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What would you choose to give up?


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Friday, 27 May 2011

What would you choose to give up?

A few weeks ago we wrote about the conflict between choice and patient care. The argument in a nutshell is that while choice is desirable for patients it creates problems for commissioners trying to provide integrated care at the right price.

Too much choice and competition creates spurs and branches along the care pathway, adding complexity for the patient and cost for the commissioner.

The integrated care model only really works when competition is limited or non-existent. The patient benefits from a smooth journey with few hand-offs and good information flows. The commissioner is able to get good terms from a small group of preferred suppliers.

The counter-argument is that if commissioners cannot buy the services they want, they won’t be able to do their job, the usual suspects will continue to flourish, innovative providers including third-sector organisations and private firms will be locked out and nothing will change.

But the competitive free-for-all takes us back to square one, a convoluted pathway where doctors struggle to prescribe the most appropriate care and the best interests of patients are soon lost.

It looks like a straight choice between anticompetitive care cartels or a free market where cost and quality go downhill together.

There is no cure for the NHS if this is the only scenario we can describe. In no particular order we need to get our heads round the following issues.
• We already have choice for patients in elective care (after a fashion). Choose and book may not be perfect, but it hasn’t broken any hospitals either.

• GP commissioning means providers will commission themselves. If this is in the best interest of the patient is it still a conflict of interest?

• Competition will make sense in some parts of the care pathway and not in others. Not always in the same parts and not in every case. It’s complex. Can we deal with it?

• The regulator must not be the proxy for the patient in matters of choice.

• Most people agree that the NHS needs a managed market not a free one, but who does the managing? Again, if it's the regulator we're in trouble.

• In true markets choice is determined by demand not by supply. Is a quasi market worse than no market?

• Can we configure regulators to intervene when things go wrong, not to constantly interfere to make sure they go right?

The “any qualified provider” policy, which is often seen as part of the problem, is really part of the solution -- but only if the message gets out that it is a tool to be used discriminately, not a blunt instrument.

Choice for patients is good even though they might not always make the right choices – “no decision about me without me” also entitles people to make the wrong ones against the advice of the GP or the will of the commissioner.

We have to start from the premise that integrated care, choice and value can co-exist in the same system. If we get that right, healthy competition will follow.

Choice matters more to politicians than to patients. It is most potent where it doesn’t exist -- where people don’t have access to decent services. If we’re not careful, choice is what they will get instead.

BULLieve says:
May 27, 2011 05:54 AM
I am sure the GP commissioners will decide and make healthy decisions if allowed to and given some slack by the government and all their monitoring quangos? Why don't they simply leave it to Twitter (and the press);-)

Chris Frith
Hereford GP
timothyrichardson says:
May 27, 2011 07:54 AM
why do we assume choice won't work? other health systems provide the public with real choice; what is so unique about Britain and the NHS that so many healthcare professionals oppose choice. is it self interest?

the founding principal of the NHS was care when needed withour charge, not the developement of a hospital dominated, inefficient, bureaucratic monopoly.

fully integrated care with a single responsible provider managing the total allocated healthcare resource is the ideal. this would be GPs [or other organisations entitled to register patients] taking a capitated contract rather than having a very limited provider contract [GMS/PMS] and a large commissioning budget [GPCC]. as patients have a choice of GP and as real financial overspend risk would pass to the GP [or registering organisation] so practices would choose their consortia partners much more carefully than is happening in the large completely geographic groups that have formed at a time of no real risk. this self selection of truely like minded and disciplined groups would avoid local monopolies [or be required to by the regulator].

this would develope into competing integrated care organisations where pts had a choice of personal doctor responsible for all their care through extedned services around the practice and sub contracted care to appropriate providers selected based on best outcomes. these like minded practices would link to world class health informatics [which would be an essential tool] to ensure best pathways and use of resources.

so there is an alternative to total choice at every step along a care pathway which is competeing ICOs providing integrated care.
allans says:
May 27, 2011 09:50 AM
I couldn't agree more that choice is more important to politicians than the patients. As a General Practice we know this to be true through survey and feedback from patients at consultation. I am comfortable to allow private providers into the market provided that it is on a level playing field on the following conditions :
1. no cherrypicking
2. no clinicians with dubious qualifications
3. no kick backs to referring GPs
4. a significant contribution to the training and education of new clinicians
SJBurnell says:
May 27, 2011 10:03 AM
A 'blue light' patient is not interested in Choice - they want a safe, local Hospital with required skills & facilities. An 'elective' patient might exercise choice if it is well informed by their GP, but only if it is safe, local, & highly regarded. The patient will not think about its surplus or deficit. A 'major' elective (severe burns / organ transplants etc) patient will understand why these facilities are few and far between - they will be happy if it is within 50-100 miles, so choice does not really apply.

Choice is fine if you have lots of alternatives, like Chemists on the high street. They can come & go & the health consequences of one failing & the business moving to the other are vitually nil. Can we really extrapolate this argument to Acute Hospitals? I think not.

Competition would lead to some very blunt & chunky & potentially life-threatening stepped changes in Acute service provision: it can take a long time & a lot of pain for competition to create an elegant solution via evolution. And the the government of the day will just change the rules again because of dogma or economics.

However, I can see every reason why independent or 3rd sector service providers should become sigificant partners. We need their intense cooperation & that is the paradigm we must design: mutual benefit in the interest of patients (as service users & tax payers).
mkildunne says:
May 27, 2011 01:15 PM
Any organiation who supplies NHS should be on a 12 month contract and be in a competative bid situation with other companies for future business.As in private sector?
The other items appear to bogged down by by too many people, commitees, red tape and budgets the health of people is uppermost and talking of the NHS making proffit like the private sector who can and do cherry pick is crackers
balancedapp says:
May 27, 2011 05:10 PM
choice is great when it is informed choise and not just like shooting for fish in a barrel. Clarifying what the options are and what they give is informed choice.
Chaing for chaning sakes is what caused fear and worry and stops decision making....
pjaffrey says:
Jun 06, 2011 03:43 PM
I'd start from the place of what background does the commissioner have whether it is current commissioners or future ones? If as I have found they do not understand the health needs of their population (if I sit at one more meeting and hear "I'm no expert on this" from a commissioner I think I will scream) then what has given them the job in the first place? The other issue is having continued "mapping" exercises and "strategic needs analyses". Usually the maps show the same thing as last time. The SNA does similar. The gaps tend to remain the same and lots of money appears to be spent (by new people in new posts or by the well worn "consultants" on exorbitant fees) finding out the people on the ground already know. I've waited 5 years for investment into my team (still waiting). In addition I seem to hear about the same gaps now as 5/8/add your number here years ago.

Perhaps there ought to be a minimum amount of times that mapping can be done before the exercise is in and of itself redundant and decisions just need to be made.