One of the great flaws of the current and those of the last 20 or so years of healthcare policy in the UK is the concept of a “market”.
To simple grunts in the field the idea of a market boils down to consumers who can spend as much or as little as you want and get as much or as little of a product as you can afford depending on your means and what is available something called “Choice ®™”.
When the consumer pays nothing to get a service where is the market then?
In Northernshire if you want food there are a variety of outlets, or “providers” in NHS manager bull something speak, of food which will happily take your money, small amounts or large, and provide you with a product which may, or may not be, good quality depending on your personal “Choice ®™”.
In healthcare the local provision of services is less than that for food products and we will confine our arguments to conventional medicine rather than alternative (quack) medical provision. Locally most people have only one “Choice®™” that of the local NHS but there is an alternative called private medicine.
This is (freely?) available to those who wish to spend their own money, the minority, but some of our patients do exercise their own genuine financial free(ish) market choice, but most do this via medical insurance taken out either by an individual or provided by their employers as a perk. As such the concept of a market is limited in healthcare due to its specialized nature and limited number of suppliers (sorry any willing providers).
A bit like the aviation industry where if you wanted to buy a large passenger jet capable of flying from London to New York you would find only a few people able to provide you with this service but a ham sandwich would be much easier to find locally and cheaper too.
The NHS internal market is a true invention of the former Soviet Union for it fixed prices via the central controlled Party NHS Tariff. So if you had your appendix removed in Newcastle or Exeter the cost was the same and hopefully the outcome was the same to the patient who paid the same price for their treatment which was absolutely nothing.
So the NHS consumer is not inconvenienced by price which has an inevitable effect on demand as per any simple supply and demand curve. This simple concept is alien to any NHS manager for any excess use of the NHS is the result purely of GP failings and not as a result of NHS freedom, both politically and financially, of NHS “Choices ®™”.
The price is fixed, as is the market by the Party, and as no-one pays up front where is the NHS “market” internal or otherwise?
If Joe the Plumber wants a steak he chooses his supermarket, or butcher, or restaurant or pub and he goes in and pays for it. If Joe wants more steak he pays more for it. If Joe wants his appendix removing he goes into any hospital he chooses in the NHS and pays bugger all. If Joe is a hypochondriac he pays bugger all too and can abuse it without fear of sanction due to the freedom that is NHS “Choice ®™”.
If the price is fixed by the Party in order for a free market to make a profit on a procedure something has to give. A straight forward appendicectomy should involve certain fixed costs which may vary slightly due to local variation in costs. If the aim of a market is to make profits then if prices are fixed something has to give in order to generate profits. If all prices are fixed via the Party, Soviet style, what can give in order to maintain free market profit?
Quality of course.
So a couple of articles show that the old Party and the New ComDems are so dissimilar they are almost the same and equally deluded regarding any real market in UK plc healthcare aka the NHS.
Commissioning is not about market forces for prices are fixed it is about creating an unnecessary management structure to ensure that “quality” is provided from a fixed price structure and this is ultimately a case of the law of diminishing returns.
Someone has said that you do not need commissioning in healthcare if the cost of a procedure is fixed. You do not need 220 page contracts for NHS provision of any service for which wherever you go in England you will pay as the consumer the same. Nothing.
Anyone else twigged what commissioning is actually about?
This concept has failed in times of plenty and now is being reinvented in the times of lean.
And guess whose fault it will be when it goes belly up? Not those who invented this smouldering pile of intellectual dung but those that they have chosen to implement their 20 years of failure via the free “Choice ®™” so beloved of their Soviet styled predecessors. And those who will suffer will be those unfortunate enough to use it - our patients.
ZaNu Labour, ConDems and the market. Anyone spot the difference?
Or is it a case of ZaNu Labour reinvents the failed market of the Conservatives and ConDems it to the failure of the NHS and it is all the GPs fault for they were given the NHS "Choice®™" (coming soon to a surgery near you) called Hobson’s choice to do GP led commissioning?
Praise be to the Party for recycling failed ideas. At least we know who the fall guys are this time and we will be doing it all in addition to our day jobs as well. Quality service provision by GP led commissioning market forces with Soviet style price fixing?
Don’t cancel the BUPA subscription yet you may well need it.
6 comments:
Very well said Northern Doc. It's challenging to explain commissioning and how atrocious it is, you've nailed it well. It took me several posts ...http://abetternhs.wordpress.com/2011/02/10/gp-commissionig-private-profits-and-patient-choic/
and of course not evryone can get BUPA cover because they have a pre-existing condition. and there are the silent majority who cannot afford it. where are the checks and balances in the new system?
All I am interested in is whether the changes will make the NHS more efficient and provide a better service, but trying to be objective, I find it hard to think of any changes of recent years where I can detect any improvement.
What does appear obvious to me as an outsider is that every change seems to produce even more administrators and paperwork.
Two local hospitals were "merged" recently (they're about 20 miles apart), wards closed and medical staff cut. But was there any decrease in administration - not according to my mole who works in the finance department. Prior to the merger each had a Chief Finance Officer, both have remained in post and retained all their existing staff, but they now have an Executive Finance Officer (with some staff) as well!
We need something like schools, a patient to staff ratio, and in particular a patient to non-medical staff ratio. Something like that could be understood by the general public!
Thank you all for your interest and for posting your comments all of which are valid. Not everyone can afford or get private medical insurance and as the effects of a recession bite deeper healthcare will be rationed more. You are quite right regarding management numbers increasing but this is usually because making them redundant costs more than employing them. Even the 45% reduction only takes us back to more than there were in post 10 years ago and fragmentation of the NHS into smaller units called consortia will mean more duplication of service but this will appear to be a saving to central government.
Someone locally worked out that a million pounds a year was being spent on 10 managers to keep them doing the same jobs they did in three primary care groups with different names in a new PCT. Plus ca change?
Good analysis.
A prerequisite for gaining the benefits of competition in a market is that there is a surplus of supply over demand. In the NHS, there has never been a surplus of supply, so the "market" is just a fiction, as well as another excuse to employ armies of bureaucratic bean counters, rather than get rid of them.
I should know, I was one myself, back in the early 1990s when they introduced GP Fund-holding, a similar silly idea dreamed up by Ken Clarke when he was playing with his plastic ducks at bathtime one night.
What an image Godfrey! Ihaven't really got my head around all these changes yet, mind you I don't suppose the government have yet, then there will be a new government and everything will change again. Just money down the drain.
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