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Editorial Tuesday 17 February 2015: Market mechanisms in today's NHS: the highest-maintenance imaginary girl/boyfriend ever

Publish Date/Time: 
02/18/2015 - 00:22

There are five basic questions worth asking yourself when setting out to tackle a problem.

They are as follows:
1. Do I understand this problem and its root causes?
2. Is it a big problem?
3. Is it an important problem?
4. Is it a wicked problem?
5. Is it a real problem?

Step one is self-explanatory, although a lot of people (in health policy and politics and beyond) do tend to skip it.

Once you're past that, you can next categorise your problem. Thus health tourism is a real problem, but neither big, important nor wicked. Using care data better is big, important and real but not wicked. Hitting waiting time targets for low-urgency clinical procedures is big, real and wicked, but not important. The Cancer Drugs Fund is important, wicked and real, but not big. You can carry this game on yourselves, if you are so inclined.

In a week where the latest waiting data shows increases in long waiting times and DH bungs to distressed providers already exceed their not-unimpressive 2013-14 total, while the dispute over the 2015-16 tariff has forced The Messiah into a Do It Thyself endeavour, we are perhaps veering ever closer to the point where we can drop the pretence that the NHS is anywhere other than deep in the funky-smelling brown organic stuff.

(And no, I don't mean cannabis resin.)

Denial is, as I have previously observed, more than just a river running through Cairo. As that blog observed, we are in some trouble, due to the legacy mechanisms of a system which in the past had money, translated into a present that has not.

The situation has deteriorated since (although if you make it practically impossible to declare a major incident, you can probably pretend that it hasn't, providing you're not a member of the reality-based community. Everybody should have a hobby.)

Market mechanisms and competition: more than just MBAsturbation?
In an NHS where the money has conspicuously run out, it seems a reasonable time to review the value of the competitive market mechanisms introduced under New Labour via Simon Stevens' high-contestability-high-measurability taxonomy, and enthusiastically continued by Our Saviour And Liberator Andrew Lansley.

Some published, peer-reviewed evidence does suggest that market mechanisms, in the guise of geographically-feasible patient choice of provider, have positive effects on clinical outcomes.

Indeed, a more recent study found that increased competition in the guise of more hospitals per geographic locality has benefits in management quality and lower hospital mortality rates from heart attack and orthopaedic admissions.

Marginal gains of these kinds are not to be sniffed at, even in this season of respiratory disease. There are opposing sides in this debate, and their pot-shots at one another contain grains of truth alongside the hearty dollops of ideology.

However, it may also be time to review the market mechanisms and infrastructures to review whether they are delivering on their non-negligible opportunity costs.

Trying to get a handle on the costs of managing the NHS and its attempts at running an internal market/purchaser-provider split are far from easy. There is this by the Audit Commission from 1995; this by the Kings Fund in 2011, and this by the Chartered Management Institute in 2013.

What is the current NHS question to which market mechanisms are the answer?
It's possible to argue that competitive market mechanisms have valid uses in certain situations in healthcare. One is a situation in which we want more of something: fee-for-service structures are good at delivering this.

It does, of course, require lots of money to pay the fees to get the extra services. Yes, lots of money of just the kind that we don't presently or foreseeably have any more.

Another is to empower patients through choice. The English NHS evidence here is slightly shaky, finding that "Data from choices made in hypothetical and real situations showed that patients valued aspects of quality when choosing a hospital. However in practice, most patients chose to be treated by their local provider and few consulted published performance information on quality to help them choose, instead relying on past experience and their GP's advice. While the threat of patients choosing a different hospital led some providers to focus more on reputation, there was little evidence of direct competition for patients' custom and choice has not so far acted as a lever to improve quality".

Another would be as a driver of increased use of data on outcomes and variation. While there are some hopeful signs in the NHS Atlas of Variation and PROMS data, it is equally clear from Rob Findlay's sterling work unpacking DH waiting time data that trusts can take themselves off data reporting with what might be deemed unseemly ease. Performance and variation data are also published in those NHS systems which have not embraced market mechanisms.

A galaxy of regulatory Death Stars
The English NHS is increasingly experienced by its constituent parts as being orbited by a galaxy of regulatory Death Stars, whose remedies and mechanisms hark back to a time when there was money. It's all terribly 2000s.

Quality regulation was probably a good answer to a more closed, deferential NHS era. It seems a poor answer to the toxic combination of insularity, psychosis and Stamford Experiment prone-ness that we saw in the appalling situations in Mid-Staffs, Morecambe Bay and quite a few others.

The TDA? Its futility has been noted for some time, and is now being publicly acknowledged.

And why would you invent Monitor in an NHS which has run out of money and won't be running into it any time soon?

Observing the frantic policy scamperings of current times has the curious feel of watching engineers trying to retro-fit afterburners onto a Penny Farthing: admirable ambition, yet lacking realism.

The other way to view market mechanisms in the cash-constrained NHS of today is as an ultra-high-maintenance imaginary girlfriend or boyfriend: the theory may be willing, but the practice is weak.