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Competition and care – not a multiple choice question


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Friday, 18 March 2011

Competition and care – not a multiple choice question

No one would argue with the idea that choice is a good thing. The notion of the GP and patient sitting together and designing a tailored programme of care is central to the government’s vision of the new NHS.

The problem is that choice and better care won’t always be compatible and will sometimes be in conflict.

Patient pathways designed to provide choice at every step along the way will be difficult to manage and expensive to run. Commissioners aiming to offer the best possible journey to patients need to be able to rule choice out as well as in, or at least to limit the choices they will make with the patient.

Choice is only desirable if all the available choices are good. The “any willing provider” system will mean that the commissioner is unlikely to be able to exercise much influence over who provides services at every stage. Of course providers will all need to satisfy the regulator (the Care Quality Commission) that they are up to the mark, but some will be better than others.

The other problem is an economic one. Volume of business is one of the levers commissioners have on price. Choice undermines buying power. It also increases the direct cost of care. At each point the patient deviates from the commissioner’s optimum pathway - for example, by changing provider - the price goes up: the tariff for a first outpatient appointment is about twice that for a follow-up.

Professional relationships are less obvious but equally strong levers on the quality of care. GPs and consultants who work well together are more likely to produce good outcomes for patients.

If GP commissioning is to improve information flows, reduce hand-offs, eliminate waste, increase collaboration between clinicians and get the best results for the patient and the taxpayer, it will inevitably mean more integrated care. The political problem is that you can’t do integration properly if you also insist on unbridled competition. 

The pragmatic solution to this dilemma will come down to the advice the patient receives along the pathway. Many patients will continue to rely on their doctor’s opinion about the best course of treatment.

Choice creates a further danger which is that the best interests of the patient will sometimes involve a conflict of interest for the GP. But let’s be careful before reaching for the regulatory manacles – as a prominent clinician once put it, if there is no conflict of interest, the system isn’t working. Rules designed to ensure that GPs don’t commission services from themselves have obvious perverse consequences.

People will always vote for choice, just as they automatically tick the boxes next to freedom and democracy. Perhaps if they understood the consequences of choice, they would choose something else.



robindaly says:
Apr 18, 2011 05:55 PM
This article suggests that choice could be a bad thing for patients, as it could waste resources. Interesting, but without having tried it, totally theoretical. As a country that currently offers practically zero choice in cancer care (for example), we are spending 3 times as much as Poland for the same results. Now that's what I call wasting resources! Could be high time to start giving patients the respect they deserve, the ability to play a central role in determining their own healthcare, and to do away with the outdated paternalistic NHS system that is is no longer fit for purpose.
dworskett says:
Apr 18, 2011 05:55 PM
While there is a very strong "patient-centred" case for increasing choice in UK healthcare, as an earlier commnmet suggests, there is also a strong case for doing so from the point of view of commissioners. In most areas of economic activity, "buyers" have high levels of concern when they only have very restricive options in terms of where they can look for better quality and value. For GP commissioners faced with financial challenges far grater than anything the preceding PCTs have had to cope with, "choice" of providers may well turn out to be an indispensable lever in the battle to maintain services and quality in an ever more stringent financial environment.
CherryBomb says:
Apr 18, 2011 05:55 PM
Before you start making A/E more comfortable for people. Look at why there is so much disruption and abuse of staff .Most of it is drink or drugs related or flustration on not being a priority in a major A/E. I would recommend
attaching minor injuries units to all major A/E departments so minor injuries are seen quickly and discharged not kept waiting for hours. Keep people without means and capacity out of A/E whenever possible and create a secure area for staff. Once that been achieved then look at colour and seating etc. If they dont they will get recked every weekend in our major A/E Dept in cities.