnerships of equals. The voluntary sector was less able to compete even though in mental health and some other areas clearly it was providing a superior and more acceptable service to patients, but it should not be brought in on the cheap.

The second meeting I attended was billed as being on patient information, but much was about choice.

Jo Ellins from the Picker Institute spoke on Health Literacy. She defined it as a range of skills needed to access, understand and act upon health information. It comprises health knowledge, verbal and written communication skills and the ability to analyse and evaluate health information.

In the US there is research on health literacy, which suggests that only half of the adult population is able to exercise choice, which depends on health literacy. There is no such research applying to the UK but every reason to believe that the situation is the same. Deference affects the doctor-patient relationship, which is more common among older and disadvantaged people.

Informed choice is restricted to people with high health literacy.

Patient information should be developed with patient inputs.

There was a lot of support for the self-help model in accessing information. However, GPs are quite unfamiliar with the voluntary self-help sector where people could beneficially be referred to for help with choices about treatment options. A Sure Start model might be appropriate to coordinate community health advice.

However, it was unclear whether health literacy actually improved people’s health outcomes.

The current health reforms about choice may fix the waiting list problems. But patients require advocacy and accessible information, thus massive investment is needed. Information systems are needed to know why patients have moved to another provider. Patients need information on things other than car parking, food, visiting times, namely understandable clinical effectiveness information. It was unclear whether such information system was actually being planned or indeed feasible It was also unclear whether the effect of current patient choice policy was being monitored.

Based on a research project looking at self-referral for HIV patients, Ruth Thorlby from the King’s Fund, speculated that the move of patients away from certain providers might indeed lead to improvements in soft areas such as décor, reception arrangements and food. However, whether clinical quality would be affected would need to be monitored and evaluated over a period of time. This project was relevant in so far as the Choose and Book initiative assumed that patient withdrawal from their nearest provider under the choice options would lead to improvements.

Neil Lawson from Compass, a left wing think tank, questioned whether people knew what to choose. He also indicated that the evidence was inclusive that the market had better outcomes than a planned NHS. A mixed economy in health still had deficiencies in organising the collective voice of patients more efficiently and in finding ways to provide better incentives for health providers. The new Labour credo that economic efficiency and social justice went hand in hand certainly needed looking at in health. In a world where people wanted more personalised services it was difficult to see how these aspirations could be combined with efficiencies brought about by the market. Care coordination is valued more than choice per se. The private health care market has stagnated. There were problems in collecting information from private providers. Choices were especially needed in end of life care and those were about treatments and care packages.

Mark Duman, founder and chair of the Patient Information Forum, spoke about his organisation and their role. They were about improving patient information for users of health services and had over 300 members recruited from patient organisations, professionals providing information in the NHS and private sector information providers, such as pharmaceutical companies. They have a new website, regular email alerts, run conferences, workshops and training events. Their main purpose is to share experience and to influence information provision.

In discussion it was suggested that there should be a patient driven standard for information especially in relation to the Health Care Commission’s Annual Health Check.

Information should be accredited and reliable. At grassroots level often there is often not a joined up approach to information. Information is not readily accessible and its value therefore has to be questioned. Poor information is likely to increase health inequalities.

The White Paper recommends there to be an information prescription for people with long term conditions (5.24) In the absence of quality being assured and health literacy being improved this was of limited use.

Notes kindly taken by Gerda Loosemore-Reppen