I read with interest the opinion piece from Dr Paul Charlson on the value of competition.
Competition will keep NHS on its toes
My main concern about the promotion of competition in the NHS is that the forces of capitalism will not actually be applied in the way that proponents of commissioning claim they will in order to drive up standards. This is because for many services, choice will be at the commissioning level and not at the level of the consumer (or patients, as we once quaintly knew them). Thus to the end user, there is unlikely to be a genuine, wide-ranging degree of choice in provider. There will not be 10 different companies offering physiotherapy services to choose from near me.
So the idea that market forces can prevail and that poor providers will fail simply by being poor and good providers can grow by being the first choice of patients is nonsense. For that to happen we would need a completely open market, in which companies do the work and then bill the NHS – much more an insurance model of healthcare.
Instead, we will have a system where we, the GPs, will commission a service, and patients will have to use it. What if the service fails? The patients cannot simply go somewhere else, since the contract is with the provider we choose.
A provider might be held up to account by targets, but the fact is that healthcare is complex and ‘results' are often vague or opaque, difficult to define, and can sometimes take years to reveal themselves.
To break a contract will require proof of failure. How many patients will suffer in gathering that evidence?
This dilemma is not dissimilar to the current franchising system on our railways. Choice of provider is not with the end user generally, and without long contracts investment is lacking.
It seems to me introducing pseudo-competition to force the hand of the NHS is a high-risk strategy. The potential risk to patients from private firms looking to generate profits is huge, as margins will be tight and any commercial advantage that can be gained will be explored. When a company is failing, I do not believe we have the structures or skills in place to identify and prove failure at a level robust enough to stand up to the scrutiny of a courtroom, in timescales short enough to protect patients from poor practice. I fear for the future care of my patients.
From Dr Dan Faller,
Thame, Oxfordshire
