Choice, Markets, Competition in the NHS – What do they mean for health inequality?
Steve Harrison University of Manchester 2006
What are the reforms?
- Demand-side reforms: eg separation of commissioning/ provision via quasi-market, patient choice, direct payments (social care), easier access to GP lists
- Supply-side reforms: eg pluralisation of providers inc independent sector in both primary & secondary care, NHS Direct etc
- Transaction reforms: eg QoF, payment-by-results, national casemix-based tariffs
- Regulatory reforms: eg government targets, NICE, Healthcare Commission, stronger PCT role
What are quasi-markets?
- In common with other markets, there are independent competitive producers on the provider side but, unlike classical markets, some or all of the following characteristics may be present (LeGrand 1991; LeGrand and Bartlett 1994):
- producers cannot be assumed to be profit maximisers;
- consumer purchasing power is confined to a specific range of goods or services, so that the purchaser cannot decide to spend the resources thus ‘earmarked’ on anything else (in effect, the purchasing power is a ‘voucher’, whether or not so labelled);
- purchasing decisions are made by an agent rather than by the prospective consumer of the goods or services;
- payment for the goods or services is made by a ‘third party payer’ rather than by the prospective consumer.
Pursuing equity & equality
- Not clear how on theoretical grounds the demand-side & supply-side reforms (except possibly direct payments & easier access to GP lists) would be expected to enhance equity or equality
- Essentially, therefore, we would look to transaction & regulatory reforms to do this, eg QoF might be expected to equalise treatment of chronic conditions
- Most NICE appraisal decisions are legal requirements on NHS, so reduced ‘postcode rationing’
- Proposed new PCT role in attracting primary care services to under-doctored areas
Optimisms & pessimisms of an empirical researcher… (personal views)
Optimistic that
- PCTs can increase equality of primary care provision
- Access to GP lists & GP services can become easier
- Practice-based commissioning can improve some secondary care services (provided PCTs not too heavy-handed)
Pessimistic about
- Consequences of assuming that all health care processes can be defined as sets of protocols & all outputs as casemix
- Consequences of assuming that material incentives are sole/ prime drivers of organisational/ individual behaviour
- Possible destabilisation of secondary care provider cost structures by PBR & national tariff