We can agree with the premise of the new publication of Civitas (the Institute for study of civil society), 'Analysing the NHS Market', that since 2002 reform in the NHS has focused on a market in health care, characterised by such initiatives as 'world class commissioning', encouraging pluralism in provision, patient choice, and payment-by-results.
http://www.civitas.org.uk/nhs/download/Civitas_Markets_in_healthcare_Dec09.pdf
However the counterposing of markets v monopoly presents several areas which warrant discussion, and challenge.
Efficiency
There is no empirical evidence to support the near constant mantra from all political parties that markets produce increased efficiency. There are in fact several examples of where markets have reduced quality and increased cost - the privatising of hospital cleaning services resulted in a rise in hospital infections - costs were not reduced and quality deteriorated. Private Finance Initiative (PFI) there are numerous analysis of projects where costs have been high, and quality has reduced. Again these are examples of the market in health care.
We must also challenge the misnomer that there can be increased efficiencies without cutting frontline staff. Health care by its very nature is not something which can be provided in silos, and in an individualistic way - it is an artificial argument to suggest that somehow half the workforce can taken out of the NHS, and frontline care wont be affected. For example, admin staff are the second largest group in the NHS, they are not backroom, penpushers, they contribute directly to frontline care - medical secretaries, clinic clerks, receptionsists - are all the people on the frontline.
Voluntary co-operation
The introduction of markets into health care has meant that collaboration between professionals, hospitals has diminished. Foundation Trusts are separate 'businesses', and due to the tendering process being promoted by the set-up of the Competition and Collaboration Panel actually puts one hospital against another to compete for business. Health care has seen the introduction of terms such as comercially sensitive - this does allow for professional collaboration, and certainly does not facilitate voluntary co-operation. Some public sector services are now finding they will have to work together in some areas to beat off competition for providing health care from private organisations. This is a false voluntary co-operation. It is about market competition, not quality.
Equity
The argument that markets give more choice to all, and empower more than the middle classes is completely false. Some of the recent initiatives such as personal budgets in fact embeds a divide between those who have the resources to exercise their choice, and those that do not. In fact it can be argued that the divide has widened, and equity has reduced.
Whilst it is legitimate to raise some concerns about central targets, and performance indicators, this does not lead to the market being the least worse option, or to a conclusion that the market will bring increased efficiency, equity, collaboration, or patient choice. In fact the introduction of the market, as can be seen from other countries, can bring a destablishing influence to health care, result in higher costs, and reduced quality. There has been 'cherry picking' of some services, ie. those that can be provided at low cost, and with high volume - the private sector has not wanted to enter the more challenging services with are notoriously higher cost and low volume, ie. the more complex end of health care. It is a false argument patients are able to switch services in a market economy, again there is more evidence to suggest that patients want good quality, locally provided health care.
We are in the worse economic crisis since the 1930s, caused by the extremes of the market. This is not the time to advocate more of a role for the market in health care - a option advocated for the NHS by right of centre pundits such as the Economist 'driving forward Mr Blair’s promising reforms to inject more choice and competition will help':
http://www.economist.com/displaystory.cfm?story_id=15065549
There is no evidence that markets have brought about benefits, particularly in terms of cost and quality, and the argument from the authors of the Civitas report that markets need more time to prove themselves is misguided. UK health care has a relatively low share of GDP in the G20 but the NHS delivers some of the highest quality in the world, as begrudginly acknowledged by the Economist 'the overall picture is one of a health service providing more, better and prompter treatments for patients'. The debate about rationing, and the use of quangos such as NICE has a place, and is one which should be engaged in constructively.
Of course there must be a correlation between public expenditure and results, however the introduction of the market into health care will not bring about positive benefits but is in fact drawing time and energy away from the real focus which should be about continuing the deliver high quality health care where collaboration and collectively is encouraged, not consumerism and individualism which are the facets of the market.
