How can we best ensure that competition and patient choice drives NHS improvement?
We are interested in your views on this area, including:
- Which are the types of services where choice of provider is most likely to improve quality?
- What is the best way to ensure a level playing field between the different kinds of provider who could be involved?
- What else can be done to make patient choice a reality?
This page was closed to comments on 31 May, the last day of the listening exercise. All comments have been fed back to the NHS Future Forum to consider.
The Forum will submit its report to the Prime Minister, Deputy Prime Minister and the Health Secretary in June. The government will consider the Forum’s findings and then publish its official response
i think competition can prevent services from being complacent but there is a point at which this must impact upon the quality of service that is provided.
from what i understand where options are provided many patients will choose the service closest to them or the one they know about rather than an unknown service offered by an alternate provider.
I do not know how patients can have sufficient and detailed information to make informed choices, even if geographically this is, in reality, a “pipe dream”.
Another point, many hospital admissions happen at very short notice – on these occasions any thought of “choice” becomes a nonsense.
Competition needs to be a balance between holding providers to account and ensuring patients have a service they can feel is theirs. I have worked for an independent social enterprise service provider with a good reputation. I know it can work. But people want a quality local service that provides for them. Others on this site have also said this.
This is a debate only for those people who have the time, interest and mind set to engage by means of the internet.
Is it not a fact that those who currently have ‘choice’ by means of private health insurance just use the same people the NHS pay but at a much higher rate.
Should the population as a whole not be given a say on this very emotive yet important issue by means of a referendum.
We are being asked how we wish to elect our MP’s so why not ask us how we wish our NHS services to be delivered.
I totally agree with a previous person who said it is our NHS MR. Cameron and not yours to sell.
Nationalised dinosaurs like the NHS have never outperformed private practice in a competitive environment. The NHS falls short in most areas giving the people of Britain second rate healthcare. For all the pockets of excellence, the devoted and hard working individuals are let-down by a monolithic nationalised industry that is unwieldy and grossly inefficient. The NHS is the second largest employer in the world after the Chinese army! The managerialism that has been eating away at it for decades reflects the Peter Principle – excellent nurses and doctors are promoted to managerial positions they are ill equipped to serve: we lose an excellent practitioner, and gain a poor manager. The alternative models in France, Germany, and Switzerland have been ignored: the UK must start to look at what more successful healthcare systems do, break up the NHS, and adopt a successful model.
choice discriminates against those unable to choose for reasons of geography or socioeconomic circumstance. Enabling access to services of an agreed standard of excellence and finally allowing those services that fail to meet that standard to close might be better.
competition is ok, it does get innovation of service delivery – but does the public really know exactly how much of their money is spent on tendering processes for competitive services and how long it takes?
I believe that all acute hospitals should be at the same high standard, and financed by direct taxation. I should have a choice because all NHS hospitals should be as good as each other at the essentials, and excellent regionally for specialist care.
I can not believe some of the comments and opinions given in response to this post. The NHS is an excellent model which could work very well indeed with the right leadership. It has been the envy of the world for years. Yes, it has it’s shortfalls, but nothing that can’t be resolved. Breaking up the NHS is not the answer.
Let me tell you that I have been in the fortunate position of receiving care both privately and on the NHS and I would rate the NHS as being far superior.
A great number of people work for the NHS who are dedicated to providing a high standard of care for their patients but they are let down by services that are poorly managed, where resources are unnecesarily wasted because of the way the system is structured (Yes, I can give specific examples).
Competition is one thing, but in my opinion, allowing private companies to provide services means that money is being sapped from the NHS to pay shareholders, something which is fundamentally unacceptable.
Unfortunately, choice and competition are mutually exclusive in the long run. If your local hospital isn’t “chosen” by lots of patients, it will lose income and close down (in the unlikely event of politicians allowing these reforms to reach their logical conclusion). It follows that you will no longer be able to “choose” that hospital, any more than you can choose to watch Premiership football live on the BBC. I’m afraid capitalism tends to monopoly, except this time it’ll be a less regulated private monopoly solely interested in profit rather than patients and public service.
I agree there needs to be more providers in the system. Patient numbers are increasing quickly, transport and parking (including costs)are getting forever harder for patients. New providers are a great oppurtunity to move services closer to the patient, not further away.
I don’t believe it’s helpful that they are private companies legally obliged to make a profit out of the tax payers health system. Why can’t there be simply more ‘newer NHS providers’. Within my domain which is hearing, a provider that values hearing/ long term detriorating sensory conditions/services for older people, and recognises the service as a key part of its portfolio would make a lot more sense thatn trying to compete in a large Trust arena geared up to providing A&E, Heart Disease and Cancer Care.
With more NHS providers comes competition between the NHS providers since some patients will always choose to travel if they’re not getting the service they want. That is as long as they can genuinely choose, CHOOSE AND BOOK despite its name has never really genuinely allowed this to happen.
Competition is an entirely inapplicable model for quite a lot of what the NHS does, as there is only one group of people who have the skills to provide a particular service in a particular area. An example is my area of work: dentistry for people with special needs. The important thing is that professionals are allowed to get on with treating the people they serve, without overcomplicating the system by introducing unnecessary illusions of ‘choice’. The way to make these services more efficient is by good-quality epidemiological studies and joint working with service user groups to ensure services are targeted appropriately and reduce access problems.
I agree and would like to add that each hospital should be held accountable for the successes and failures of their operations and treatments.
For example my local hospital has a bad reputation for failed treatments and patient complaints regarding sustaining physical harm when having routine procedures, and routine surgeries going so wrong that reasonably healthy people are not surviving routine surgery. Who is looking into safe practices, and reviewing what is going wrong.
@Dr Julian Sims seems to have an axe to grind about the operational efficiency of the NHS, which I don’t want to get into. He does however raise a good point about the Peter Principle in the clinical workforce. Good clinicians don’t necessarily make good managers. Unfortunately the NHS, like most of the world, falls into the trap of thinking that managers are more valuable, or “better” than the people who report to them.
We need to see a sea change in the way we assess the value of leadership. Granted, managers have responsibilities, but it is the workers who add value to the business. Why not have the most gifted employees on a higher wage than the managers to whom they report? If you really think about what each job entails, there is no reason at all.
So let clinicians do what they do best, and reward them accordingly. Don’t make them think they have to become a manager in order to be promoted.
Anyway, all this is digression: it really belongs on the Advice and Leadership page (I’ll go and add this to that one shortly), but I wanted to respond here to Dr Julian Sims, and thank him for raising the Peter Principle.
I feel there should be more emphasis placed on dental treatment in hospitals, particularly for those people who have extreme dental phobia. This is becoming more and more widespread, with people suffering agony for years rather than go to the dentist and receive proper treatment. Add to that the heinous costs involved and also the difficulty in finding an NHS dentist, and we have a severe hardship on our hands, particularly in the current financial climate. I do feel that dental services should be more affordable to encourage people to take charge of their dental health and thus avoid future problems. Making this service so difficult to access and expensive (unaffordable for me and most people I know) is surely not the most practical solution? I personally feel that some dentists (not all) surely take advantage of the situation by carrying out unnecessary work; I am sure malpracticing dental surgeons exist as surely as malpracticing doctors! I just feel that something needs to be done as lack of dental hygieine can lead to othre health problems, and the public need to be educated about this in an environment in which they feel safe. A cold, clinical dental surgery with a brusque and unsympathetic dentist (yes, I have had my share of these) is not the place and it is precisely this kind of attitude practiced by the dentist which leads many people to hold dental phobias in the first place. I just feel that our hospitals need to provide an element of education, preventative action and restorative care, whilst raising the profile for the Trust and at the same time not breaking the bank.
I don’t want choice. i want a good hospital within reasonable distance from my home. Nationally, hospitals sharing best practice rather than competing with each other.
Competition comes at a price. Economists call this transaction costs: the resources taken from the health care budget to undertake the tendering, negotiation, monitoring and re-tendering involved in competition. In the US, transaction costs absorb about 30% of expenditure on health. In England they have risen from 5% to 14% with the opening up of the market to independent providers in the past decade. Do we want to increase transaction costs still further at a time when we are required to make massive cuts? They can only come from two places: the NHS budget or patients’ pockets.
I have locumed in a NHS-hospital where there have been serious quality problems in the past. The hospital had faced the problems, revewaled the truth, and found the way to improve and be back to highest standards.
Not because of any concurrence, but because the motivation was ethic, commitment to the patients best and the will to reestablish a workplace where everybody can be proud to be a member of the team.
I have seen different health systems in the world and I think NHS is the best construction at a moderate cost and it should be kept as it is, it lives and is able to improve.
Privatization will increase costs, replace ethical standards by profitmaking gradually and focus healthcare on the needs of the worried healthy.
The moment that the NHS is privatized patient care will surely begin to suffer. Competition for profit between health providers will result in cost-cutting measures that won’t reflect the interests of the general public. I find it worrying that the government is even contemplating these measures.
In the past expertise has been shared, we have coperated with our colleagues in other areas. Now we will be in competition. I spent time on the phone to a colleague in another area; I am a speech and language therapist with a specialism and my colleague is in a location where there is no specialist support available so she contacted me. In the future I would have to charge for the service or a service level agreement would have to be drawn up with monies flowing accordingly. Meanwhile the client would be left waiting.
I am also concerned that only ‘informed’ patients would be able to access and fight for services. Many long term disabled and chronicly ill have little energy left while coping with their illness or disabilty, and may not have the capacity to fight ,they will be left without services they need.
I agree with Ruth about the treat of competition protects against complacency and drive standards up however unbridled and poorly regulated competition can and will lead to cherry picking of the easy to deliver and profitable aspects of health care leaving the complex cases for a destabilised NHS to mop up. I see nothing in the current White Paper thats leads me to believe that the coalition understand this and will protect against this. The paper is clearly about opening up the so called NHS Market. All the areas that require addressing can be done without the need for this white paper.
Competition should indeed raise the standards of services as we would expect GP consortia to refer patients to the best and most effective services so it would be in the provider’s interest to raise the standards. However, it cannot be ignored that the cost of the service is going to play a huge factor. For example, a patient needed follow up after a stroke, and the options are a first class service with highly specialist therapy staff that is very expensive but effective, or a less experienced but cheaper rehabilitation team that would produce less favourable outcomes – who would you choose if you were a) the patient or b) paying for the service?
Though we have been told in the NHS that we must work collaboratively across such boundaries and help with training etc, why would we do this when it would risk us losing our patients and therefore our income?
I believe that some competition is healthy but in terms of making choices it has to be balanced against the fact that most patients do not want to travel too far for their services.
A competition driven service will have the effect of fragmenting the NHS and making larger more lucrative trusts driven to advertise and provide services whilst smaller hospitals are going to lose their services.
I agree with the points made about so-called ‘patient choice’ which in fact is only really going to be used by the better informed and articulate patients as it is currently.
In terms of GP commissioners, this will have a variable success as most doctors are clinically trained but have very little management experience. The changes must be done with proper consultation with secondary care as the NHS is still the best provider of these services rather than private companies.
I don’t really want choice or competition. I just want my local GP and hospital to offer a good service. I don’t want to have to make choices about where to go and who should provide the treatment, I just want somewhere close to home that ofers everything I need without having to travel too far. I want to be able to build a realtionship of trust with my health providers so that I can go to the same people for lots of different reasons and get to know them and trust them, rather than simply going somewhere different each time.
I understand that some level of competion can help improve stanards, but if the NHS is opened up to private companie there is a risk they will just cherry-pick the most profitable proceures. Thus leaving the NHS to pick-up the most costly annd least attractive end of the health care. I do not see how lining the pockets of private company share holders is going to improve the NHS or patient care?
I agree entirely with Roger Hart who said
I don’t want choice. i want a good hospital within reasonable distance from my home. Nationally, hospitals sharing best practice rather than competing with each other.
I don’t believe the basic proposition that competition promotes quality or choice. The notion comes from a market place where choice may be promoted because someone spots a gap where her/his idea for a new product can be sold. But healthcare is not a series of separate products: what we need is integration, not a scattergun of competing providers. If we think that the present NHS is offering poor quality (and overall it’s clear it offers good quality) then that’s a failure of management; it seems to me that the government’s claim amounts to something like this: ‘the NHS is too unwieldy for us to manage it effectively’. Dividing it up will shift responsibility from the government to GPs and other, often private, organisations, but I see no reason why that should improve either efficiency or quality. The NHS is clearly expensive, but I don’t believe it’s more expensive than the sum of public, private and insurance money in a GP-managed system, supposing that system maintained the present quality of service. What increases costs is our own ageing and the development of new treatments and tests; a more rational solution would be to increase general taxation, an obvious course which none of the mainstream parties seems willing to consider.
The question “How can we best ensure that competition and patient choice drives NHS improvement?” has a massive ideological bias! A better question is “How can we best maximise the quality of care in the NHS while maintaining affordability?” Choice and competition do not feature in my answer (and I guess, many people’s answers) since they are pretty much inimical to a good quality comprehensive service (http://www.unison.org.uk/acrobat/14564.pdf).
How about democratising the running of the NHS, empowering staff (and patient forums) to shape and develop services to respond changing circumstances. For instance.
Or what about increasing staff, decreasing hours and improving the wages for the lowest-paid NHS staff. Funded by a more progressive income tax.
Or simply de-politicising the running of the NHS – developing a cross-party commitment to a comprehensive nationalised health care system (the NHS) forever. Full stop. That might inject some confidence into the poor NHS workers.
To repeat: choice and competition cannot feature in improving the NHS. Making profits from the sick and broken is simply immoral. Government policy should reflect this. People demand it.
Let’s pay people well whose work is to heal and care. Let’s not allow public money to be siphoned off to people who already have money to spare and happen to invest their money in a hedge fund that happens to have bought a derivative that happens to contain a smidgeon of a share in a global multinational with a poor human rights record, a subsidiary of which has won contracts for cleaning services in a few NHS hospitals and recruits low paid and undervalued cleaners. Give the money straight to the cleaners, whose work should be an integral and valued part of the hospital’s work.
profit profit profit……
my nan needs a cataract op she has had one eye done they say now she can see tv one eye is good enough
how will this change with the competition /profit motive involved
save our nhs or is it already a done deal …the kaiser principle
see you in a and e david and george on no may not see you at harley strret
pp pip old bean
The danger is that powerful companies that are uncomfortably close to Government Ministers will cream off the easy, profitable operations. The motive should be overall efficientcy and increased care not concern to fill the pockets of the encircling wolves!
If we are forced down the privatization route the ordinary citizens will not be able to afford good health care.
When I lived in America from 1994 to 2003 I had dreadfully expensive health care until I could no loger get insurance.
On my return to the UK I found that the Labour Goverment was making sure that the NHS was modern, efficient and far superior to that of the American system. For your information my cousin who is a world expert in Myasthenia Gravis (MG) had to become a US citizen after working in America since the 1960′s because he could not get health care when he retired.
Do not force my doctor to spend time working out the cost of my treatment let the doctors spend finding better ways of keeping me healthy and curing me when I am ill.
Stop the Conservatives from destroying our NHS.
A worried patient
I am extremely worried about the proposed reforms to the NHS. I think Andrew Lansley is not acting in the best interests of the public and his plans will destroy the NHS. I don’t feel the need for choice, all that is required is a good standard of practice nationally throughout all hospitals. I had major surgery in 2009 and the level of care from the nurses was excellent. I also had to have a blood transfusion. I am very grateful for the kind people who freely donate their blood to save peoples lives and I hope that the blood service does not become privitised. If this is truly a listening exercise then you will hear enough voices telling you to leave the NHS alone and you will drop the Health and Social Care Bill and leave the doctors and nurses to save lives!
I don’t want choice. When I get ill, I want to be treated and get better. The NHS does this for me very well. Thank you.
I agree, ‘Choice’ and ‘competition’ are two of the concepts that have served to damage the NHS and delude the electorate. Everyone, including politicians, knows that the vast majority of people want equal access to a good service locally – just the same as education, social services and the rest of the welfare state. For the majority of people, in the most cases ‘choice’ is a myth. The main difference is between the rich and the relatively wealthy who choose private health and the rest who cannot afford to do this. Competition within the NHS may drive down costs for a temporary period but in the long term costs more and delivers a poorer service – ask any NHS manager or politician to be honest about this.
How can we best ensure that competition and patient choice drives NHS improvement?
Competition will not drive improvement. Competition means that the cheapest service provider will be chosen, and that will not necessarily be the best for the patient.
‘Patient choice’ is a fiction. How do I as a non-medically-trained person have a clue who is the ‘best’ service provider? I just want the nearest one. And what does ‘best’ mean? If I have a broken leg I want it to mend. How can one service provider make it better more quickly than another?
■Which are the types of services where choice of provider is most likely to improve quality?
See above.
■What is the best way to ensure a level playing field between the different kinds of provider who could be involved?
Meaningless question. This is not a game of football – people’s lives are at stake.
■What else can be done to make patient choice a reality?
Listen to the thousands of doctors and health professionals and members of the publice who say we don’t want a competitive health service. No-one should be allowed to make a profit from sick and vulnerable people. Multi-national companies should not be able to cherry-pick the least difficult procedures. Co-operation between the different agencies involved is much better for patients. Keep private companies out of the NHS.
I think the principles underlying a desire to increase competition make people anxious – understandably so given the outcome for the many industries in this country that are now in ruins following privatisation.
I disagree with Dr. Julian Smith, I have experienced health care under both the US & NHS systems, my feeling there is nothing second rate about care under the NHS system. I feel the NHS system provides better care, in most circumstances, than the US system and the NHS system does not discourage people from seeking care due to cost.
If someone where to ask me how would I change the NHS? I would say, cut senior management pay, make senior mangers more accountable for their decisions, keep private companies out of the NHS, regulate / license health care professions, and establish “targets” for patient care. For me, I believe the Health & Social Care Bill should be pulled, rewritten, and submitted to MPs for scrutiny before the bill is approved.
I think it is misconceived that competition and choice produce a better service. Like JEH I don’t want to have to make choices about where to go and who should provide the treatment. I just want somewhere close to home that ofers everything I need without having to travel too far. I want to be able to trust health providers to supply a consistently high level of service. Private suppliers will first and foremost be thinking about their own margins, not what might be the best outcome for patients.
I have seen how private providers cherry-pick easy profitable cases, and distort local healthcare.
Our service is suffering from such a scenario. Our straightforward one stop patients have been taken away and given to a local private provider. We have been left with only the complex cases who require a lot of tests and follow up appointments.
At the same time the local commissioners want us to be as cheap/efficient as hospitals in other areas who still see a mix of straightforward and complex cases. We took this case to the commisssioners, but no allowance has been made for this problem. Ultimately, our patients are going to get a raw deal as our service’s budget is reduced for our apparent ‘inefficiency’.
Either the funding system needs to be significantly more flexible and clever, or strict rules to prevent cherry picking need to be introduced. I would prefer the latter – in fact i would prefer a single NHS to provide services rather than to commission them from a variety of providers.
You are obviously supporting the interests of those working for a monopoly supplier. I assume that is where you are employed. The interests of the taxpayer – largely ignored in this discussion and “listening exercise” – are that there should be some competition.We know from history that nationalised monopolistic industries are largely incapable of reform.
Living in France, I find that the state/insurance funded but privately provided model works quite well. After all, GP’s are private contractors, responsible for their own business. I don’t see any proposal’s to make them salaried state employees.
I completely agree once the easy cases have been cherry picked like cateract and hip ops the main hospital will loss its income and then nopt be able to treat the expensive hard cases like the car crash or problem birth or dementia in the elderly. The most vunerable people will suffere the greatest loss. This will lead to increase health inequalities not a reduction. The porrest will be sicker and the rich will live off private insurance
I’m rather surprised at A Robert’s reply to this comment, they seem to be putting the interests of the taxpayer ahead of the interests of the patient.
They also seem to be confusing ‘industry’ and ‘health’ the two are different.
I agree with you Rheum, but feel that strict rules would be difficult to impose.
Far better to have an efficient NHS than bring in private health carers who do not really care….
My view is that competition can focus the minds of managers within the NHS to improve service, but it needs to be a level playing field and it is not. Private providers will cherry pick the easier cases so that they can make money, so we need the tarriff adjusting to recognise that and the more difficult cases need better funding.
the other problems this brings with competition is training, the private sector have no commitments on doctor/nurse training.
the removal of certain volumes of elective work at NHS hospitals may undermine their ability to deliver acute work
Finally I do not believe you can have competition and co-operation working unless you have a complex monopoly where it is in everyone’s interest to do so
Emergency Care is expensive, relatively unpredictable and requires a lot of resources to be available just in case. No private bidder is going to want to take on a service and have it “standing by” and not generating money from tariffs for operations. Whether this is for simple broken bones or major polytrauma it takes a lot of resources which get in the way of more profitable elective/planned work.
Add to this further dispersal of specialties to any willing provider and offering a true major trauma centre or unit will become increasingly difficult without having the elective contracts/operations to pay for enough neuro /ortho/ cardiothroacic / plastic / general surgeons and all the support teams with enough experience to man an on-call rota.
In response to A Roberts, I am amused that you think nationalised services monopolize the sector and private services do not. Hello, Virgin Trains anyone? The idea of privatisation generating more choice and better services to the customer is a cheap myth. So called ‘choice’ has nothing to do with patient care or the rights of consumers, private companies are going to be focused on their bottom line and that means delivering the service as cheaply and as efficiently as possible. How is that going to improve patient care?
By the way, I thought this listening exercise also involved Andrew Lansley et al meeting members of the public and listening to their feedback face to face – when and where is this happening. It all seems very cloak and dagger to me!
Cherry picking challenges institutions that habitually cross-subsidize services (or products). Such cross-subsidies distort the communication mechanism on which the market relies: there is no clear signal what things really cost and hence no competition or innovation will be forthcoming to drive costs down and quality up.
In the NHS, and public sector services generally, we see lots and lots of managers, but we still don’t know what anything costs. We have lots and lots of “performance management”, reporting on any number of targets, but the targets are brain-dead stupid: failing to measure value added and easily faked. (And faked, especially, where penalties or rewards are linked to targets.)
So, cross-subsidies mean we won’t know what anything costs and performance management tells us nothing but lies about how we perform. And you’re telling me we should keep it that way?
Last week, when I suffered a post-tonsillectomy bleed, the paramedics asked me, while I was gushing blood in the ambulance, which of four hospitals I’d like them to take me to. I had no idea – I just wanted the hospital – any hospital – that would sort my bleeding out. This notion of ‘patient choice’ is something that politicians are getting their knickers in a twist over and I, as a patient, don’t want. The paramedics, doctors and nurses are the experts, not me, and I don’t want to have to consider the merits of various hospitals myself – I’m quite happy to take advice. No-one in my considerably large social and professional network opposes my view. This began with Blair and is being needlessly perpetuated by Lansley. We don’t need patient ‘choice’, we need reliable expert recommendations!
@Sean Ferrer: Exactly.
Choice is one thing expertise is another. There seems to be a general assumption that the majority of the public are well informed about thier condition, what treatment intervention they need and where best for this to happen. This is not the case . Most patients like to be informed by a specialist, who has the knowledge and skills to undertake the treatment/procedure, has the backup of a team of nurses and Healthcare professional befitting their condition in a sensitive and individual way. Where best for this to happen but in the NHS where the services are already provided and in most cases, provided very well. Why try to mend things that are not broken, yes, look at how savings can be made, look at efficiency, look at patient empowerment, but the private sector! Good profit making out of health, not sure they go hand in hand.
Choice is only good if there are qualified doctors and healthcare professionals available. I find that the GPs I’ve visited do not listen to the patients any better than the government listens to people who are experienced where they are not. They have a preconceived notion of what’s wrong far before any real investigation has been done. If the GPs pay little attention to what their patients say, how can they possibly lead the NHS?
Regarding Ambulances I see that private firms will be able to ‘bid’ for 999 jobs in the near future. I have recently had the oppertunity to meet a private crew. Between them they had the collective training of 12 weeks. GPs, MPs private firms, please be aware of this if your thinking of taking the emergency service away from the NHS. You are risking lives.
Choice is all very well provided it is informed. When it is an emergency all hospitals should be of a standard to provide a high quality of care. If it is elective treatment then one of the things to bear in mind is distance. My wife had excellent care for her kidney stones in a hospital 35 miles away. I drove nearly 400 miles that week to visit her and take her to out patient appointments. The NHS is one of the best Health Services in the world and free at the point of contact BUT the relatives have to pay – Petrol , Car Park fees and bumped up phone charges.- never mind the grapes and the flowers.
As a patient I have always wanted a local hospital to provide quick help when required and I have always been extremely happy with the service provided in the time of emergency. As a member of staff I have seen challenges when the patient needs to be discharged from the care, trying to get the patient home when they are eligible for patient transport is not cost effective and often disorganised, reflecting poorly on the organisation and the great care they may have already received. I strongly feel that the focus of change should be within the structure of the NHS, the follow up after care and not about choice.
Choice & Competition is a means to having services provided by third parties. Leading to Privatisation with massive cost increases as British Rail.
More effort should be given to retaining NHS as a public run non-private/non-mutual/non-partnership organisation run by NHS emloyees not “carpet baggers”.
The “listening forums” are ill advertised and as meetings appear to be closed private clubs.
Thank you
From personal experience I don’t want choice of health care professional I want choice of location and choice of date and time so I don’t have to ring to rearrange or take leave from work as it is only between 9-5 mon-fri. I would be happy to see a GPSI or specialist nurse etc rather than a consultant or their team if it meant being more local and at a time more suitable for me.
The problem with “choice and competition” is that private sector providers will compete for the choice services; the services that will generate the most profit. Typically, this means they’ll choose the kind of services like hip replacement or cataractectomy, that are quick and profitable to deliver, leaving the NHS saddled with the complex, difficult services which are difficult to turn into revenue, thus exacerbating the NHS’s financial difficulties and creating a two-tier system.
My experience of working with private hospitals is that they discharge patients with rarely a second thought about how they will cope on the outside. They are far, far worse at referring on to community rehab, intermediate care or social services, as these referrals generate no income for them. The result: poor outcomes for their patients due to a complete failure of joined-up working. Health and social care are just too important to be left to the anarchy of the market.
I work as an occupational therapist in an integrated comunity NHS and social services setting, and I see lots of cases of what Mike describes.
I also know that we often become co-ordinators and facilitators of many hopsital discharges and complex cases within the community, which is not necessarily part of our job description, or something that is recorded in our monthly targets and statistics.
I do not believe that most private companies will entertain carrying out the breath of work I am currently involved in, as liaising with other professionals will not generate profit.
I agree with you Mike Griffin . A friend had an operation at a private concern which had a contact to perform a range of operations for the NHS.The aim was to improve waiting list times.The presentation they made when the facility was opened was very impressive promising amazing success rates. However the promises were not the reality.My friend needed an addition operation in and NHS hospital when the first operation was not successful. This was not an isolated case.
I woulds reiterate the comments about discharges from private hospitals. After care is non- existent. Is the service agreement for any after care? They don’t think past their front door and income generation. So they will bid for the most lucrative business. Abolishing PCT, I also have major concerns about GP commissioning. Is there not a conflict of interest here as they are private business. Will patient choices be side-lined by GPs purchasing those companies who can bid the cheapest. We know cheap is not always best. Who will monitor GPs and will they be held to account if the provider does not deleiver on quality, patietn safety etc. Who will be monitoring governing at a local level. No disrespect to CQC. At least PCTs were held to account and had infrastructure in place to ensure the quality was there. Where does training of staff fit in to all this? Are GPs going to commission this too?
enforcing competition with the two tier code will just result in a race to the bottom with staff being paid the lowest wages possible. This will result in poor morale, a lack of development and increased stress and sickness levels.
Exactly, the reforms will mean that the private sector can “cherry pick”, their way through routine treatment to bigger profits, whilst the NHS will be left to pick up more expensive and complex treatment, leading to frontline service cuts and compromised care.
Take heed David/Nicholas, the Brown legacy of super schools and academies has done little to improve education.
I totally agree with Mike Griffin and most of the comments left on here, having worked in the public sector whose duties were taken over by private companies, initially everything in the garden was rosy,at the first tendering stage to reduce their cost and increase their profits staffing levels had to be reduced to a bare minimum,at the second tendering stage the quality of the materials used were reduced, once again to maintain their profit margins.We have examples of this throughout the country where cleaning contracts have been awarded to private companies and there has been a massive upsurge in hospital aquired illnes e.g. MRSA,CDIFF.Patients, myself included are now frightened to be admitted to hospital. Admittedly there are things wrong in the NHS but adopting Mrs Thatchers and the conservatives mindset of selling everything to the highest bidder does not work. Keep the NHS out of greedy private hands
I agree, with your points and would like to make another. If a patient has complications during surgery, at a private hospital, that patient will then need to be admitted to an NHS hospital for treatment. Private hospitals are sometimes not equipped to deal with an emergency, so when things go wrong it will be left to an NHS hospital, to incur extra costs clearing up the mess. I have not done enough reading into this subject as I am a first year podiatry student, but I would hope the NHS charges these costs on to the private hospital.
As a therapist with 10 years service to the NHS I totally agree with your comments about follow up. When the government speaks of healthcare it is often the doctors and nurses mentioned with little regard to the rest of the Allied Health Professional workforce that are involved in patient care. The NHS has robust care pathways that take into account the rehabilitation required after periods of illness or injury (including surgery) with well trained therapy teams that often rotate through different areas to gain more training and experience. This gives a more holistic approach to patient care and follow up as we appreciate the after effects of hospital care and how this can impact on daily life. Often I get referred patients from the private sector who have had their quota of therapy input and now are seeking NHS input to fix the problem as private companies do not have the experience of the complexity of cases seen on the NHS.
To keep costs low, I foresee companies using lower graded staff/unqualified staff to keep the costs down which will have a potentially huge impact on patient outcomes and quality of life. While in some cases this may be appropriate use of staff, there is also the potential for a lower standard of patient care. Given the ‘choice’ I would rather have experience over cost.
I do not want choice or competition. I want one good hospital, dentist, GP close at hand so that I don’t have to travel. I want some spare capacity so that I don’t have to wait too long or have an operation cancelled due to emergency.
….and I want world peace but I am a realist. I realise that the NHS pockets are not bottomless, changes have to be made somewhere, care costs money.
Unfortunatly if an emergency occurs, routine operations etc must be changed, we cannot have excess empty beds just in case you need one at some undisclosed time, and how sad that you cannot wait a little while for what you want, go private and when they kick you out of the hospital early because you are no longer finacially of benefit to them you might find that the NHS is not a bad option.
I want a service that is integrated for the benefit of the patient, and I have already seen where clincial teams are unwilling to share the detail ‘because it may help people bid against us for running clinical services’. And the worst offenders seem to be GPs.
Private companies cut corners, increase costs, and generally are not, as most NHS front line clincians, putting patient benefit before profit.
I don’t think you can have a competitive market which properly joins up the healthcare system. Yes there are innovations and changes we need to make, but many of these are from idiotic waves of system change that are forced on the NHS, and partially unpicked by the next wave of changes before they get a chance to bed in.
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I dont want these choices of provider brought in (particularly US style private health care in the NHS) I want a quality service that is properly funded locally. Competitive pricing will bring down quality. Id rather we paid a bit more and had a quality service.
I want GPs to be doctors and democratically accountable health administrators to run the NHS.
I want free free health care including dental care. We have the money in our society to have a fully funded NHS if we can fund three wars at the same time.
None of these health changes were in the Con Dem manifestoes. This is a right wing coup by stealth.
I strongly agree with this. GP practices are small private companies. Giving them such huge public funds to direct breaks all ideas of probity and separation of provider and commissioner, as has painfully been achieved for NHS employed staff. Under GP fundholding, services were not always brought “in-house” for purely clinical benefit.
We do though need more care delivered outside hospital settings (which addresses some of the cost issues if done well), and this can better be achieved through an integrated collaboration between health services, not competition.
How are GPs to be viable commissioners? Dealing with business savvy providers, with serious bid-teams who know how to work the system will take commercial expertise and management strength. This can only come from large organisations with critical mass. Such commisisoners must also have the resources to assess bidders fully and face down the shameless under-performers. This means continuity and monitoring, as well as the ability to write a meaningful service level agreement and manage all its changes.
I do not want choices of provider, I just want my local service to be delivered by the NHS and to be accountable to keep it to a high standard.
As for GPs, it is difficult enough to get an appointment with one now, when they do not have the time-consuming full responsibility of administering and managing budgets. With this legislation they would have to employ administrators to help them manage, so there would be no saving from the present system, it may cost more as they would lose economies of scale.
I have no worries about competition provided it’s a fair process. Don’t allow private providers to cherry pick services as that leaves all the complex stuff with the NHS services who have no “easy” work to balance the contract.
Before this “choice” agenda and choose and book a GP could if they chose send a patient anywhere now they are restricted by the commissioning process and I doubt that will change.
There is no way to forbid private providers from cherry-picking services. Why? Because a profit-making organisation will deliberately perform loss-making functions so badly that the good ol’ NHS has to bail them out. Pragmatic? Yes. Sensible? Probably. Ethical? Well, this is business, you understand!
The biggest two problems I have with the concept of competition in healthcare are
(1) there is no free market in which to operate. Patients do not really have money that they hand over, and sky-high tariffs for the most complex work aren’t allowed (yet).
(2) competition is based on the concept of winners and losers. In business, when a company runs out of money it is allowed to fail and disappear (except banks it seems). But we can’t afford to lose a major community hospital!
Like most people posting to this chatroom, personally I don’t want patient choice – I just want sound medical decisionmaking on my behalf by the experts, and preferably the most convenience possible.
How much does the management and implementation of choice and competition cost? what additional support services and non clinical people are needed to meet this agenda and how much more of £80bn gets taken out of front line services. Invest in high quality leadership, strong managers and enough clinicians and patients will have choice on their doorstep as services will continue when gaps caused by sickness, maternity and other leave. Junior staff will have the support they need to become autonomous quicker. Choice and competition is putting more money into the back office functions.
The answer is currently 14% (Committee HS. Health Committee – Fourth Report. Com-
missioning. House of Commons; 2009-10. Available from:
http://www.publications.parliament.uk/pa/cm200910/cmselect/cmhealth/268/26802.ht)
On the side of our local buses is a stepwise path for Out of Hours care:
Self Care > Pharmacy> OOH Centre>Emergency GP>Casualty
Some of my patients see this as a challenge and manage to get through all of them in one evening. By providing multiple choices for care we create demand, not reduce it.
Then they come to see me the next morning!
Doctors spend 5 years at medical school and then several more years learning on the job let’s not waste their precious clinical skills and time on commissioning work. ‘Manager’ is not synonymous with ‘bureaucrat’ and the NHS is performing many healthcare procedures every day and needs people to ensure that there is lighting, heating, medical supplies, staff education (to ensure the most up-to-date skill levels) and so on. Let trained managers do this vital work and agree and monitor the contracts that deliver the things that clinicians need to their work. Lets not fragment the NHS and whoever thought that introducing the profit motive into healthcare was a good idea just look what happened to hospital food and cleaning when we gave it to private providers who want to squeeze the maximum profit margin from the contract.
I agree. As a patient I want my GP to be a GP. I don’t want my GP to be in meetings, dealing with commissioning services, dealing with performance management of providers and all the things that I do each day. I am an NHS manager and I am proud of what I do. I’m not a clinician. Whilst I support more clinical involvement in commissioning and re-design of pathways, I do not think that GPs should be involved on a day to day basis and from the scores of GPs that I’ve spoken to, they don’t think so either.
The real issue with all of this is not AWP, because it’s been around and successful for a long time now, but the fact that the government has completed failed to comprehend exactly what NHS managers, PCTs and even SHAs do.
I believe that patient choice is a bad thing. Patients do not make rational, impersonal decisions about what they want at the time that they want it. These decisions should be made by health care professionals in possession of the facts eg NICE. Internal competition is artificial and wastes resources – eg marketing/advertising.
Parts of the health services that are not doing well should be given more help/money, not punished by funding being removed!
The government is abolishing NICE. A lot of that is due to the fact that NICE made the difficult decisions about what the NHS could and could not afford strictly, as you say, according to the evidence base.
Unfortunately, the government got all hot under the collar about expensive cancer treatments refused to individuals whose sad tales were splashed all over the tabloids and NICE took the flak. Hence their abolition.
So now it will be down to your GP to make that decision and he/she will be expected to have in depth knowledge about every pharmacological and therapeutic intervention on the market so that he/she can guide you to make an informed choice. No wonder they don’t want this poisoned chalice.
I don’t believe ‘patient choice’ is a meaningful end in itself, if I go to the doctor and need an operation, I believe the doctor is in a better position to decide than myself. What is desirable is for the doctor to make this choice based on who will provide the best care, rather than which provider has approached his consortium with a good deal on price.
‘Patient choice’ is a govt sales slogan, used for all the sell offs of the nationals to the private but it doesn’t apply to the real situation. I can say I want to go to St X hospital, but the doctor should send me to where he/she thinks is correct.
The PO was split, cherry picked and is now even more unviable than ever. Likewise railways, Virgin Trains gets the ticket fares, but the state still has to mend the rails, via Retwork rail which costs millions but has not help from the ticket office money.
The same will happen with the NHS. Private clinics will make the NHS too expensive to run by taking money for the easy jobs. Those clinics have to be cheaper and give a profit – two slices off of money that should have been for patient care.
When the NHS hospitals are left half full, the private sector will step into the void the government has planned for it, to ‘save the NHS’.
Patient choice is an awful idea that just causes a lot of problems and costs us, as a country, more money rather than saving it. Any drive should be put into making sure every part of the NHS provides the best possible service through support and investment rather than punishing them by removing areas to the private sector who will cherry pick and profiteer. If there is profit involved it is money that is not going to patients who need it.
I am unconvinced that choice and competition will drive improvements in the provision of health care. As a patient I expect all health providers to meet the required standards for quality of clinical care, driven by professional ethics and clinical audit; and by bodies such as NICE. Whilst I might like a degree of choice in questions of timing and location, I expect health professionals to guide me in matters of clinical benefit. In too many areas of modern society competition means a race to the bottom in terms of price at the expense of quality. This is unthinkable for health care.
Choice of place and time does not work. We have had that three times in the 18 months we have lived in Durham.
When we go on the site to choose which hospital, there has only ever been one hospital with any appointments available, and that was never at the hospital we would want to choose, which would have been the local Durham University Hospital.
Lets cut to the chase.. The government for purley ideological reasons wants to carve up the NHS, bringing in private companies, who, will be duty bound by european competition laws to make a profit.
GPs will bring in third party private administrative/accountancy companies to administer the £80 billion budget. This married with the £20 billion savings that are expected of the NHS over 4 years will leave patients with limited treatments. So the choice will be made NOT by your GP or not by the patient it will be made by an accountant, deciding whether your treatment is affordable or not.
I do not want choice for choice leads to surplus. I do not want surplus resources in the NHS.
Personally I do not subscribe to the almost religious belief that ‘competition’ is a good thing in every situation.
What the last Conservative government’s ‘infernal market’ brought us was MRSA!
To go down the route of the United States, where the health care is the most expensive in the world, would be a major mistake.
I have experience from both sides of the pond and can honestly say that the NHS is superior.
This all seems like an operation to enrich the Insurance companies who see an opportunity to parasitise populace to even greater extent than at present.
What I want to see is competent and caring medical staff able to provide the care the nation needs.
Have a look at reducing the armies of Management Consultants stalking the Hospitals perhaps?
I want a public health service, provided by our existing hospitals and staff. I do not want privatisation .
My mother trained to be a nurse before there was such a thing as the NHS. She thought it was a brilliant idea as she knew first hand the difficulties of people not being able to get health care when they needed it.
She also worked in isolation wards, and would have been sacked if she had transferred any disease to another patient.
In 2006, before she died, she was in hospital and contracted MRSA. We saw nurses not wash their hands after she had been seen to.
Competition will only make this worse. Contracting out the cleaning has made wards dirty. Making nursing an all-graduate profession has led to too many nurses not wanting to nurse.
Most people, when prompted, don’t want choice in the NHS in any substantial form. Instead they want a good local hospital. It is also true that the majority of the public don’t have a clue when it comes to the performance of various different treatment options, and prefer these decisions to be left with trained professionals. Moreover, the whole process whereby we have a plethora of different health providers within an internal market is incredibly inefficient. Stop trying to promote the choice agenda and start listening to the people who actually work in these services.
Scrap the bill – if 99% of nurses have NO confidence in Andrew Lansley, it’s not just an imperfect bill, it’s a trainwreck.
Choice and competition won’t help – it’s not for patients to choose, it’s for doctors to do so. GP-based commissioning will dump lots of admin on them and cost a lot of money to implement. Doctors should be caring for patients, not filling out forms …
In the context of healthcare, choice and competition are not ideal. As has been mentioned before, medical professionals are best informed as to what a patient needs and where best to get necessary treatment. Competing on cost will shift the focus from best care to cheapest provider. I am concerned that the reform plans are going ahead with little obvious support from patients or clinical staff.
There is a difference between “choice” and full-blown commercialisation of the NHS. Having some element of “choice” is essential for all practitioners, the best drug, the operation, the best consultant, etc. but few would welcome the NHS heading down the path of rail privatisation. That was meant to introduce “choice” but instead ended up with monopoly private train operators providing a poor and expensive service. Empower patients by giving them more say over their treatment and input into health service organisation but do not privatise the NHS to become Railtrack in a white coat.
Whilst I agree with a lot that has been said here, let’s all live in the ‘real world’ this is back door privatisaion of our wonderful NHS – there is no real patient choice unless you are the worried well who have the money and are articulate enough to get what they want. Why do sucessive governments insist there way is best? the Tories introduced ‘GP Fundholding’ which was a disaster and in a few cases lead to fraud being comitted and waiting times went through the roof – competition in the NHS is a non-starter and management needs to be reduced and more ‘worker bees’ in service at the end of the day the NHS is a NON PROFIT MAKING organisation NOT Corporate based!
Competition is the basis of health care in the USA, the world’s most inefficient and costly health care system in the world which produces very poor and unjust health outcomes. We do not need more competition, we need collaboration between different elements of the NHS and with social care services. Choice is not what patients want most – what we want is good quality services, readily accessible, near at hand.
The questions set above show that far from listening about whether we want choice and competition, the government only wants to hear how they will be ramped up. Are these core principles of the NHS? I don’t think so.
Patients deserve a say in determining their health and well-being, with the vast majority of health care for ailments such as colds, headaches and aches and pains being self-treated outside of formal health service provision. So patients should be able to prove themselves to be the best “doctors” for all but critical and emergency care by exercising an element of choice and participation in their treatment alongside health professionals. Passive healthcare is no longer an option.
I agree with the Professor, and what is more annoying the USA pays more for its publicly funded health care than the UK does, pays as much again or more from private funding and still many people do not have any health insurance and overall the USA has worse health outcomes. We want more co-operation and integration, not false choices.
Choice and competition do not work for healthcare. Services should be combining efforts to treat patients not to compete against each other. Most people would prefer treatment in their nearest health care centre, rather than have choice, I don’t understand how the practicalities of this would actually work.
The rule out any element of “choice” is belittling and patronising to patients. They need to be empowered to make the best choices as active participants in their health and well-being. In the online age, an NHS resistant to patient choices would belong in Stalin’s Russia, not Britain in the 21st century. But the solution is not to give GPs all the “choices” by controlling the lion’s share of the NHS budget.
Prior to the introduction of the internal market the NHS was rated in the top 10 of financially efficent healthcare systems
There is also evidence that healthcare outcomes have been improving at a greater rate than most western nations for the last 20 years.
Since the internal market we have plumitted in the financial efficency ratings.
From my experience as a nurse competition has caused some efficency in departments but often of the order of 1-4% but this efficiency has been grossly overwhelmed by the cost of administrating this market.
My department has saved £10,000pa by changing some of the tests we take but we employ someone at £30,000 plus pa to administer the payments from the PCT and I am sure the PCT pay someone a similar fee to administer the payments to us.
The best thing that could be done is to dismanyle the internal market not expand it.
There needs to be decent regu;lation of efficeincies but also of quality of care the NHS needs to maximise calue for money and this internal market wastes huge ammounts
Agree completely. Dismantle the Internal Market, and get managers to support/enable clinicians to innovate and deliver more care closer to home. The barriers between health organisations, and between health and social care cause all sorts of inefficiencies and faults to good communication.
Look to Scandanavia, where integrated health and social care works well (and yes, they face similar financial stricture). And to Torbay and others in the UK who have found ways to integrate despite the Department of Illness
Well said!
The internal market has caused huge increase in ‘backroom’ expenditure since it’s inception. It should be dismantled forthwith. Clinicians and others working ‘at the coalface’ to provide the best health care we can should be acknowledged and encouraged to get on with the job…not ceaselessly undermined by politicians and others using spurious statistics to compare and contrast different ‘service providers’. We need collaborative healthcare…NOT competition through the ‘free market’. Of course we need some regulation and maintainance of standards but the ‘market’ will only uncover the underperformers when things go horribly wrong. There will be no desire to openly admit problems and look intelligently at ways to resolve them…as you might lose your contract!!
I am not terribly interested in choice, what I want is an effective health service something I believe these reforms are jeopardising which will threaten the service provided and undermine the principles of the NHS.
In terms of competition I am against increased private sector involvement in the NHS, healthcare is too important to be left in the hands of private businesses whose motive above all other things is profit. I do agree that could potentially lead to improved service but constantly repeated in numerous industries things like safety, quality of service, obeying regulations are pushed aside for profit. I do not want more competition in the NHS.
As a GP I offer choice to my patients each time I refer via ‘Choose and Book’. The majority want to be seen and treated in their local hospital and expect this to provide them with excellent outcomes. Only very occasionally do they choose to go elsewhere and this is usually only if there is a significant reduction in waiting time. In fact many patients prefer to wait longer to be treated locally than have to travel. Choice may have a role in the large metropolis where there are numerous NHS providers in a relatively small area but for those of us not in that environment it seems barely relevant and even before the advent of choose and book I could refer a patient to hospitals across the country if this was appropriate or desired. The internal market caused the reduction in choice when PCTs commissioned services from specified hospitals for each locality!
Choose and Book has never worked for us. We live near Durham and have used Choose and Book 3 times in 18 months. There has only ever been one of the three choices with any availability, and each time at the hospital furthest away.
My husband has cerebellar ataxia. When it was diagnosed we lived in York, and he was supervised by the neurological unit at York Hospital. Even speech therapy was situated in the unit.
Since moving to Durham, he has been as far South as James Cook hospital, Middlesborough, West to Shotley Bridge, East to Sunderland North to RVI Newcastle and and various places in between. We live six miles from University Hospital, Durham which has a neurological unit, but he has never been there, although he goes there for the diabetic clinic.
That would be the hospital of his choice, but he never gets there.
The idea of choice and competition in the NHS is anathema to most people, apart from those who stand to make money out of it.
I agree totally with patient choice regarding location of treatment and choice of healthcare specialist. I also agree with healthy competition between Health servcie providers to provide the highest quality and most cost effective service. However i do feel that ‘Any Willing Provider’ has the potential to result in 2nd rate healthcare for patients and cause the destruction of the NHS as we know it.
Within the NHS we strive to provide a high standard, cost effective service and seek to support staff in their learning and development so that they can provide the highest quality , ‘evidence based’ practice and services.
‘Any Willing Provider’ has the ability to undercut NHS services by using less experienced and less qualified staff. It is unlikely to provide a such a supportive learning enviroment for staff and and thereby the standard of service given is likely to suffer. The nett result could be a poor quality of service to patients and patients not being able to reach their full potential.
These a valid points, especially regarding the “any willing provider” concept. There is a place for choice, but not if it undermines the quality of treatment and opens the doors to full-scale commercialisation of the NHS.
I do not want choice. Competition is a context.
It’s much simpler than that. I want universally good-enough doctors, hospitals, medical staff and care.
(Where did competition in education get us? Good local schools are all that people need. Take heed!)
I agree. You put it so simply. However, who is listening?
I do not believe that patient choice is a good thing. What matters is patient care and choice and competition do not drive that in healthcare.
I do not want to be in a position where I can’t trust my GP because he might be making a decision based on cost as opposed to what is best.
I do not want my health care to make money for shareholders.
These reforms are a terrible idea and instead of ‘listening’ they should be scrapped
Your GP has been making decisions based on cost for at least the last 10 years.
The notion of competition will only have one outcome in the medium term, and that is decreased choice for Patients. A good example is Opthalmology. Most of the activity undertaken in acute hospital Opthalmology departments relates to cataract surgery. This is high volume, straight forward surgery which is ripe for private hospitals to take from NHS hospitals. The problem is that once this work goes to private hospitals, the volume of work the NHS hospital Opthalmology deparmtent will be left with will be loss-making. The result? The NHS hopsital will close it’s Opthalmology department. If you need cataract surgery, fine you can go to the private hospital. But what if you need something more complex? The private hospital won’t do it and your local hospital has closed it’s Opthalmology department. So great, you get to travel 50 miles to the next nearest hospital. But what if that one has also decided to close it’s Opthalmology department too? 100 miles?
The NHS has to make savings, meaning NHS hospitals, like any commercial thinking organisaiton, will look to decommisison loss-makign services. It is already starting to happen.
: Choice and Competition. There is an assumption here that competition will provide more choice. This is not necessarily the case with the NHS as a whole. It may be true in large urban areas such as London with high concentrations of GP practices and hospitals. However for most of the country competition will merely reduce the range of services that can be afforded with the limited resources available.
As a patient I want high quality care delivered locally in a reasonable time. I want my local hospital to receive sufficient investment to make this possible. I don’t want the option of travelling 50 miles. I want NHS bureaucracy to be reduced. I want the wasteful internal market scrapped. I don’t want one hospital competing against another. I want them all to work together, sharing best practice for the benefit of society as a whole. I don’t want the organisation looking after me to be motivated by profit and I don’t want ideologically driven reforms.
Last year, I undertook a consultation of 2,500 people with Multiple Sclerosis in the East Midlands. One of the key findings was that many people are not aware of the healthcare services they can currently access. As a person with MS, I feel that widespread provision of information about how to access existing services must be addressed before choices are offered.
What I want to see is a consistently high standard of care and I just do not see that at the moment. I think the NHS should provide good general health care not peripheral issues such as IVF which is a life style choice. Also there has to be some rational with regard to hip replacements. My great aunt was given one at 95 and died the next year. Is that good value for money?
The other situation I have noticed is how top heavy the NHS is these days. Back in the 1970′s the NHS in Hampshire was run from one small office block. Now it seems to be run by an army of nameless managers.
We are not nameless and we do a hell of a lot more work than you care to realise. Who exactly do you think has been doing all this commissioning for the last few years? Who has managed the out of hours services? Who has been responsible for making sure you have all the services that patients need?
You may not be nameless but an awful lot of you are called ‘nhs manager’ on this website! Hardly surprising if people regard you as faceless bureaucrats as a result.
I too am an ‘NHS Manager’ (in commissioning) but i’m also a nurse & Health Visitor & use this experience to ensure quality & patient safety is integral to what my PCT commissions. I could use my ‘official title’ but just for ease I use NHS Manager – stupid really as being a ‘NHS Manager’ seems to give folk the green light to think you’re a waste of time & space & according to Mr Clegg we shuffle papers around …
I am proud to be an NHS Manager, proud of what I do, know I make a difference to patients e.g. help to keep them safe. For these reasons I sleep soundly at night & dont have any doubt that I am worth what i’m paid. When others dismiss NHS Managers its this that stops me getting down or mad !
I am a GP. My view is that managers are essential, but the issue is what they should be managing.
Health care is unusual compared to most businesses in that the managers are less highly qualified than those they manage and understand less about the front line service provided. (Thought experiment: if managers and clinicians all swapped places tomorrow, what would happen?)
Despite this our experience as GPs is that we are being managed in increasingly onerous detail; we are given more and more detailed guidelines to follow and are asked to count more and more things. This perhaps allows our PCT managers, or indeed our PCT managers’ managers a sense of control but I can tell you it adds nothing to care of patients ‘at the coalface’. As qualified professionals, why can we not be trusted to do the work we understand? On the other hand, there are a lot of tasks that need to be done, that are not directly clinical, which we could do ourselves if there were enough hours in the day, but which we are glad to pass on to the managers we ourselves employ. I argue that is the place of managers in the NHS – to work alongside clinicians to achieve clinically-led objectives.
One of the craziest things about the latest round of ‘reforms’ is the idea of disbanding PCTs completely. What is needed is a change of emphasis. Instead of being tasked to control us, it would be great if our PCT managers who already have the necessary knowledge, skills and experience in commissioning could work alongside us. This would surely be cheaper, better and less disruptive than what our political leaders are currently planning for the NHS and still achieve the objective of allowing doctors to lead.
As penultimate note, most doctors don’t want to be managers. There will always be a few who do, and more who reluctantly go along with the latest NHS ‘reforms’ because experience shows that once announced they are inevitable. (Our political leaders only hear what they choose to.) A final note, it is our political leaders who decide – with every change of Government – that the NHS is broken. It is a testament to all its staff that the NHS has continued to function despite repeated ‘re-formations’.
How does competition benefit a patient, I mean really realistically benefit him? The cheapest surgeon? The hospital with the best food? The hospital least likely to leave a swab sewn up inside a patient?
All I want when I have my operation later this year is to be assured that I am in the safest hands and that my care/recovery will be second to none. Does this mean that I should ask my surgeon to include me on his NHS list at a private hospital? If “yes”, why?
There is a difference between competition and choice. The patient should have the option to play an active role in determining his (or her!) well-being and be guided in making the right choices by doctors, consultants and other health professionals. Some hospitals are excellent, others simply dreadful and patients should have some element of choice to enable them to avoid the poor performers and get the best treatment.
This is where the GP consortium and “any willing provider” model is a worry as GPs may be under pressure to choose the cheapest alternatives to balance the spreadsheet each month. That is why quality of treatment must the primary consideration in a “choice”-driven NHS.
Yes, you should be prepared to make sure that your surgeon is making the best choices for your treatment and be prepared to seek a second opinion at an alternative hospital to ensure the best outcome. We need a patient-focused, flexible, proactive NHS, not a privatised one.
In consumer goods markets, choice has just led to vast fragmentation and brand extensions of what are often the same core product.
A crisp is still the same nasty deathly salt-ridden product event if it purports to be from organic potatoes or differently flavoured.
Will we see “new and improved” NHS services appearing on our high streets soon?
I think you are wrong here. All crisps (and many public services) may have been “nasty and salty” in the 1970s but consumer choice has drive down salt and saturated fat levels and there are all kinds of “healthy” alternatives available, just look in any health store. Most sociologists are hardly right-wing ideologues but they have long recognised that choice is a potent social phenomenon in the modern age. Let us hope the NHS “crisp” that emerges from this Bill is a high-fibre, oven-baked, low-salt healthy one, not a high salt, high fat processed “disc” made from dried potato. It is a mistake to dismiss the importance of choice in health care as having some element of control over one’s health is beneficial to well-being. Passive patients are the ones whose outcomes are usually poorer. Passive health care is no longer an option.
I agree. I think there is ample evidence (eg. see the work of the economist Nick Barr at LSE) that in markets providing a “complex” product such as healthcare, most consumers do not have sufficient information to make choices that are in their own best interests. This is not to say that choice is a bad thing, but to put it at the forefront of reform is ill-advised, because the risk is that a lot of public money will be spent offering a gimmick that will not actually benefit the population’s health.
I think Anthony’s point about crisps is not quite right. Improved uptake of healthier eating has, I think, more to do with education than with the availability of choice. Informed consumers will demand better quality products, and “providers” will shift their product range if they want to stay in business.
Talking of the LSE, sociologists (not usually the most right-leaning people) agree that consumer power “from below” has been one of the most significant drivers for change in the last few decades. Consumers have driven the food industry away from hard fats and high salt through their own pressure aided by the information given to them by scientists. That is how “choice” should operate in health care. After all, the disabled are now free to employ a carer of their choice funded by the state so why should patients not have similar choices?
No patient has ever asked me for a choice.They simply want a good local hospital to attend.I believe competition should be about standards and holistic care not cost.
Agreed on the need for holistic care but when patients are exercising “choice” with almost every other service and product they use, why should health care remain a service-led, not user-led activity? After all, the patient has exercised choice in attending one health centre over another and signing up to one GP over another, so surely this is just an extension of these existing acts of choice in NHS services? Eye care patients exercise choice in choosing to opt for glasses, contacts or laser surgery and styles of frames so why do they need to accept a “one size fits all” approach in primary care? And yes, I think optician services (and dental) should also be free at point of delivery! We only have a partial NHS, our eyes and mouths live in a privatised free market already!
I do not want choice. This bogus “choice” the government is attempting to impose on us is simply an effort by politicians to reward the private companies who have given them money. Unfortunately for the politicians and the private companies, the public know what you’re up to. Price competition is good for supermarkets but devastating when applied to healthcare. I simply don’t see a way to prevent cherry picking from private companies. They are all about profit. They will only want the services that are profitable. This is a truly horrific bill that should be scrapped outright.
Simple, no private providers in the NHS. Problem solved.
So where does that leave your GP? An independent contractor since 2004.
Stop the patchwork privatisation of our public health service. Choice is part of the cute propaganda of a market driven ideology. The idea of competition within healthcare contradicts the ethos of healthcare. Keep Our NHS Public.
I believe that the general public have no understanding that their healthcare is some areas will be provided by “private companies”. There will not be an option to choose NHS primary care as it will not exist, therefore this is not competition, but a removal of services.
NHS foundation trusts within primary care will give the option of NHS care providers, along side private companies, but PCT areas should not be allowed to have only social enterprises, or private companies offering community health care provision as this limits competition and could destable the NHS care in areas without an alternative option. The options shoudl therefore be NHS foundation trusts or private companine/social enterprises, not exclusive to one or the other. PCT’s shou8dl not be allowed to become social enterprises if there is not al alternative general primary care NHS fo0undation trust within the county area.
Anyone really ‘listening’ to the people on this forum should be able to see that no-one wants a wholesale change to the current model. I’m fairly sure the ‘listeners’ (if anyone even is bothering to read the public view) will wisely decided that each of these opinions is ill informed/guided by self interest/missing the big picture/a minority view.
Let’s be clear. There is no-one who genuinely thinks these improvements are going to make the NHS better or more efficient. Please stop.
My family has had the very best of the NHS, my wife has had stem cell treatment to cure her cancer, I was in a car accident and in a coma for two weeks. my eldest son recently had a staff blood infection.
The NHS works. we do not want it to be privatized in any way, we will stand up and be counted.
We must never allow profit before people, the NHS sets us apart, as a public service, it is a shining light, that we will not let carpetbaggers rape for profit.
Stop this vile NHS reform bill now, can you not understand plain English, it is not yours to sell Mr Cameron,
We the people do not want this wholesale privatization of our NHS.
We can afford a public NHS, without the corrosive creeping cancer of privatization, we can not afford, more wars, PFI scams, tax dodges,
to bail out banks, large standing armed forces, sort out these, and we can afford our very special NHS and free uni educations for our young people. Scrap this bill now.
Well said.
This is a listening exercise?!
The listening consultation document is leading in the extreme. It makes no attempt to manage outright objections to the HSC bill, only for minor alterations that are superficial at best.
A typical question from the document is:
Q3) What else can be done to make patient choice a reality?
This is outrageous and it is published by the Department of Health! Perhaps the best use of this resource in the first instance would be to research and demonstrate that there is any evidence in fact that these changes will be beneficial to patients and taxpayers. Mr Lansley has categorically failed to provide any proof but has used dogma and anecdote in its stead. He has also cherry picked (a shadow of things to come?) a snapshot of numbers to suggest unsatisfactory health outcomes when a glance at the bigger picture illustrates how distorted these are.
This hasty and politically motivated attempt to drive through a baseless agenda will be looked back on with incredulity.
As an experienced individual in healthcare I was surprised to find that when I was offered ‘choice’ I felt I didn’t have the appropiate information or ability to make a choice and fell to the normal stance of ‘what do you think doctor?’
In reality there isn’t choice for the majority of helathcare it only applies to cold elective surgery, any other healthcare is based on availability ie where is the nearest bed available, where is the shortest queue for A&E. In primary care patients do not have the freedom to change GP’s easily as they cannot find out where the good ones are. In reality if Choice plays out it will require services and/or a hospital to close, where will choice be then? and can the politicians really face the concept of their local hospital closing?
where I would like choice is in the realm of the day of clinic, the time slot, availability of services in the community, a longer working day and true 24/7 services
With Commissioning Support being provided to GP Consortia by private Companies where will the checks and balances be to ensure that these commissioning organisations do not end up ‘buying’ their own provider services?
Exactly. As GPs are already private (by their being independent of the NHS) they will be commissioning & supported by other non NHS staff. So for this huge part of the process of commissioning & provision, the NHS does not feature … So for half of the process (the commissioning) the ‘NHS’ will not feature. All we need is to increase the number of private providers to support the choice & competition agenda & there will be no NHS left. Strange when Cameron says he believes in the NHS …
The principle of choice and competition is essentiall a good one. The hard part is how you measure them.
On the whole choice of hopsital works well in large conurbations but does not work well in rural areas or towns not large enough to have more than one provider, that’s why Scotland and Wales have not adopted this model! It is entirely up to patients as to whether they exercise their right of choice of provider, but at least they have one.
We will never really have true competetion because it seems that organisations can not compete on price. Competiotion on quality is fine, just too many variables.
Most people would choose to use their local service if it was of high standard, so national quality standards are key. Care must be rationed, as however large the budget is, it must be finite – NICE has provided guidance which is easy to access and really helpful to frontline staff. NICE ensures some parity of rationing decisions across the NHS.
The current “reforms” have knocked staff morale and in my workplace many good nurses have left. Nurses and other healthcare staff have mostly opted for these professions because we get job satisfaction from providing the best quality care. What is needed is a system which supports staff who are providing the best care and does not leave them feeling undermined and isolated. The reality of competition for services is that I loose my job security – I have witnessed this leading to the collapse of staff morale – this then impacts on the quality of patient care. If I apply for a job in a “social enterprise” I will no longer get NHS pension, or the national pay scale. If, as will surely happen, some of the arrangements to transfer from PCT fail (partly because everything is so rushed due to the very tight timescale imposed), the private sector are poised to move in on the tasty bits.
When I started my nursing career Mrs Thatcher was in power, the existing cleaning and catering staff at my hospital were sacked and the services were commissioned from the private sector. Cleaning and catering staff working within the NHS thought they had job security, stayed for long years and felt part of a team who were providing quality care. Now there is a high turnover of cleaning staff and if something is being missed in the cleaning, or not cleaned correctly it is not simply a question of having a word with the cleaner – I would need to ask my health centre manager, who can bring this to the PCT commissioners, who can pick up the issue with the firm who employ the cleaner as a temp, in my experience the reply from the firm is often “Oh that is not within our original spec. we can do it but it would cost more.” I think we are at a stage again where we don’t know what we’ve got till its gone – in 5 or 10 years time I hope we won’t be saying “it used to be the case that you could build a relationship with your local nurse / doctor, now I have no idea who will be there next time.” High turnover of doctors and nurses will also impact on the development of high quality services.
I received from our local PCT prescribing committee detailing how the work of the committee saves £7 for every £1 spent on prescribing management. The whole thrust of the email was not “how can we spread the word to other parts of the country?” but “how are we going to manage to protect and maintain this work when the organisation we work for is abolished?”
The ideology which has led to these changes holds that public sector equals British Leyland equals inefficient, costly, old ways of working. This is not the NHS I know. The scale and speed of this change smacks of this ideology, rather than a wish to find and promote good practice. I would prefer to see a system which recognises the importance of staff morale to providing quality care, which looks for examples of best service in one area of the country and then pushes to replicate those improvements elsewhere.
Rather than commissioning what is needed are clever systems which reward quality care – I think QOF (Quality Outcomes Framework) does this. The reward does not need to be financial as with QOF it could be that local teams who achieve the quality standard are given greater autonomy – this would be excellent both for staff morale and quality care.
The government have got hung up on “ choice” as some sort of holy grail – in fact it is more of a red herring. From my extensive experience of engaging with patients and carers, “choice” per se, is rarely high on a patient”s agenda. If it is important to people it is often becuase of factors such as convenience around time and location of treatment. The things most people are really concerned about are quality of care, patient safety and timely care, provided with clinical excellence and with compassion. They do not want to HAVE to choose in order to be sure of accessing healthcare that delivers on those things – they want it to be available to them at their most local hospital. They do not want to have to trawl around websites ( if they can, and if they have easy access, neither of which is universal) looking at data, which they may or may not understand and interpret correctly.
(2/7) If offered choice, for example by the referring GP, the most common response is, I believe, “ what do you think Dr” and so people not only do not use that choice, they defer the decision to the person they perceive as having the appropriate knowledge to make that decision based on the things they really care about – quality, safety and how long they will have to wait to get the care they need. Incidentally this pattern of behaviour also raises issues around conflict of interest in the proposed future commissioning process and how it might affect referral practice.
The choice mantra has been waved as some kind of gold standard, but I fear it actually detracts from what our time, attention and indeed our money should be focused on: making every hospital a centre of excellence so that no matter where you are referred to you can be sure of that quality, that safety and of a clinically appropriate timescale to be seen.
(3/7) I would add that there are dangers there of a narrow clinical focus and accepting a slide back to waiting for an appointment for such a length of time that, whilst not necessarily clinically dangerous for the person, they do experience an unnacceptable reduction in quality of life and sometimes on ability to function e.g. because of pain. This needs to be borne in mind as well as more critical clinical factors – e.g. waiting 6 months or a year for a kneee or hip replacement may not kill you but it would almost certainly have a huge impact on quality of life, ability to function, including working and possibly on mental and emotional wellbeing.
(4/7) The SoS of course claims that competition is they way to ensure that this quality, safety and speed goal is achieved. But I have not seen a single piece of evidence offered (and, in the interests of validity, I would want to see a lot more than a single piece!) as an evidence base that competition and choice drives up quality. If this is the case why have you not been trumpeting it from the rooftops? I suspect the reticence is becuase there is no evidence base to justify this approach, which seems to be pretty much the basic driver of the shape of this reform.
If I and the many, many other individuals and bodies who have questioned this are wrong – please do show us – bring forward your compelling evidence that choice – in health care provider, not in another area of life, let”s have a valid comparison please – drives up quality.
(5/7) Even if there was such a compelling argument and evidence base, it is not the end of the story. What will happen, for example if a provider, left without the critical mass of patients necessary to keep a speciality or procedure or department viable because so many are choosing to go somewhere else that is alleged to be better, then has to close a ward, a deparment, or offer a particular treatment? That will reduce choice not increase it, and for some patients, that may mean for example undesirable effects – having to go much further for treatment, which could be difficult for all sorts of reasons, or wait longer for it because the number of providers has decreased. Should the focus not instead be on providing whatever input is necessary to the provider who is not meeting the mark, to enable them to be just as attractive an option, thus maintaining choice?
(6/7) What about the patients who are not equipped to makesuch a choice – will they not still allow others to “choose” for them and what will that do to the theory of the best will survive and get the business?
I also fear that to say that competition will only be on quality and not price is just not realistic in an increasingly cash-strapped NHS. It will put those who commission, with an eye on their own budgets, in an invidious position when chooosing a provider – of course price will be a factor in that process no matter what policy says. You have 2 potential providers, both making very similar claims on the quality of their outcomes, but one is 20% cheaper than the other. What will be the final factor in that decision? Most probably, the cost. How many times have we seen providers fail to be able to deliver the service at the standard specified becuase they have undercut on price? Sadly, by that time, patient care will have suffered.
(7/7) “Choice” is over-rated – let”s instead focus our policies and our purse on making every UK hospital one where there is such quality, such safe, timely care on offer that the need for choice will become redundant.
I only hope that the RT Hon Andrew Lansley takes the time to read the above comments. I am against private providers being brought in.
Local experience of this has been damaging to patients and extemely expensive.It has definitely not improved quality of services.
I hope time will be taken to look at positive work already present in the NHS and build on its strengths.
The problem with competition is that there will always be less desirable/profitable people and procedures.
Who will pick up these operations and patients?
Extremely good point, that’s why competition on quality alone will not work. Competition on price for these sorts of procedures will enable new market entrants. But the catch is, as you point out these procedures are the ones that the private sector wont touch so price is artificially inflated in the NHS. If we had a truely competitive market the NHS would go bust. Vicious circle!
I would prefer to go to a specialist hospital for cancer treatment not the nearest general hospital. Likewise if I had a heart condition I’d rather be treated in a hospital which did a lot of heart ops and had developed expertise in that area. The idea that anyone can turn their hand to anything is silly.
I don’t think GPs have either the time or the knowledge to commission services. My GP told me she only had three patients with breast cancer in a practice of 3,000 people (most of them under 40 years old) so I can’t see her giving much priority to my condition. I’d rather have outsiders commission. GPs are providers of services and shouldn’t muddy the water by also commissioning things.
Completely agree. Also GP’s are not trained to commission or manage but to be a first port of call and access point into more specialist care. Why waste all of their highly specialist training to put them in a managerial job that they have little to no training for when there are specialist managers in the endangered PCTs who could do the job?
Leave the jobs to the specialists so that they can improve and keep going at what they are good at. This will improve standards so ‘choice’ isn’t an issue… evryone is happy with their local service. (or is that cloud cuckoo land)
I find it very difficult to make a response as the framing questions are so prescriptive. I fail to see how ‘patient choice’ in any way can help deliver the best possible quality service free at the point of delivery. How can a patient make choices? The patient should be consulting a well-trained professional, a GP, who will advise on the best available treatment or will refer on to the best available expert. There may be legitimate questions about how the best experts and/or best treatments are made available within a given budget – but I fail to see how patient choice answers those.
Similarly I do not understand how competition between providers can deliver the required outcome – in fact competition would require a multiplicity of providers which by definition means wasted resources.
Perhaps I’m thick.
Choice is a movable feast. It is held up as the Holy Grail by Government, and yet this choice is not a real concept. Choice is only choice within certain narrow parameters in my experience, that is, you may choose from whatever is on offer, as dictated by vested interest in the status quo. If I wish to use Chiropractic or Homeopathic treatments, both of which are underpinned by a range of evidence, I cannot choose these via the NHS but must use these privately. This is because these treatments may not fit into the norm of medical testing processes, and despite evidence to the contrary, they are not accepted as efficacious. It appears to me that when we talk about choice in the NHS, we are not talking about choice that represents the whole populations’ preferences, but only those sanctioned by the scientific establishment and the pharmaceutical industries. If the Government really wanted to look at choice, and to invest in prevention, self-care and long-term wellbeing, then it would look at all treatments with clear eyes and make bold decisions on choices actually offered.
There is no evidence to support the use of homeopathy or chiropracty. Sorry!
I think what Health Economist means is that there is no evidence which meets current criteria for it to be acceptable…..
The lesson to be learned from the likes of homeopathy is that just giving patients time to discuss their worries can contribute to healing. Too often, NHS doctors have their eye on the computer screen, the door and the prescription pad, not the patient. Consultations are often rushed even with a half-empty waiting room.
It seems to me that the suggested benefits of both Patient Choice and Competition of providers are just two of the legion of highly questionable concepts developed by those wishing to justify, on ideological grounds, the reduction and ultimate privatisation of the NHS. In mental health, for instance, private companies will never pick up the bill for years of complex health and social care packages needed by tens of thousands of people. What choice will these disadvantaged and excluded people have in the future world of patient choice suggested by Healthcare by Any Willing Provider? The potential for disaster in terms of governance is also very considerable, when thinking about competition and bringing in profit making companies.
Hear Hear. Well said.
Choice & Competition
As a GP I think patient choice is important when it comes to deciding whether or not to have a treatment or to help select between treatments when there are different pros & cons.
If patients need referral my experience is that they want good care close to home & rarely want a choice of provider unless there is a substantial difference in waiting time.
As a referrer I do not have enough information to allow patients to make a choice between hospital on any grounds other than location and to some extent wait.
Therefore I think the choice agenda is largely spurious and we should be working with local providers & specialists to improve quality and not rely competition and market forces which will have the opposite effect. If the quality at the local hospital is high patients will rarely want another choice.
I think this totally wrong attitude in a modern health CARE service. The doctor is the expert who should offer the patient the information to make the best choice. Feeling in control and empowered enhances a patient’s sense of well-being. After all, many patients often “choose” to flush their prescription down the lavatory and might not do so if they had more input into their care.
Anthony: the HSC bill does not allow for this kind of ‘Choice’. The removal of the treatment tariff opens the market to competition law and Commissioners will be forced to purchase services at the lowest price; Monitor will ensure that this happens.
The ‘Choice’ will be with the private to providers to decide of your ailment is profitable enough to bother with.
That’s a good point, few want to see the NHS go down the path of the privatised railways or British Gas. The HSC bill needs to be modified to ensure that it puts the patient, not the private sector in the driving seat.
Anthony
Your idealogical view fits rather nicely with the politicians who seem to think that they know better than the experienced professionals.
Just like Mr Lansley, you are missing the main point – here we have a GP who is telling us exactly how it is for him and his patients.
Time to put ideals to one side and listen to what is being said by the people who have the experience-based facts…
I agree. It is time consuming now and will be more so. Life’s very simple when you are looking at it through the rose tinted specs of a government or academic department. Very different when you are the one having to find the time to do it.
It can sometimes be counterproductive.In this economic model what we are trading is people’s health and not wealth.It has pros and cons, so you may need to weigh the impact of ‘clinical efficiency’ driven by competition againt universal service delivery. A better modeled competitive environment could have a positive impact but bear in mind that the universality of NHS is what makes it unique. Its important that we separate service delivery planning from clinical care. Proper and adequate consultations should have preceded the white paper to say the least. Thank you.
Just to pick up on a point above – yes, choice is not absolute, is it, not now and I doubt very much if it would be so in the world of GP commissioning consortia. In a sense it is an impossibility. It will be the same as now, you will have a ‘ choice’ from a range of providers ( and no guarantee of how wide or narrow that range may be for any particular referral need) with whom the consortium has a contractual arrangement. Just as, when I needed a referral to a very specific type of specialist, I could not get referred to the specialist I needed, as the PCT did not have a contract for that speciality in a particular NHS hospital in the region – and I had to see him privately. It’s an illusion, and not a helpful one.
What is the best way to ensure a level playing field between the different kinds of provider who could be involved?
To insist that any private hospital treating NHS patients sets aside a number of beds specially for the 80 year olds with dementia who have ‘gone off their legs’ for the third time this month.
To insist that any private hospital whether treating NHS patients or not employs and fully trains student nurses, foundation year doctors etc. at the same level as the NHS currently does.
To insist that any private hospital treating NHS patients has full 24 hour appropriate medical cover, and appropriate high dependency and emergency facilities so that if it all goes horribly wrong the patient doesn’t end up landed back on the local NHS hospital at no notice
(And I do understand that the government currently believes that the slope of the playing field is actually in the opposite direction)
Private provision does not mean better provision. My experience of private provision for children with complex health needs has been extremely concerning and worrying. Private providers glossy brochures and promise of a good quality service has never equated to anything like a safe and satisfactory service. You would be horrified at some of the practices I have seen. It is inconceivable that the government would encourage private providers to compete for NHS run services.
I quite agree. I had an (NHS funded) op in a private hospital last year and the lack of care was shocking, examples included having my BP taken with a cuff that was so large it was loose even when inflated, having my oxygen removed when my sats were low (as they would be after GA and morphine) and being released when I could barely walk without collapsing. Luckily the local NHS A&E was within a mile….I ended up there and was kept in overnight.
In my experience what is more important to patients is excellent local services when they need them rather than a choice of provider.
I doubt we will ever achieve real competition with numerous providers to choose from, instead we could finish up with a small number of providers dominating the market.
Choice is a myth, the only thing people want is a professional, quality, first class service close at hand. Competition is divisive, leads to duplication and creates lowest common denominator services.
The question asked is hopelessly tendentious and begs the question “how can we best ensure that the NHS improves?” It is assumed that competition and patient choice will succeed but I don’t think this is proven. It would have been better to have sought views on this fundamental point, and perhaps even a democratic mandate, before launching legislation.
What daft questions. Quality of what exactly? There’s the basic treatment, which is likely to be the expensive bit, with anaesthetic/ medication/medical/nursing care. Surely this will be standard, or do you get sewn up with gold thread if you ‘go private’? So is ‘quality’ having your own room, an extra comfy bed, lovely food, flowers on the table, newspapers? Being in hospital is not the same as booking into a hotel. If you wish to pretend it is, pay yourself. Otherwise, be grateful we have an nhs. What might help is having medics who are interested in finding out what is wrong and not dismissing the patient as an unintelligent malingerer.
A lot of posts say that choice is illusory. I agree, and I would rather that you politicians pay more heed to quality than to choice – in my experience patients go for geographical location of services and waiting times.
Quality – at least in terms of value for money and access – is best achieved in low cost high volume specialties eg ENT, Ophthalmology, dermatology – they need less in the way of expensive investment.
A “level playing field” is v difficult because of irreconcilable structural problems eg high overheads of NHS Trusts. I would be inclined to limit the type of provider – for example can you favour in some way socail enterprise, or charitable venture?
I have had a chronic illness since childhood. I used to be able to go to my consultant who could look at my health needs holistically and refer me to the relevant specialisms within the same hospital an my notes would all be in one place. Now for some reason this is not possible. Any other illness or problem impacts on my disease so it was helpful for me when going to see the consultant as he understands this. Now though, I have to go to 4 different hospitals because each have different specialisms, each time referred by my GP, each of the hospitals have different systems that don’t ‘speak’ to each other so I spend much of my time and theirs explaining what procedure, medication changes, operations etc I have had and giving them a full history. My choice would be to go back to how it used to be, but I doubt that’s possible, I don’t feel their is much ‘competition’ as only certain hospitals now have certain departments/specialisms.
Choice is already available in the NHS. I’ve seen an endocrine patient in Leeds referred to King’s College Hospital to see a consultant who he had researched as being a world expert on his condition. He had asked for this himself and it was provided free of charge by the NHS, needless to say he was very satisfied. What more does the Government want to give patients? They have all the choice they need! Most patients don’t even want choice, they just want good local services.
As a future clinician I want nothing to do with commissioning of services, I want to treat patients. And I don’t want to have to refer them to a second rate private provider because the NHS hospital has been put out of business.
Oh, and I don’t want to work in a privatised health service – ever.
@Medical Student. This is just the sort of patient choice that shoudl be encouraged. The argument is less with commissioning as such, it is the dogma of handing the majority of commissioning and funding to local surgery-based GPs.
They will need to spend around 10 mins per day on patients and the rest of the week on admin for the local hospitals, mental health services and midwifery services on their books. And if the GPs spend all the money outside the consortium’s area, will the local hospital have to put up the “closed” sign? Don’t turn docs into paper-clip counters!
The best person to commission surgery is a surgeon, let hospital consultants become NHS commissioners too!
choice and competition are irrelevant to the acute medical and surgical patients who are the main reason for the existence of NHS hospitals. They are patients, sick, passive and dependent, not customers, and they need looking after, not offered choices. Always will be like this. Our choice is either, look after them, or just let them die.
Patients tell me they need specialist services for hospital care near to where they live, so that close relatives and friends may visit and assist on discharge. For example a hospital where surgery, radiotherapy and chemotherapy for cancer is available within the same hospital and nearby is surely a better option than a patient travelling to several different places for each treatment (i.e. one place for surgery and another district for their radiotherapy). Why not recognise the strengths in the facilities available, including equipment and staff and ensure patients have access to this.
Competition in a public service, especially one that focuses on the wellbeing of others, is quite frankly disgusting.
I think more attention to customer care and having some competition is good. However, the constant change in the NHS is costing a fortune and leaving the organisation in a constant state of flux.
This flux has other hidden costs in the massive uncertainty and stress across the NHS as well as not allowing the great performers to shine, take responsibility and of course be shown to be rewarded for their good work.
It’s an environment that allows the poor performers to take more not less advantage and lets poor management practice flourish.
I am not convinced by the arguments for competition, but even allowing for health services being subject to a degree of competition, something must be done to stop health and social care budgets being leeched away by tendering processes and consultancies.
Experienced practitioners are having time wasted that would be better spent on patients, meanwhile posts for senior clinicians are cut (such people along with managers often leave the NHS only to return as contracted “consultants” – what a waste).
Having worked in the NHS for 10 years, Canada for 1 year, and now in my own private physio business, I’d like to ask what would happen if there were more transparency in what we have already? We fund the NHS, not the government of the day. I agree that the NHS, where it’s good, is excellent, but there is huge waste and ineffiency also, which needs to change. My experience is that when we are aware of the value of what we’re getting, we are more engaged with getting the most from it. We need to change the belief that we have no responsibility for our own health and well-being and given that funding underpins our medical care, knowing what it costs us, is giving us choice. From my 15 year experience of working with private medical insurance I can also confidently agree with those who say they will promise the earth and not be able to deliver. That includes ‘not for profit’ organisations.
Competition where private companies are allowed to bid for services with the ability to exclude complicated and more costly cases is not fair competition. This places a greater financial burden on the NHS and actually makes the NHS less cost effective. Allowing companies to make a profit from delivering NHS services is wrong. If services can be run more cheaply or effectively (as long as patient care is not affected), this should be done within the NHS, and tax payers money should not be allowed to boost the profits of private companies.
Patients will surely be signposted to service providers by their GP. So in my opinion this gives GPs the ultimate power as to who provides the service. The GPs can choose the cheapest providers of services and any money left over they will get a pat on the back for saving money and will then be able to do what they like with the cash.
New topic: why shouldn’t other health care professionals also become commissioners and form consortia? For instance, a team of midwives could form a consortium to provide specialist maternity services and a hospital consultant could become a commissioner to provide cancer care. Share the NHS budget out more fairly between the range of health specialists now working for the NHS.
And when, exactly, are they going to see patients?
I think that all this discussion about competition ignores the sheer professionalism of the people in the NHS. Competition is not needed to make the service better; the cost of all these changes would be better spent on the existing services.
There is currently not much choice in the NHS. You can not choose a GP as zoning is in place and in many areas you are resticted to the GP of the area. People are afraid to move lest they be excluded from the other practices.
Not much better in hospital either. You can choose a hospital but the important choice is the consultant you see. Can not be done here.
Generic “Dear Dr” letters for referall are the orders of the PCT. So no choice.
I have just been discarged after six weeks as a patient and found that the quality of care in each of the three wards visited mostly depended on the patient to staff ratio. In the less specialist wards, a particular junior doctor’s training was a major concern, (they insisted on taking blood from my arms when I had an Hickman line already inserted!!!!). I’m not sure where competition come into this.
Competition = End of the NHS, health insurance will be a must, health care has to be provided in a proper facility, we have to have every type of care in a facility, it is called a hospital, not individual companies only providing profitable services, it is time to think again.
What clinicians want is for patients to have the best care possible within the NHS without having to wait for long periods of time to get it and to have the reassurance that the standard of care they have recieved is the best.
Change all of that with shifting boundries, changing management, etc – it costs more, frontline staff will be lost and gues who will end up lossing out or falling through gaps in the system – the patient!
Tot up the cost of changing names of organisations, e-mail addresses, paperwork, signage, etc and imagine how many nurses, physios, clinics/services, that would pay for.
Currently I watch the prime minister and his deputy talk about protecting frontline jobs on the news, but on the ground, nurses etc are loosing jobs, being made redundant or being TUPE’d over to organisations outside the NHS.
I think if we do not speak up, we will loose what so many people have fought to achieve over the decades – a healthcare system that is free but of the highest standard for the people who need it.
The proposed reforms are a recipe for a disaster. Competition has never worked for the NHS and will not do so. What patients want is good quality local services not services miles away from home. Competition, if allowed, will fragment the service and lead to cherry picking with the the resultant loss of local services. As a result hospitals etc. will run up huge deficits leading to eventual hospital closures etc.
I have spoken to many GPs who have great reservations about GP commissioning. From the past we can learn that very few decided to become ‘Fundholders’. This is mainly because GPs like to concentrate on what they do best, i.e. look after the patients.
When PCT were introduced, it took them about 2-3 years to understand their role and set things up.
I am sure that the present change will cost over £2 billion (some of it hidden cost) at a time when there is no money available in the NHS and when front line staff are being reduced.
The PCTs in their present form has been reduced to a skeleton service of people who do understand about commissioning. Why not keep them and involve GP in that stucture.
Finally, it has always been difficult to have GP on commissioning groups in the past. Why would it be differnt now?
Several observations
1. Application of the market philosophy to the NHS with the values it has is misguided – a true market should allow enterprises to fail. When was a district general hospital allowed to go bust? When was a GP practice shut down?
2. Competition will mean that expensive patients will receive a second class service from failing providers. If its managed compettion, its not competition
3 Who will train our future workforce? This one is soluble, but if you base it on lots of providers doing this privately, its not going to be cheap
4. I have no faith that replacing 150 not particularly good organisations who are just about beginning to sort themsleves out (the governance structure in world class commissioning could work -although quite frankly Id be happy with county class commissioning) with 500 who have no track record lead by interested parties who in the last round got a huge pay rise is a good idea!
It’s ok having choice for the profitable areas of the NHS such as hip and knee replacements, but where is the choice for the essential and difficult operations which the private sector don’t want to touch?
Enforcing competition will destroy the NHS as we know it leaving under resourced teams left to pick up the pieces and the operations and difficult cases that are left.
It wasnt that long ago that revision hip surgery was commonplace because inferior (cheaper) materials were used. It is obvious that profit margins will be put before quality if private company`s are allowed into the health service. The reforms should be stopped in their tracks with immediate effect.
This bill will result in fewer options for patients:
1 ) Private providers will cherry pick the most profitable procedures
2 ) NHS Hospitals will cease to offer those services
3 ) As a result individual trusts will be forced to specialize in a handful of services, closing the majority of services they currently offer
4 ) Patients will be forced to travel to find the treatment they need because there will be fewer places offering the required service.
5) People will die because their local A&E departmetn has closed as a result of the lack of funding.
For the politicians who need to have it spelled out again, that means patients will have fewer choices than they currently have. But your friends in the private health industry & banking / insurance sectors will make huge profits.
What was the rationale behind this bill? I’ve forgotten…
Everybody has a vested interest in the NHS and will find it difficult to be objective in making changes.
We do need reform because so much money and time is wasted in the NHS but there has been too much change, too quickly and too much time has been wasted on management and not always for the better. The patient and professionals often get lost in the process. The NHS is to supposed to be there for patients. There should be pilot projects before change is swept across the entire NHS. This should be researched and then audited to find out the pitfalls and learn.
No one group should be given control of the commissioning process. It should be a consortium of lay/patient representatives and a variety of professionals- primary and secondary care nurses as well as doctors, public health representatives and managers. No one group should have dominence. What is wrong with democracy? This will then give a more holistic view of the needs of the service.
I dont want choice, – Patients would like to see all hospitals brought up to the same standard so that whichever hospital I am referred too I can expect the same level of treatment.Obviously this would not include specialist procedures as the patient would be directed to the specialist hospital according to need.
Competition is an anathema to health care. Profit should not be the motive for treating anyone.
The NHS would be in danger of becoming a meaningless logo,much the same as British Gas.
competition already exists – it’s called ‘Choose and Book’. It is awful for some patients. For the rest it generally makes no difference. When I asked Simon Burns what the research was that this premise of desperately needed competition was based upon, I was sent a few references that pointed to Kings Fund work done across London using choice of NHS hospitals. Morbidity rates showed it was good! Surprise! Lucky that’s the system we alresdy have then.
As for the pt’s for whom C&B has been poor – they have their C&B number, receptionist somewhere helps them choose or they choose from home – opt for quickest wait, local private provider. Letter arrives days before appt date to say sorry, please get on NHS waiting list. Why? Co-morbidity which means they have to have ICU at the ready. Cherry picking gonna get lot worse
If a patient has a long-term disease, they must be seen for all the related ailments within one organisation (NHS as this is all that will accommodate them) and if the disease is systemic, that means every ailment they have pretty much . Currently, x-rays are being duplicated, reports unable to be seen by consultant, gone-wrong procedures being shipped into the NHS from private hospitals…. Patients do not want choice so much as quality and with the fragmentation about to increase in the new system, patients will be lucky to get any fluidity or consistency in their care
Patient choice is all very well for the people who feel empowered to exercise that right. What about the millions of people in our society who do not feel they have a voice? The older generation; People from ethnic minorities; people with learning disabilities; people with mental health problems; people from disadvantaged backgrounds – without homes, jobs, families…. This is just another way of allowing the middle classes and above to get better healthcare in order that the gap between rich and poor, healthy and unhealthy gets bigger and wider. It will do nothing for the already huge health inequalities in our society. As has already been mentioned, the ‘easy’ and cheap health problems will be cherry-picked by the private companies, whilst people with the more complex problems will be left to be picked up by the NHS and Social Services – while the GP’s focus on managing their budgets. And with the severe reduction in Social Services, people will lose the small amount of support they once had that may have helped them to have jobs and to improve their health by accessing health promoting activities and services. Choice? A huge minority of people have no choices, and this health bill will do nothing to increase this inequality.
NHS staff should be trained by the Government, the cost settled by the Government. Upon qualifications – suitable staff – Consultants, Doctors, nurses etc enter the military profession, subject to military discipline but working in the NHS Hospitals.After an agreed period ie. 10 years – staff released from the military bond.
This system worked very well in 1960/1970 in Jordon !!
Competition: I don’t think there should be competition in the NHS, it adds multi-million pounds of bureaucracy to a system that is supposed to treat all patients free at the point of need. Everyone should expect the best service possible. If all that administration was cut out of the NHS, think how much more money there would be available for clinical use. The NHS is PUBLIC SECTOR and not something to be shifted bit by bit into a market, private economy. Where waste can be cut it should be, but not by competition, rather by responsibility on the part of staff, patients and relatives.
As for choice: Everywhere should offer a high standard of treatment, if one place is lacking, it should be improved. Most people want local provision where possible and expert centres where necessary, and many want continuity of care.
Governement pressure on the NHS has caused it increasingly to have no time to consider the individual. People do not fit neatly into tick boxes and many clinicians would like the flexibility to treat people according to their unique circumstances rather than a set of remote ‘rules’.
Choice does exist in the NHS in many areas. GP consortia can quite easily be a mechanism for reducing choice – patients will only be able to access the services that their GP chooses. How is choice being improved? There is no evidence as pilot schemes have not been run long enough to test how consortia work. The bill is too risky and seems like a smoke screen for breaking up and privatising the NHS. Health professionals and the public are well informed and have every reason to be concerned about this risky and devisive agenda.
Limited competition has been of benefit to the NHS. I say limited because there MUST be a uniformed tarrif – this ensures that competition is based upon Quality NOT price (the evidence is that this drives down quality). However there are transaction costs to ensure that the Commissioners of service can properly hold the provisers to account. The World Class Commissioning reviews in 1998 were suggesting that £25 per head of population managements costs were insufficient to do this properly… The GPs are expected to commission on £15 per head or less. There is NO requirement of FT’s to reduce their management costs, so there will be a huge inequality of information and management in the direction of the service providers. This cannot be good news for service quality or patients.
I have huge concerns about the conflicts of interests inherent in GP Commissioning and fear that GP interests rather than patients will become that promoted. I note that they are already seeking huge `incentivisation payments’ from PCTs to get involved in reforms…
Efficiency savings are best done on a health community level, not through competition (already a paraoxical feature in DH calls on the NHS! to come together to save money whilst at the same time competing…)
Please ditch these planned reforms. Allow the PCTs to repair the damage already done to them and to increase the representation of GPs and Patients on the Board. THAT is the best way to achieve better patient and clinical involvement in commissioning.
well said. It’s a well known fact that if you want to get a GP to do something, you have to offer them money to do it. We’ve been trying for years to get more GPs involved in commissioning, service re-design etc, but with no joy. And it’s not just that they all want to see their patients.
At the moment impossible to choose GP apart from recommendations because no preliminary chat possible without signing onto practice especially important if patient interested in homeopathy, acupuncture etc (a current GP apparently forbidden from practising homeopathy by NHS).
NHS Choices informs me that it is up to consultants as to whether they want glaucoma listed as a speciality on website (can’t see any)
I am a big believer in true patient choice but see above
In 20 years of practising medicine, no one has expressed a wish to choose – people want to have confidence that their local services are good. Competition should be about quality and encouraging trusts to compete about cost is likely to reduce the quality of care, reduce the coverage of the population and different types of services as well as push up costs.
Just read The Functions of GP Commissioning Consortia:
A Working Document. Its clear that (at the least) the PCT clusters should become the means by which the NHS Commissioning Board monitor and ensures the quality of functioning of the GP Consortia – including conflict of interest issues that may contravene EU competition laws. This `middle layer’ will be essential if the National Health Service is to maintain some quality assurance of commissioning.
I presently am under Lincolnshire Partnership NHS Foundation Trust and would be happy with any choice at all. I get no choice in time, venue or type of treatment – its do as you’re told or get lost. I would like to have a choice in the time and venue of my appointments and in what treatment I get.
This would be a good starting place here in Lincolnshire.
Making Doctors manage budgets is a nonsense. Doctors are medical practitioners, not accounts. Keep the PCTs and have the resources to allow patients to have their operations in an NHS hospital when they need it. Link up the hospitals with after care services as required. Don’t let the insurance companies and private firms take over health care, they are only interested in profit. If our health services are privatised, will European law prevent the UK from ever taking back those services into public control? I believe this might happen under European Procurement law once the UK has opened healthcare services up to private organisations.
Well said
I should like Future Forum members to make a statement disassociating themselves from the inaccuracies and misuse of statistics made in the Government leaflet about the ‘listening exercise’ (see http://www.guardian.co.uk/commentisfree/2011/apr/16/bad-science-goldacre-nhs-statistics) and to set out how they will work in a way which actually enables them to listen properly (eg to the many sensible comments here) and avoids undue influence from DH and ministers.
I couldn’t agree more
I do not want choice or competition. What I want is a good standard of healthcare, irrespective of where I live in the country, and irrespective of which hospital I choose. I want to know that the nearest hospital or clinic to where I live is as good as the next one. I want choice if I am going on holiday, or buying a television, not in my healthcare. Choice will mean differences in standards dependent on geography, which will spell the end of “national” in our NHS.
I fully agree with Laura – I’m not interested in choice or competition, I want good quality across the board, wether I fall ill at home in Essex or on holiday in North Uist, I want to get the same good quality care.
Choice means that their must be waste – in order to be able to choose this or that, either someone is forced to have the thing I don’t want (meaning they don’t have a choice) or we can all choose not to be treated somewhere – which means it will be a waste.
I agree totally with Laura
The last time we had competition between services, it became very difficult to share information with colleagues. Everything was deemed “commmercially sensitive”. One of the best ways of improving services is to learn from others, especially from the best.
Patient choice and competition are largely myths that detract from the more important issues. They only come into play in elective procedures, and they lead, as others have pointed out, to cherry picking by the private sector. We have seen plenty of this in the last few years. What we need is good care at all hospitals, with a reasonable availability of choice of time/date for elective admissions. Please listen to those of us who know.
The problem here is neo-liberal economic dogma. Alas all three political parties believe in it. It is, like religion, a question of philosophical belief.
The danger lies with “Any Willing Provider”. Suppose that Capitalist Hospitals Ltd. builds a district general hospital in Alfreton. It will attract some business. Probably, it and the three district general hospitals nearby (Kingsmill,Calow and the Royal Derby Hospital) will all start making losses. This will attract political attention and one of them could cease trading. The Royal Derby Hospital is PFI, so £ 30 M a year has to come from somewhere whether it treats patients or not. Is there a government guarantee on this £ 30 M ? If there is, it would suit Whitehall to pay for losses up to £ 30 M.
The question arises ofa level playing field between PFI and non-PFI hospitals.
There is doubt about “Money Follows the Patient”. If a GP consortium has a contract with a particular hospital, will it send all its patients there ?
As already noted by several others, I – as both an NHS Patient and as an NHS employee – do not believe that choice and competion are the best drivers of a national health service. They may work for private independent companies but not a single health service organisation whose objuective is to provide the best health service within the resources available, rather than maximise both personal income and company profit.
What we need is co-operation among all services to give the same high quality service to all patients. Once you go down the competition route, you will end up with a postcode lottery and widening of the current inequalities gap between rich and poor.
The questions as posed are not useful. And you cannot include competition and choice as part of the same package. Choice for the pt and in particular informed choice is a must for every user of health service. However, exercising such a function does mean that the health care professional including GPs need to be able to spend more time with the individual. In the context of choice – primary care is not fit for purpose and needs to be reformed.
Competition is useful for improving quality of care and should be used whenever, it is required. However, it is foolish to base a whole system such as the NHS on competition because as other commnetators have said, in many instances, it isnot appropriate to use competition.
I don’t believe it’s a productive use of public money to have competition in the NHS, because we’ll end up with slack in one service or another, meaning not only more job uncertainty for those involved, but duplication of services.
Further, competition will never extend to all the NHS services which are provided, and I don’t believe that most users of the NHS want to have to choose one service over another: they just wanted to be cared for well, as and when they need it. Since the provision of choice will never be spread evenly, geographically, it’s wrong to suggest that choice will somehow solve the issues the NHS faces.
What will happen in areas such as mental health and learning disability? The local services are discharging patients into the community mental health service which can only provide one year of care, and then these patients are discharged to fend for themselves until they reach crisis point only to go through the whole process again. Where has the notion of holistic care gone and seeing the patients as numbers who have to be moved into “recovery” because the books don’t balance? Front line staff as made redundant and the managers and “pen-pushers” remain. How is that right?
Competition and patient choice will not drive service improvement. Well managed, well resourced, well staffed and well educated primary and hospital care will drive service improvement. The Government’s proposals to push commissionign onto already overworked primary care providers will cause service deterioration. The notion of competition in the provision of service is quite ludicrous. When I am ill and in need of care, I want care, not to exercise choice, which in any event is largely illusory – when I am ill, and need care, I do not want the chance to go to the “best hospital” on the other side of town, county or country. I want good quality, reasonably local hospitals and other healthcare provision.
Choice isn’t what patients want – why do we need to choose from a number of different providers of a service when one good quality service is all that’s required? What we really want is good quality advice and care that is as close to home as possible. Having a choice of 10 hospitals doesn’t improve my patient experience – it just makes it more complicated.
I do not want choice in how and where to be treated – I want my local services to provide as good a service as any.
The problem with ‘choice’ in healthcare is that it is not like choosing a snack or a pair of shoes – people all deserve access to good quality health care.
The system proposed will provided the biggest post code lottery for services that you could possibly imagine.
Private providers will pick simple easy to do procedures in built up areas. Leaving the complicated work and rural hard to reach communities (expensive) for the NHS to pick up. Though I am not opposed to private providers per se, I just believe that they should pick up the whole service or non at all. It would be interesting then to see how many could actually run at a profit, and a lower cost to the NHS (bearing in mind that a lot of staff work in the NHS to help people, as well as have a pension, etc. at the end of it all, will they still do it as willingly for a private provider?)
Choice has never been big amongst the patients in this area. Good services locally has always been the requirement, choice just pushes you further away from home. Okay for MPs who don’t mind being away from home a lot, not so good for most of the rest of us.
Re-organisation costs in terms of money but also moral for the majority, why do it on such a grand scale again (every 5 years or so and it doesn’t make much difference each time).
The British Acupuncture Council (BAcC) is the largest body for the regulation of traditional acupuncture in the UK. With over 3,000 members and a track record of delivering robust self-regulation (recognised in the Secretary of State’s announcement on herbal medicine on 16 February 2011). We believe the BAcC believes that it has a significant and expanding contribution to make to national healthcare delivery. BAcC members offer over 3 million patient treatments a year and wish to expand this service work within the NHS. The inclusion of acupuncture in the NICE guidelines on the treatment of low back pain is a demonstration of how BAcC members can significantly benefit the nation’s health.
The BAcC believes that one of the great advantages in placing the commissioning arrangements closer to patient needs is that small providers will now have a much greater opportunity. The BAcC hopes that the commissioning arrangements will permit individual acupuncturists and consortia of acupuncture to compete effectively to provide evidence based services to patients without undue bureaucratic burdens.
Choice is a non-issue.
I want a working – non-corporatised – NHS, for all.
Most importantly I do not want predatory capitalism profiting from the NHS, every penny in profit is money taken away from service… this stinks.
What about asking the General Public if they would consider paying a little more TAX for a better NHS, honestly I think the answer would be yes.
Look at the best national health services in the word, emulate these, if it means raising taxes, do it.
A specialist NHS clinic not far from here is failing to provide adequate care, I’m told. Word is starting to get around local people and GPs, but they are powerless to do anything. Patients will die, coroners will express their carefully worded concerns, the NHS complaints system will creak into action, the CQC will adjust its percentages, and years from now change might filter down through all the layers of management.
To fix that problem fast and save those lives, patients must be able to refuse treatment there. (That’s called choice.) Other providers must be able to step in to provide proper care. (That’s called competition.) An NHS without choice and competition will just get steadily worse. The current proposals are a step in the right direction.
I have some reservations about Patient choice, and whether this is an effective tool for driving up quality.
I am a close observer of the Stafford Hospital inquiry and have noted the relationship between competition, payment by results, the importance of public opinion and patient choice. In the case of Stafford it could be argued that these have had a negative effect on quality.
The move to Foundation trust status placing the hospital in competition with other hospitals. This coupled with financial pressures meant that the board became very closed, and reluctant to share anything that could be perceived as bad news.
Patient choice means that the relationship with the press becomes crucial, as most patients perception will be formed by the press. As many local papers have strong political affiliations there is always a political dimension to this.
Once payment by results and patient choice became a reality, buying into Dr Foster intelligence mortality data became an economic necessity for many hospitals. They needed this to be able to demonstrate that they were offering quality. The Dr Foster system may have been insufficiently tested with the large number of hospitals that joined in the system, and since Stafford the academic research carried out into HSMR have indicated that the system may not have been as robust as people first thought. It is clear that the system depends on coding, and that most hospitals, at least in 2007 when this became an issue, were coding badly. Like many statistical systems the result of this was rubbish in rubbish out!
It is unfortunate that the Dr Foster “league tables” were published in the national press, leading to reputational damage to a substantial number of hospitals.
In the case of Stafford this was compounded at the time of the release of the healthcare commission report in 2009 by an “interpretation” of unpublished material related to the Dr Foster data, being leaked to the press by an unidentified person and passed off as authoritative material.
The reputational damage done by this misreporting has totally unbalanced “patient choice” and has actively damaged the service, because of the damage to staff morale and the difficulty of building a stable staff base.
It has also cost the taxpayer tens of millions in bail outs to keep the hospital functioning effectively, and of course in the multiple public inquiries required to satisfy the public concern caused by the high level of political interest and the misreporting by the media.
the anatomy of this complex story is shown here. http://pressreform.blogspot.com/2011/04/what-forms-our-perception-of-stafford.html
If we are to have a system that depends on patient choice, then this needs to be accompanied by the development of meaningful systems for measuring quality; Something that both the public and the health service can trust. There will also need to be robust protocols to improve the accuracy of media reporting of the health service.
Without these safeguards in place the damage that can be done by patient choice may outweigh any potential benefits.
Patient choice is irrelevant – what’s required is the spread of best practice across the NHS, thereby bringing all units up to the standards of the best. There is no evidence that competition will either improve patient care or reduce costs. In fact, using the model of the utilities privatised by the last Conservative Government, we can see that competition increases prices and reduces standards. Doing that with our electricity supply is expensive and irritating; doing it with the NHS could cost lives.
Choice and competition are complete fallacies where private companies are concerned in delivering public services. Thatcher promised cheaper train fares and greater choice when she privatised the network. There are ever more crowded trains with sky-high fares run by monopolies that act as a cartel. Energy companies have done the same since privatisation. How have these reforms made us better off? If this is what you want to happen to the NHS then back the reforms.
It is my experience, as a nurse, that patients are not too concerned about having choice. They are concerned about having decent healthcare in a local setting, provided by NHS staff, rather than a private company.
NHS care should be equitable, that is, it should be of equal standards wherever it is being provided – however, equity is not something this Government or Foundation Trusts care about.
Once again the Government are out of touch with what the general public are wanting.
Why competition at all. Fund all hospitals fairly across the country. Ensure adaquate staff levels in all hospitals and keep the private sector out. Paying only 30% of the cost of all emergency admissions is stupid. Cars crash, broken bones, sudden illness is just that. People want good local services, not have to travel. Keep the GPs out. I want my doctor to doctor not look at me as a £ sign he cannot afford. I believe that passing the budget to GPs is a buck passing exercise. the Doctors will get the blame instead of the condems. Gps beware your relationship with patients will deteriate quickly. England beware it will be harder to get rid of your GP if you don’t like the service than it will be to get rid of your MP. Where is the accountability. How do we sack a GP consortium. Where are the caps on wages.
Most patients do not necessarily want more choice. They simply want their local service to provide good healthcare. If you introduce choice into the system, then those populations that are most vulnerable and least mobile will be left with a poorer service. There is a real danger of introducing a two-tear system, with wide variations between regions.
I welcome more involvement of doctors in decision making, but GPs are trained to be clinicians, not managers. They will either have to spend less time with patients or contract out managerial services to external providers, introducing an extra cost.
There is no doubt that the NHS needs to become more efficient, but introducing massive changes at a time of austerity is not the way forward.
The Kings Fund Document A High Performing NHS? concluded that the NHS improved substantially between 1997 and 2010 but that growing health inequality clouded this otherwise welcome news.
I believe that expanding choice, particularly where numbers of clinical staff remain the same or are cut, can only exacerbate health inequalities. These arguments have already been made in some detail elsewhere (see J Med Ethics 2008; 34: 271-4). Briefly, well educated individuals with friends in the medical profession, flexible hours and access to transport, will both choose better and have access to a greater range of choices. The likely result of increasing levels of choice is that well to do patients will access the best providers whilst others, likely with greater health needs, will receive their care from other providers.
I think we can learn much by looking at healthcare in United States. As Harvard Professor Atul Gawande has pointed out, in their mixed market, the best healthcare is to be found where providers group together and cooperate to improve performance (see http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande). Fragmentation and competition seem to limit opportunities for quality improvement and drive up costs.
The NHS works very well at the moment. As a patient who sits on many patient involement groups it is easy to see how removing PCT’s and some SHA’s from the chain is already affecting services at this stage of the venture. There will be less patient input and less democracy under Government plans, furthermore, most GP’s I have dealings with simply don’t have time to tend to their patient lists, let alone become involved in commissioning which is a highly complex affair. What may happen , if this plan goes ahead, is the the GP Comissioning bodies, mainly employing ex PCT commission staff, will simply merge creating de facto PCT’s again. WHAT A WASTE OF MONEY.
Patients by and large don’t want this, GP’s by and large don’t want this, Hospitals don’t want this plus it was never in the Conservative manifesto and the plans have so many hole you can drive a bus through then for the Government papers I’ve read. Totally appaling plans from someone who claims to have spent years on the project. THINK AGAIN LANSLEY !
It is dangerous to naively apply standard economic principles to healthcare i.e. ‘choice’ and competition. People who are unwell do not necessarily have the luxury to travel, or to delay treatment, and are often not in the right frame of mind to consider the relative merits of complicated alternatives . Choice is an attractive word and and at first anyone would agree that they want it but the evidence suggests that we want confidence in our local providers, not the burden to choose among complex options. We would like choice of appointment times, and the option to choose a GP, to choose a hospital etc. but the priority is for good local provision.
Competition could work for common, non-urgent, non-essential simple services but even so should not be introduced without considering the knock-on effects on other services.
If the Government want to listen to the people, I agree with Malcolm Swinburn, let us choose how we want the NHS services to be deliveredby by means of a referendum. Its Our NHS not the Governments.
How will competition and choice help those patients who are taken ill and are not well enough to make a choice? Or those who do not have a diagnosis?
The ability to deliver improved services and reduce inefficiencies by developing more integrated care, within the timescale that QIPP challenges, is presently in danger of being seriously undermined by the requirements of procurement and competition. Old systems are remaining in place as long drawn out procurement processes are considered, service redesign is prevented as stakeholders consider whether the redesign will require tendering and procurement procedures, possibly with the consequence of significantly affecting their own position in delivering the service, and local initiatives, often involving existing primary care or federated working in primary care or social enterprise, are undermined by the ability to participate in complex, potentially expensive and time consuming tender and procurement processes.
If the aim is “competition” then full steam ahead, if the aim is improved patient care and value for the taxpayer, pause, and think again.
Choice is fine but it seems likely that private providers will cherry pick cheap services – like joint replacements – and the difficult matters, like geriatrics, will wither.
Also, those of us in country areas, seem unlikely to be provided services in our local hospital or anywhere near. My GP, who is on the steering panel, seems confident that we can keep services local.
My deep fear is that services will be subject to European competition rules, which means the cheapest will win, not the best or nearest.
I agree completely with the above comment by Dr Tom Yates. I also want to point out that most hospital admissions are emergency admissions and therefore choice does not in the majority of cases come into the picture, the ambulance takes you to the nearest hospital. It is therefore important to have a well set up hospital providing comprehensive emergency services within each area. If choice and competition take the profitable services eg. elective surgery from general hospitals, where will the surgeons be to provide the emergency operations? A hospital to provide emergency care has to work as a whole.
Leading questions much?
Personally, I don’t want choice in health care provision, I want a professional medical opinion about what care I need, and where I should obtain it. The last thing I want is a fragmented service where I am constantly having to make decisions about what, which and where my health care will be provided. There seem to be two possible scenarios:
- The choice is likely to lead to a different outcome in terms of my health. In this case, I want a trained medic to make that choice for me.
- The choice will make no difference to the outcome in terms of my health. In this case, I don’t care, just get on with it.
At the moment, I trust the NHS and the people within it to make decisions based on what is best for me. My trust is likely to go down once competition is introduced into the system and if the system becomes fragmented.
I am worried that NHS managers now are conveying to us (consultants) that NHS is going to loose lots of surgical cases mainly becouse of the competetion which is unfair. for example in my trust now there are many cases which have to go to the ISTC even if the patient is asking for her operation to be done locally.
We are asked to send all simple hysterectomies there, imagine the impact on our funding and on the training if the trainees will have no chance to perform any simple procedure.
We are asked now to put down our theatre sessions this will on the long term de-skill us so what we are doing now which is performing complex cases will be extremly dificult in 5- 10 years time. and then all these cases will go to the private sector.
I believe that NHS Leaders are Deskilling their Staff and heading towards privitization which is also against patient choice.
How disappointing to witness a great organisation being delibrately put down to fail.
I hope some one will answer my fears if they are wrong
Some questions:
How will the government ensure that best practice is shared across providers if they are in direct competition with each other? Will private companies happily share all their ideas with NHS providers, and vice versa? Will money be wasted on services having to advertise/promote themselves?
Will patients be told about the whole package different providers are offering – care after treatment, further appointments, liaison with other professionals, reports etc as well as waiting times and the easier to measure parameters, before making choices? Will the GPs making the commissioning decisions also bear the whole package in mind?
How will good practice around information governance be maintained if a patient ends up “choosing” a variety of providers, some NHS, some private, for a complicated condition? I hope the”any willing providers” are signed up to have all the stringent procedures the NHS has.
And a last point: I don’t see how private companies generating profits from tax payers’ money can be a good thing. It’s not what I think I pay taxes for.
The starting premise, that competition will drive an improvement in the quality and efficiency of the health service, is misguided and will cause irreparable harm if pursued in the way being proposed. If passed, this bill will result in a fragmented and unequal service, with a loss of public accountability, and a damaging focus instead on services which are financially profitable. It will mean that resources are diverted towards the self-promotion of healthcare providers within the market, and towards the transactional costs of administering such a system, which will include the costs of defending legal challenges arising from the tendering process.
At a meeting of BMA members held to discuss the health bill in Liverpool last month, attended by GPs, hospital consultants and public health doctors, I did not hear a single positive comment expressed about the current plans. This is not about protectionism or vested interests on the part of the medical profession. It is much more important than that – it is about the guiding principles of healthcare provision in this country.
What the health service does need to improve its efficiency is more collaboration, not more competition. And there is no doubt that difficult decisions must be made about how resources are to be allocated and rationed. In this, NICE must have a leading role, and I find it concerning that its powers are to be reduced.
This legislation has been presented as a “done deal”, whose details only need to be ironed out, to the public and healthcare professionals (including GPs, who have been given no choice but to go along with it). In fact it has no electoral mandate. It is being forced through at great cost – both financial and in loss of expertise from the PCTs, despite the serious concerns of healthcare experts and professional bodies, without being piloted, and with no good evidence that it will work.
Please drop this ill-conceived bill. It will mean the end of the NHS as a public body in all but name, and I sincerely believe that our generation will not be forgiven if it is allowed to proceed.
I remember when I needed to go to hosopital last time, I was ill, in pain and needed an urgent operation. No choice was offered, they just made me better… the only choice i would have expressed at the time. Leave the NHS alone, stop the £20bn savings and keep NHS funding as secured by 2009/10 + add at the rate of inflation. Efficiencies will need to be found, some treatments will stop but all we want is a well run, public not private health care system. The idea of choice is a lie and a myth… hobson invented this one.
The whole thing is a complete joke and masquarade. It is no different to privatising the forests. Greed and avarice will lead us to a point where healthcare will be affordable to the rich only, and all the rest will be simply sidelined. Privatising public sector industries such as NHS, Railways, council services etc. is done for the sake of securing profit for a bunch of people who already have more than they can spend in a few generations and not out of good intentions, and we, the people, know that.
Competition has the potential to fragment joined up working, create protectionism and hand offs and slow the process of the patient through the system – none of this will help improve quality. It is interesting to see that in America since Obamas healthcare reforms there is consolidation of hospitals through M&A as a way of ensuring continued financial viability. Smaller hospital are being taken over and in some cases closed – I do not think this is a bad thing to see in the UK – certainly where Darzi was successfully implemented (Stroke and Cardiac care in London) and where Cancer networks have encouraged sensible redistribution of services outcomes have improved. Unfortunately the Health Secretary is taking a too “top down” approach to provider landscape reconfiguration – as seen with the Barnet and Chase Farm debacle – he is still too politically involved in healthcare – even when local GPs and Consultants are reccommending this is the right way to go. Patients want to choose high quality services – even if it means travelling!
It is easy to make that judgement in London, or other large urban area. I live in a rural area where there is one major hospital in the county and few transport links around the county. The next nearest hospital is nearly 100 miles away in the next county. Patients in my county don’t have choice because basically there isn’t any, and they would not want to travel to the next county for treatment (we had an issue last year where some procedures were being transferred to the hospital in the next county….it caused a major scandal). How many times does it need to be said for people to listen? All patients want is good healthcare close to home.
Competition only works where there is a real choice, have you asked people if they want to research, travel and possible wait longer when they are unwell or have you just assumed competition is always king. NHS should mean excellent care for all not a post code lottery. Accident and Emergency care is about the nearest hospital or the nearest specialist service how do you expect children’s hospitals to compete against each other they 50-100 miles apart. The bill is ill thought out it undermines the principles of the NHS. GP practices are private business but you rarely see people moving because another practice offers something else because the majority of people don’t need to see their doctor weekly and just want to be treated when required.
Choice requires information, relevant information. E.g. does a local service improve the health status of patients who are treated there? Do patients subsequently get back to work? Do they subequently live in the community? If they have a progressive condition, are they supported to optimise their level of functioning and quality of life?
The current arrangements do not routinely collect the information that is relevant to answering the above questions. Instead the focus is on the busy-ness of staff – how much is done, and not whether there are long term benefits to individual patients and their carers.
Activity data may be useful locally, forinternal management purposes, but ‘choice’ requires new sets of data to be collected some time after interventions/treatments have been provided – to see whether they made a difference to someone’s actual life.
No good as ever come so far by bringing in external providers to sit on top of exisiting NHS services ‘to run them better’ . There is huge potential to streamline NHS services and make cuts in expenditure, without cutting services. Unfortunately with the curent policy these will be realised by private companies, probably not even UK ones.
Suggest you stop the practice of emptying the coffers on the 31st March every year as a start, then reduce the burden of endless, mindless, and often meaningless reporting to the centre, which costs PCTs millions to do. Getting PCTs to pay other NHS bodies to manage thier provider services for less than a year is another blinding piece of nonsense from the DoH
The Cost Conundrum in The New Yorker thoughtfully supports those who value cooperation as I do. See the post by Dr Tom Yates above.
This section assumes competition and patient choice will improve the NHS. Capitalism requires competition to curb the self interest of its free operators. But religion advocates restraint, concern for others and cooperation. I urge government to deploy in the essentially socialist NHS, emulation to improve efficiency and subsidiarity so services can respond to local circumstances including, of course, what GPs advocate and what patients want.
As several posts note, patients value good, local services over choice. Note, prior to the money following the patient, anyone could ask to be treated elsewhere. Then many fewer were in admin!
Competition and patient choice will not improve the service. Well managed, well resourced, well staffed and well educated primary and hospital care will drive service improvement. The Government’s proposals to push commissioning onto already overworked primary care providers will cause service deterioration. Patients do not want choice they want good service accessed locally.
Choice is important in so far as patients and users of care services should be seen as equal partners in the outcome of delivering good health. Too often this is not the case. There are still massively outdated attitudes in the medical and nursing professions of ‘we know best’. Having said that the NHS is a fantastic serice run and staffed by many, many fantastic people in a very efficient way that needs continued support and funding and absolutely must remain public. We spend far less on administrating health services that other countries but this would change if more and more providers are enabled to skim off profits at the expense of patient care. What we need are more responsive services, better joined-up working between departments and professionals, more sensible patient pathways, better customer service and genuine involvement of patients, better patient experience, better public health and prevention and more support staff to let clinicians do what they do best. The public will never forgive you if you sell off their NHS.
I think people want their local health providers (NHS) to provide effective, prompt, high quality services. They do not, as a rule, tend to value choice – people think that their local doctors, hospitals, clinics etc should provide them with the high quality care they need, when they need it. They want to trust their doctors and consultants to make the right choices for them, based on their expert knowledge. Privatisation, choice, further opening up the market to private providers will allow the above mentioned cherry picking and will further undermine the NHS that the nation values so much, until such time as it is completely unsustainable – and at that point its demise will be inevitable. This should not be the direction of travel, it is idealogically unsound and will not serve the people of England well in the future.
I have a number of concerns which I will detail below but the real frustration is that the amount of missing details and areas where further clarification is needed makes it impossible to really understand the true implications of these reforms.
1. The removal of the duty on SOS to provide a comprehensive healthcare system and only to promote it must be changed. This undermines the underlying principle of the NHS and relinquishing this duty sounds the death knell. This duty must be retained.
2. Monitor should be responsible for ensuring the cost/clinical effectiveness and value for public money of service provision , not for promoting competion. Competition should be a by product of providers demonstrating they are providing high quality, clinically effective, value for money care.
3. The quoted figure of 30-40% of the NHS budget being retained by the NCB is a realistic % but the maths/actuality of the figures simply do not add up. Local comissioning will be responsible for more than 60-70% of the care. Clarity is need on this based on real costs before budgets are allocated.
I genuinely hope you are listening – but I doubt it!
Choice is a luxury we can no longer afford. The general populus are clear that they are happy to have quality local services above choice.
getting it right first tiem is more important that choice. Not duplicating and therefore creating waste is more improtant than choice!
People choose to have good quality health care, to have an nhs that they can trust and to know that health care providers are not motivated by profit. When you are ill you do not want to be asked how you want to be treated, by whome and where! Choice is about being able to choose a system of health care that is open, transparent and honest. This cannot be achieved by free market forces where you have to undercut to survive.
Personally, we do not want choice in health care provision, we want, and ‘deserve’ a professional medical opinion.
We need better quality which requires understanding of the health system – something lacking from this stick up job. Privitisation, choice and competition will not give us a better system under the ham fisted changes being proposed. GPs and clinicians generally don’t have a clue how to commission services but they do need to be involved. They don’t understand what their patients as a whole need – they only see the sick patients coming through the door. Not the same thing.
Service users want reliable, properly funded local services. Choice is a chimera: how many users really have the expertise to choose properly between particular providers, particuarly when all the PR of the private sector is brought into play to blur the picture?
I believe that the greatest threat to the NHS arises from a dogmatic assumption that competition is always the right thing to do.
As a Hospital Chief Executive, my main concern over the next four years is to be able to maintain quality whilst also having to make 25% efficiency savings against a trend where demand rises at the rate of 3 to 4% per year. This is an extraordinarily difficult challenge and I believe that no modern healthcare system has ever managed savings on this scale. The best chance of meeting this challenge is to keep as many people as possible out of hospital, by organising all health and social care services in a way that seeks to look after patients in their own homes. The evidence shows that this can be achieved provided that there is very strong collaboration between all of the providers of care. For example the Kaiser Permanente Healthcare system in California is a fully integrated care system and has roughly one third of the hospital beds compared to the NHS.
Not only is collaboration the only solution to our challenge but competition is at best at distraction and at worst could force some hospitals into failure.
What good is choice to a patient with an urgent condition or emergency? Patients want good treatment by a reliable provider as close as possible to their homes. Competition may work when there is the potential to grow a market, although in healthcare this leads to duplication of services. But when money is tight, competition will hasten the collapse of what is evidently an unsustainable configuration of services. We need a proper strategy for healthcare in the UK, which grows the collaborative capacity of the NHS rather than destroys it.
Choice is not essential..people want to be treated in a clean hospital by competant staff in an area close to their home – travelling miles and miles for treatment is not what is wanted.. Choose and Book has never worked… won’t work in how it was truly meant to be used – very few hospitals actually have opened up their slots to direct booking (particularly specialist hospitals where capacity is a huge issue already; last thing they need are inappropriate referrals eating up valuable slots).
privatising healthcare (because, let’s face it, this is where it seems to be heading… american model) is not the way forward… being american, i have first hand experience of this system and it favours those who can afford it.. or have the appropriate insurance to recieve the best care – countries should take care of their people,
Time after time the evidence (which has been reinterpreted since) is that patients don’t want choice they want high quality local services. The precept that choice improves quality is based on consumer purchasing not healthcare provision of which there is little international evidence. In supermarkets people can make choices over quality and price by spending more for Heinz or less for own brand. This is not a model suitable for healthcare. The choice agenda has already cost the NHS £billions in higher payments to private sector providers and part completed contracts that have been fully paid. The excuse was that this was about funding the private sector market entry costs. No other ‘market’ system would do that. This is a flawed plan from a flawed policy based on flawed and deliberately misinterpreted evidence.
If just 10% of the NHS worksforce has spent 10% of their time on the *transformation* then over the last year anything up to £1 billion has already been spent in the last 12 months on something with no evidence base or evaluation. What would NICE have to say about that?! How many more scarce NHS resources will be wasted in this manner? What a shame the taxpayer hasn’t had any improvement in service from this waste.
Many of my patients are very happy with the alternative to our local trust. They enjoy the ease of parking, face to face consultant care, short waiting times. etc I encourage patients to use this service when they are mainly seeking reassurance or need a quick diagnostic and opinion. I do not feel this detracts from our NHS provider but rather gives them space to deal with the more complex conditions for which they are ideally placed.
In the future , Gps as commissioners will be setting the specifications for all providers factoring in such issues as training, clinical standards etc. We have an excellent local trust but not all the services it provides are excellent. Just because it is local and NHS does not always mean it is the best place for my patients to be seen .I welcome this opportunity to raise standards
Question – would it be possible to arrange this page so that the most recent comments are at the top of the page & be able to leave a reply at the top of the page to save scrolling through all responses?
Hi Baze – thanks for your question. The comments appear in chronological order as we think this makes it easier for people to follow conversations and to see what others have previously said.
Annelise@DH
I agree with both of you, so would ask for an additional option in this page, or a copy of this page, that will order comments as Baze suggests.
Rather late for this but I search each page with the current date then one day earlier.
‘Choice and competition’ is not a panacea and focusing on them as a silver bullet to cure all ills is mistaken. More important than choice is access to good quality local services which is what most people want. More important than competition is collaborative working between different agencies and services to provide quality care across the whole patient pathway. Competition can have negative consequences where it impedes information sharing and leads to quality being undermined to deliver low cost services.
Some of my views as a Public Health Consultant are:
that choice and competition are probably not the right levers to deliver the required improvements in the NHS;
that the current appointment at Monitor appears to be even more of a potential liability for the future of healthcare than the health secretary;
that pushing through an ideological reoganisation of the NHS without any manifesto pledge puts the Conservatives in a position which they are going to need to do a lot more than “stop digging” to extract themselves from;
that I havent really got a clue as to how I would recommend getting out of this mess but it really is a bad mess – I would probably ditch the whole bill; appoint Steven Dorrell as health secretary and try to aim to regain the status quo ante as the least worst outcome.
Wider than the NHS, I consider the ditching of all regional structures as equally barmy, and another area where the government will need to revisit.
Choice in healthcare is important to me, but not choice between providers.
I would like my local GP practice and hospital to deliver safe high quality services (and be subject to external inspection), genuinely engage me in the planning of my care (e.g. explain the choices of treatment available to me) and to offer me choice of appointment time.
I don’t want to have to ‘shop around’ between providers in the way that I have to shop around between utilty companies.
In answer to the question how can we best ensure that competition and patient choice drives NHS improvement. We have to ask ourselves if it is appropriate when patients are at their most vulnerable are they always capable of making an informed rational decision, when the drivers for the providers is financially driven and not driven by quality. PCTs or GPs referring to a ‘centre’, not because it is the best care, but the best price creates a huge conflict of interest (real or perceived) which will damage the trus in the relationship between NHS professionals and patients. So the question should be – is it right to create competition in the healthcare sector?, and what impact will this have on patient care and professional integrity and training?
Provider organisations working in partnership, not competition will allow professional integrity to remain intact, the appropriate professional training to be delivered, whilst also ensuring patients receive the right care at the right time – and this should be the priority.
Competition can drive improvements in the market place – up to a point, but then the quality, cost or time will begin to suffer, and that will reflect directly on patient care. It is understanding the end point that no more efficiencies can be achieved in an area that causes the greatest concern. The question should then focus on priority areas for the health service – what is in and what is out of the NHS – i.e. should cosmetic surgery of any sort be provided on the NHS? e.g. tattoo removal, vary veins, breast augmentation if there is no physiological rationale – should IVF or PGD be NHS provided? – there is no doubt there are economic benefits for fertility treatment, but wider health benefits can be challenged? We need a public debate on this!
Competition will not work in the balanced healthcare economy – it risks distorting service provision – competitors would need to offer the same or equivalent ranges of products and that is not built into models – and the consumers/customers do not have enough information and do not necessarily have a reasonable mindset to made rational or reasonable choices
Bad question. It assumes the answer it tries to solicit.
Public-owned institutions can be very badly run – patients drinking from flower vases in Mid-Staffs and so on – so the ability not to choose such a place can be valuable. But much more important is the provison of local services, whether private or nationalised, which are paid for in advance out of our taxation, meet most of our needs, and are administered with a human face. Thus – get the GP surgery to be open 12 hours a day, with a pharmacy next door, and a hospital and minor injuries place within a few miles.
I don’t mind whether the money to build facilities comes from private shareholders or government-borrowed funds (for which they pay interest). Let the NHS be manifest near me as a Local Health Service as good, in its own way, as Marks and Spencers and I’m happy.
I have concerns that as a listening exercise, comments are edited? Is this really listening?
Hi James
We do not edit comments in any way, and we publish all comments that are in line with our moderation policy.
Annelise@DH
Quality not choice
Collaboration not competition
In answer to the question “what is the best way to ensure a level playing field between the different kinds of provider who could be involved? “, the playing field will not be level unless all providers wishing to supply NHS services do so with the same pay, terms and conditions for staff as other providers. Otherwise, providers can undercut each other in the commissioning phase which will mean less qualified and experienced staff. In addition, there would be a risk of clinical staff moving to a different area precipitating a ‘brain drain’ if one location offers superior pay, terms and conditions such as pensions.
I think that increased choice will express itself as increased choice for commissioners rather than patients. There will be a larger number of organisations willing to provide services, and commissioners will choose between them. I do not believe that there will be a greater number of hospitals, dentists etc for patients to choose than is currently the case. Commissioners will then try to choose the provider that they think will best meet the needs of the local population. This will reinforce the image of the dreaded ‘postcode lottery’.
Choice is meaningless in such a highly regulated business, the capitalist model doesn’t work when everyone has to do the same thing or get struck off. The concept of competition is only useful when you have a monopoly that is working on a 10000% profit margin. This is not the case in the NHS, its run on a shoestring. By breaking up the NHS you stop co-operation and sharing, the two things that make the NHS so cheap. People don’t want a choice, they just want good healthcare.
Is this a genuine listening exercise? Who judges what is off-topic and how quickly is the moderation done? Why wasn’t there a 5th question such as “Is there anything else we need to know about how to make these reforms work?”.
I’m concerned that the phrasing of the 4 questions can be used to set aside a whole tranche of legitimate concerns about the reforms, like how the way the internal market rules are managed is likely to really make GPS frustrated that they can’t actually properly fulfil their role.
Thanks for your questions.
The site is monitored regularly during normal working hours, and we aim to process comments as quickly as possible and usually at least hourly. We are publishing comments on issues other than the four specific themes and these will be fed back to the Future Forum as part of the listening exercise.
In this context, ‘off topic’ generally means something that is not related to the modernisation of health and social care.
Annelise@DH
This is a leading question, making the assumption that choice in healthcare is a good thing and is something that people want. the concept of choice in healthcare is a figment of the imagination of politicians.
All we want is an assurance that good quality services are available locally. It is impossible for most people to access sufficient comprehensible information to make an informed decision based on “quality”.
The Choose & Book experience showed that most people chose either a service with the shortest wait or one with the easiest parking.
Giving a choice of providers is likely to fragment healthcare and give a poorer service overall.
Need to look at co-operation and collaboration to provide the best care and services at optimal costs to both customer and supplier. Its called partnership and is a win-win!
I believe that creating a competitive environment within the NHS was the first step to its demise. Recreating an atmosphere of team working at all levels would improve the situation for patients and staff alike. A genuine sense of working together to provide the best service possible not only gives a sense of pride and achievement to staff but also ensures that patients needs come first.
Contracting out services like the cleaning of hospitals is a good example of what happens when competitive tenders replace a sense of ownership and commitment to a hospital team. Hospital infections increased dramatically when services were contracted out because the sense of being a vital part of the hospital team was lost.
I agree with you. Speaking as a part of the NHS management that has burgeoned since 1991, the creation of an internal market has: a. identified the prices of services (good), b. led to the employment of thousands of management and admin staff charged with protecting the financial position of providers and purchasers, c. without any discernible quality benefit (in my opinion, and d. but with a bias towards investment in acute hospitals at the expense of mental health, LD and community services (because acute hospitals have been able to generate extar income as a result of the PBR system).
All of the quality benefits have come from top-down directives as to priorities, and not from choice, which has been around since 1991. Even though there was an internal market, some of the problem areas (MRSA, C-diff, poor care of the elderly) got worse.
Choice and competition are possible in UK healthcare but come at a cost, a cost that would have to be borne by the UK taxpayer. Costs are incurred because choice is by definition wasteful – to be a meaningful choice there has to be more than one alternative available, this means that some alternatives would be left unused – hence the waste. Market enthusiasts will say that only the less popular providers will be left unused and they will either have to change or fail. However, resource from somewhere in the system must still be expended to provide the unused choice – in a taxpayer funded system this will ultimately be from all of us.
Can services be allowed to fail? It is difficult to see how this could be permitted in health since patients may be left without essential healthcare provision. If a service did fail – become insolvent for instance – there would need to be a safety net, we are assured there is to be such provision, to ensure that no patient suffered. In other words these services are too important to be allowed to fail and so must be bailed out – just like the banks in fact, which is how we got into this mess.
Competition implies a market, markets have costs – their transaction costs. Market transaction costs are made up of the costs of accounting, generating bills, sometimes gaming around billing, marketing the organisation’s services together with profits to shareholders in private organisations. These costs can be substantial even in healthcare – please examine transaction costs in the US healthcare market, they are enormous. Transaction costs in a healthcare market mean money that is part of the health budget that is not spent on delivering healthcare, it is spent on running a competitive business. I am far from certain that, in such cash strapped circumstances as we currently find ourselves, that it is sensible to waste our resources on establishing a competitive business environment rather than spending the money to help sick people.
I agree with the many other people on here who have said that patients do not want a choice of health providers, they want good local services.
I also do not want a privatised health service. The raison d’etre of any private company is, by definition, to make profit. How can you possibly think it is conducive to introduce profit into a system that is supposed care for people?
Millions of poor Americans have been unable to access decent health care under the terrible US system and now, just as Obama is trying to reform this, you are proposing to destroy our great, world-famous NHS.
Dividing commissioning of services into ever smaller packages with hundreds of consortia will return us to the good old days of declining procedures becuase the purse is empty. How on earth will there be equity of access for patients when each little patch will decide what it wants and more importantly can afford to pay for?
I think choice is meaningless. People want healthcare not choice. It’s irrelevant. And all the is sompeteition so called free market workship. Its rubbish. Health should be public services not provided to make profit for shareholdersetc.
The govt reforms miss the point anyway. The only good idea is to locate public health with local authorities but until they say how much budget will be protected for public health it’s just rhetoric.
The issue is using our public resources holistically to promote health. Now far far too much is sucked up by hospitals and hi-tech costsly treatments when we need to invest more in health promotion etc. What we need to debate is how to achieve this. I think it means giving more power and resources to Directors of PH and having democratic representation via the health and wellbeing boards that are being set up.
Patients do not want choice of different health providers. They want good quality services that are all of the same good quality whereever they are accessed. They may want choice over where they access those services and at what time to fit in with their personal commitments. They want services to remain free (within the NHS). I agree that services should offer value for money but how can making a load of staff redundant in one organisation and then re-employing them in a new organisation to do a similar job be offering good value for money which is what appears to be happening at the moment. Patients do not want a privitised health service.
I desparately hope that these messages do penetrate to the “great & good” who are in the driving seat of the planned changes. I am in complete agreement with the comments which emphasise that the NHS is not for profit and should not be in the business of creating profit for other organisaitons.
However, I fear that we may all be deluded into believing that these views will truly influence the decision makers and this listening exercise is simply a diversion!
What if there are no types of services where choice of provider is most likely to improve quality?
Choice can only be in planned NHS care, by creating too much choice we risk those who are unable to choose missing out, a two teir service. In an emergency who can choose, if choice is there and there’s no time to in an emergency situation, how are patients going to feel if where they go is not where some would choose to? A see a vicous circle promoting some options by seeing others delcine. Why not drive up standards another way? patient satisfaction surveys, open reporting, audits etc
The reforms will mean significantly increased privatisation of the Health Service and the commissioning of services being subject to EU competition law. This will in turn mean vastly increased costs for the taxpayer due to legal challenges, and the closing of hospitals as activity is siphoned off to private providers to promote competition at the expense of quality and cost-effectiveness. In the long-term there is a good chance that it will mean the ‘dismembering and dismantling’ of the NHS and its core principles. If this website asked the public whether they wanted this then im sure the answer would be a resounding no. However, the level of misinformation coming out of Downing Street on this issue is astonishing.
There is no evidence whatsoever that increasing competition within health will improve quality or save money, and in fact the evidence from other privatised public services is a decrease in quality, and more cost for the taxpayer and the consumer (e.g. social care, electricity and gas, water, etc.). Im all for positive reform of the NHS, but why does it always have to be the same blinkered nonsense about markets and competition?
My main concern is one of management.
Just because a doctor is excellent at their job does not make him/her a manager.
Managing a budget whilst caring for people is a skill few possess and I suggest that a medical centre manager with responsibility for finance will be the key to success.
There must be no hesitation in replacing managers who are unable to provide the service expected of them and any regular audits carried out to prevent bribes etc being accepted or even offered.
I disagree with the contention that competition or choice can provide improvements to patient care on the following grounds:
1) there is little evidence to support this from healthcare systems that have employed such a market approach (USA)
2) Patient choice caters better to elective non-urgent services – providing a second class of patients requiring acute services – these will typically be the poorer, elderly, less articulate end of society.
3) Healthcare workers have little interest in making money , but are interested in providing caring care. It is “big business” who are interested in market values – conversely they are not interested in providing care, but rather making profit for their shareholders.
4) Health services cannot be sufficiently controlled through market regulation because the complexity and unpredictability of treatment makes it impossible to set out all eventualities in contract.
How can you have competition in an environment where women are accessing services that are equipped to safely deliver their baby. Women and babies are not commodoties with a market value that will generate an income. They are human beings that require a service that supports them through pregnancy and childbirth. Both are extremely unpredictable and serious problems can occur. Our service is already stretched, midwives work long hours, 0ften without breaks to provide this service, they are demoralised and often disatisfied with the level of care they are able to give. If competition increases the amount of women booking then the service and the midwives will be further stressed and unable to cope. I really don’t think that competition will help us to deliver the standard of care we all strive for. I see these reforms as yet another of the conservatives efforts to privatise our health service, to the detrement of those who are poor and vulnerable. Everyone is able to access health care when they need it and this is how it should stay.
Wheelchair Services:
The forgotten part of the NHS.
Under funded
Under staffed.
Under rescourced.
Therefore under performing, (from the patients point of view)
As many others have said, there is no evidence at all that bringing in the private sector will improve care or lower costs. There is plenty of evidence that such policies will increase costs, because of higher administrative costs, shareholder profits and so on. Quality of care is very likely to suffer, particularly when there is competition by price. Integration and co-ordination of care are essential but will be far more difficult with multiple providers which are in competition with each other.
The Bill is a real disaster, is hugely unpopular, and must be thrown out completely. Any party which supports it will not be forgiven by the electorate for a very long time.
As a patient, I want choice. I don’t want competition.
When I go to my GP and (s)he thinks I need elective surgery or to have an outpatient appointment, I want to choose where and when to have it, much as I would choose a hotel or flight by looking at the options on the internet and making an informed decision. I should be looking for when they could fit me in, how far the provider is, etc. and listening to my GP’s recommendations.
Obviously all providers should be meeting the minimum agreed standards for care but some may be more specialised in certain areas and some doctors may be better at some aspects within their specialism, so quality of care should be visible when I’m making this decision with my GP.
The least concern to me, as a patient, is the cost because all care on the NHS should be free at the point of need.
As an addendum to my note above, what I don’t want is my informed choice to be overridden by a well-meaning organisation, whether it’s a PCT, GP Consortium or the NHS CB, who think they know better than myself and my GP, and for my referral to be switched without my consent.
We are unable to afford a system where cost is disregarded. Everything will only be free at the point of need if we are wise with the money we have. If we all say we are not concerned with the cost then the NHS will collapse.
We do however need to look carefully at services and ensure that they deliver acceptable outcomes and it is vital that value and not just cost is looked at.
Choice of provider will only work if there are restraints on expensive services, particularly where there are cheaper alternatives that deliver quality outcomes. We simply cannot sustain patient choice without cost being part of the decision. Any qualified provider could be a disaster.
If you were looking for a hotel you would certainly include cost in your decision. Don’t you think it is unreasonable to ignore it just because someone else is paying?
It seems fairly clear that as far as patient choice is concerned the public has aleady chosen. When it comes to deciding between a privatised health care system and a public service funded by taxes we want the NHS to remain a public organisation. Any other questions of choice are quite secondary to this.
False Choice!
The only choices regarding illness are (1)Treatment or no Treatment
(2)effective treatment or inneffective treatment(3)universal access or pay as you go.
The NHS used to be centrally planned with resources provided to meet known and anticipated need – this has been long lost due to clinicians being forced to “compete”with other clinicians with whom they used to collaborate.
Competetion is usefull in business but since when did pain and suffering become a commodity to be traded and profitised?
The internal market was brought into the NHS in the 1980′s & at that time had a big impact in shaking up what had become a complacent & wasteful beaurocracy.
The NHS has moved on. Almost everybody in the NHS now realises that money is limited & value for money is key, everybody I work with is desperate to improve efficiency and patient care.
There are 2 main things that keep getting in the way, the first is that every time we start making some headway everybody gets diverted into a big reorganisation & all the improvement plans that were half done get forgotten & we have to start again.
Secondly, the internal market focuses all the managers efforts onto budgets, tarrifs & contracts when they should be focussing on supporting the clinicians to look after patients.
The internal market, whilst a helpful tool initially is now hugely wasteful & past its usefullness.
people need very good information in order to make informed choice. Who is making the choice the patient or the GP or another professional? The question is not clearly defined. For therapies neither GP nor patient will necessarily have the knowlege to make an informed choice. Choice will therefore depend on the ability of providers to build a good website with good links, advertising, or word of mouth, as it does with private sector services. Stat sector services should already be providing clear info on what they provide. Think the whole choice question is not the right one to ask- think the right question is how can you ensure good quality local services in all areas. Getting a good GP and dentist in the first place are the major challenge for us in London, let alone getting referral on to secondary tier services.
I completely agree with what Kate has said. Real choice can only happen when patients and clinicians have access to accurate, clear and unbiased information on outcomes or quality. And we know that healthcare quality is incredibly difficult to measure. It’s simpler for one-off elective surgeries (hip, eye, etc) but nigh on impossible for people with complex and long-term conditions or for co-morbidities.
Providers will have to provide information (aka marketing material) and who will be ensuring the accuracy of this? (and paying for it…?)
And this marketing will also cost money – driving up costs for providers.
Healthcare is a team effort, we drive up outcomes by collaborating with our colleagues across the NHS. We tell people about or best practice and seek advice and second opinions when we need to.
We do not compete with them!
Real choice will eventually cost more money no matter what competition is generated! Choice in the current NHS set up is just a farce, titivating around which treatment centre one would wish to go to – this isn’t real choice! Let’s stop all this choice nonsense – what we need to be realistic about is if the NHS needs to stay afloat with good quality health/ill care then the fundamental focus should be that NHS care should only be provided as an essential need, not one of choice or luxury! Why would I care if I get treatment at Hospital A, B or C – as long as Hospital A is safe and near to my home, why would I want to bother with Hospitals B or C? And if Hospital A is not safe to provide treatment, why should this Hospital remain in business? The costs of operating what the NHS terms as choice currently is a pure waste of money!
Outside the NHS. We have retirement homes, Care homes and Nursing homes. Over a number of years there has been and it continues media criticism of the interfaces between patients when they are admitted. Nurses are now much better educated and highly trained almost to degree level. Therefore there must be a fundamental change in the way patients and dealt with. That is to say the NHS should seriously consider splitting the “Care” side from nursing and introduce two new grades. The first grade would be responsible or ward cleanliness including toilets and bathrooms and also the provision of beverages etc.including the provision of water outside meal times.
The second grade would be responsible for the Care side involving personal hygiene, combing hair, serving meals and helping with feeding and dealing with continence issues. There could be career progression through to nursing. This could be cost effective and free up nurses to do the job they are trained to do
I have needed expensive cardiac care for the last 20 years. There is really no choice as to where it is provided as it has to be a regional heart hospital. I cannot see how competition could possibly change this and am really afraid that the government will wreck a perfectly good service.
I live in dread of the day I go to my GP and am told the cheapest option is 300 miles away or, worst still, there is no money. That is the reality of the proposals.
Doctors I have spoken to say they are alarmed by what will be expected of them. One GP said that doctors were being setup to fail as they could not possibly cope when they private providers will be brought in. What choice will there be then? How will the private sector make a profit out of the chronically sick?
The NHS has served me and my family well for a long time but I feel future treatment will be compromised by an ideologically motivated government that knows little about the experiences of ordinary people. We do not have a choice now and will not have a choice under the new system. The message I get is that my treatment will be too expensive so the alternative, or is it the choice, is to go away and die quietly.
The question implies that competition will improve quality: is this fact or just ideology? The consultation should presuppose answers if it to be anything but phoney.
A level playng field is best assured by requiring common standards, a common tarriff and no opportunities for picking the easy and profitable – i.e. no repeat of the ISTC fiasco.
The keys to make patient choice a reality are ensuring good information is available about teh things that matter, and restoring to GPs the right to refer to wherever they wished which they had until the “purchaser-provider split” and other market based systems were imposed on the NHS.
What a dreadful leading question!!
‘How can we best ensure that competition and patient choice drives NHS improvement?’
Anyone with the minimum level of expertise in genuine consultation methods will know this is an entirely bogus way to invites views.
Why not substitute ‘co-operation’ for competition? All the academic evidence I have seem demonstrates that health systems based on co-operation deliver better patient care for the level of investment than those prioritising competition. The truth is the entire health bill is just a cover to privatise the NHS.
I believe Cooperation is the key to a top-flight health service. Those who think competition is the answer are wrong. You cannot run a health service as if it were a greengrocers,with cut prices and special offers. The supermarket model is not the answer (unless it is the Co-op – have you studied their principles?)
I want a good quality, local hospital, well funded and well staffed, with suitable patient input where necessary.
Why do men always go for competition?
I agree one of the key attributes of the NHS is the co-operation to be found in all parts of the service. The emphasis on competition will be the downfall of it. Personally I don’t want an NHS where competition is the sole management driver. My own health problems would not be attractive to a private provider.
David Owen has produced a small pamphlet on the NHS bill and highlights some of the problems associated with introducing the form of competition proposed in the bill and especially the role of Monitor. I think all Dept of Health civil servants and MPs should read it. It seems to me totally inappropriate and unacceptable that EU competition law would be applicable to the services of the
NHS . As a previous comment highlighted, this is a very loaded question from the Dept of Health, aimed at getting the answer it wants. I did expect better of our civil servants
The reforms are asking GPs to undertake a task that is broadly going to be impossible to achieve. We as GPs are being asked to slow/stop the upstream traffic from our surgeries into the secondary care sector. However the front door into our surgeries is wide open and there are no brakes on anyone consulting us for anything they so desire. Although we can bat away many of these requests ( this week I had someone asking for suntan lotion as he thought that it was too expensive from a chemist), this open door to general practice creates unlimited demand and does lead to activity up the chain. Politically incorrect this will sound unless there is some mechanism either insurance or a charge to enter the NHS, we are never ever going to be able to curb demand.
It is ethically and morally wrong to restrict healthcare to the rich and refuse healthcare to the poor, simply because they can’t afford it. That’s what happens in the US, where practically all of their healthcare is privately run. Letting health insurance companies into the game will drive us towards this disgustingly unfair system.
Health is not a commodity and should not be subject to market forces. The new bill places far too much emphasis on promoting and increasing competition and this could ultimately be detrimental to the NHS, opening the way for full-scale privatisation. I am glad to see that the Royal College of GPs have come out against this.
An element of choice already exists within the NHS but we are suddenly being told we need even more. I don’t think we, as patients, are actually asking for this. I think when it comes down to it, most people are happy to rely on the experts to guide them in the right direction. More choice and private providers do not necessarily equal better care. The White Paper on the NHS reforms mentions that these reforms borrow elements from the utilities, rail and telecoms sector. That’s all we need – a bewildering array of choice but not very good service.
The writers of these questions just don’t get it. Health (and illness) isn’t an industry with commodities to be bought and sold. Health is deeply personal and interwoven with every other aspect of our lives, and illness is often unpredictable and unfair.
As a GP, I’m privileged to be able to try to help people with their health and illnesses, and I’m pretty sure what the vast majority want is the best quality services possible, as close to home as possible, and as soon as possible. Choice confuses patients – why would they want a choice of hospitals when they only live on a bus route to one? In my experience, most people choose the nearest local acute hospital; a few want to go to the next nearest acute hospital as they have had a bad experience at the nearest hospital. When a hospital about 10 miles / a 20 minute drive away is suggested because it has the shortest waiting time (according to Choose and Book), the response from patients is usually along the lines of “that’s a long way”, or “I don’t know where it is”.
I am also a patient, and have had my life saved by the NHS. I’ve no idea how much I cost, but acute,
life-threatening illnesses when everything is thrown at you despite your doctors thinking you likely to die don’t come cheap. And aren’t the kind of illness there is likely to be much competition to treat – which is what terrifies me about the proposed NHS reforms.
Competition for pile ‘em high and sell ‘em cheap elective treatments (from private sector organisations using staff trained in and techniques developed in the NHS) will leave existing acute hospitals with the expensive illnesses in the risky patients, and they will collapse financially.
Competition by “Any Qualified Provider” governed by competition law will not only generate massive process costs in an era of enormous cuts; it will be the end of the NHS.
Competition will not drive NHS improvement; it will leave piecemeal services for patients who cannot choose when, where or how they get ill. Yes, the NHS can improve to give the choice almost everyone wants – high quality care near to home as soon as possible – but competition is not the vehicle for driving this.
I agree with Deborah White. I’ve worked in the NHS for 30 years, both clinically and in public health medicine, and see these proposals as destructive, without electoral mandate. Health is not a marketable commodity. Choice is important but also expensive and what most people want are high quality, accessible services. This might mean some national agreement on what is provided within the NHS. The competition that is being proposed will drive down quality and rapidly bring privatisation. It is perverse to reorganise when we need to save large sums of money. The proposals make me very angry and willing (for the first time in my life) to go on protest marches, even riot!
Totally loaded questions.
To ensure a level playing field, don’t give the Private sector cherry-picking contracts, and factor in the costs of training for NHS providers.
Why is patient choice of provider deemed to be so desirable ? I don’t want choice of provider, I want good quality care locally. But what I do want is to have my illness fully explained, and a choice of treatment options.
Choice is something you do when you go shopping. Health care is NOT the same – If I am injured, unwell or unable to get to a different location- choice is not a factor. The current system of choice is also a non-sense I recntly got asked would you like your mole to be checked out at Warwick or Northampton? I have no idea about the dermatology departments at either hospital let alone the competency of their staff or teh results- I picked Warwick because I wanted to go shopping after!? Is this really worth the expense?
I think we have to stop thinking in financial terms when it comes to the economics of health and accept that value and cost are not measured in pounds when it comes to health and wellbeing. Choice will increase competitiveness but will not lead to better services as it is inherently prohibited by geogrphic location and the fact everyone needs care etc etc.
Instead of choice the NHS should be more “Local” with more accountability local people should be able to see on their payslips how much money they are paying to the local health service. Everyone who pays becomes a share holder and the top tier management as well as other chages should be subject to “share holders meetings”.
Patients with back pain should have the option to choose to see a chiropractor. GPs should be able to refer under the NHS. It is good for choice and competition. Waiting times are usually a few days rather than weeks by which time symptoms are becoming chronic. Research for manipulation is favourable and NICE recommend it from chiropractors, osteopaths and specially trained physios.
There is no doubt that there needed to be much reform and a shaking up of the status quo in many aspects of the NHS.
However wholesale slaughter was not required and the deep feeling that this will destroy our NHS through privatisation is not unfounded and an ideology which was not specified when cons came into power and I wonder whose friends are going to benefit in the private sector…lets have no doubt about that!
I am concerend at the proposed involvement of the private sector.
Throughout my life I have been able to consult my NHS GP in the secure knowledge that s/he has no pecuniary interest in the diagnosis being given.
That cannot be said of the private sector. You only have to look on the internet to see hundreds of so-called qualified practitioners offering dubious remedies at high cost, and I have friends who have fallen victim to these and lost a lot of money. If, under these proposals, I am referred by my GP to a private consultant, how will I know the advice I receive from the private sector is not motivated by money?
The question is loaded: “How can we best ensure that competition and patient choice drives NHS improvement?” I think we need an NHS that is driven by care for patients and professionalism from staff. Competition is unlikely to deliver either of these. Staff are overstretched and feel undervalued and this leads to poor service for patients. Our county hospital is not replacing staff who leave because it doesn’t have the finances. We must not let the NHS be destroyed by those who are following a political dogma and who, at the end of the day, will be able to rely on private healthcare. If it costs us a bit more in tax to run it properly, so be it.
I do not believe or want to have market competition within the NHS as it will lead to a two tier system. Already I cannot afford dental care and have not been to a dentist for over ten years. Although I work full-time I have not got the disposible income to find money for perscriptions and hence I have not used local health care. Please let’s have a health system that if free ,provided when people reallly need it and preventative.
There isn’t any evidence that competition will improve healthcare outcomes.
Ben Goldacre is much more eloquent than me on this one:
http://www.badscience.net/2011/02/andrew-lansley-and-his-imaginary-evidence/
It strikes me that one of the great issues in this choice and competition debate is the enormous potential for conflicts of interest. Many members of a large local ‘pathfinder’ GP Consortium are also shareholders in a Ltd Company, which also happens to provide healthcare. We are in a position where these GPs are diverting patients to their own healthcare provision company and therefore acting as both commissioners and providers. Every time we have asked for transparency on this, we are given evasive answers and I fear the public need to be made aware of the fact that GPs can in some cases reap personal financial rewards from these reforms.
Like many of the respondents, I question of the emphasis on patient choice, and the implicit assumption that free-market competition benefits the many rather than the few. Competition is no panacea, and the piecemeal privatisation of the NHS would be a tragedy.
I urge the government to scrap these ideologically-motivated proposals.
Please listen.
The key to good quality general practice is consultation with the doctor.
The time allowed, the setting and the state of mind of the people involved are most important elements. Much caring takes place below a cognitive level. We are not fixing broken parts on a conveyor belt, though at times it can seem to like that. Will increase in competition enhance this aspect of the consultation or detract from it by defaulting to the lowest common denominator of cost competition?
Why don’t you just ask us “which private company should run the NHS”. It would be a more honest question.
We have experience of the UK health system and the French health service for many years. The French system is far superier and has been assesed by the UN as the best in the world for over 20 years.
Instead of having this consultation why not just copy the best?
I don’t want to discourage learning from others but the French spend more on healthcare.
Slide 40 of OECD Health at a glance 2009 gives 20% per capita more at PPP in 2007. http://www.oecd.org/dataoecd/24/8/44231736.ppt
And the BMJ’s Does poor health justify NHS reform? gives 29% of GDP more in 2008. http://www.bmj.com/content/342/bmj.d566.full
Anyone for a big boost to spending on the NHS?
The way this question is framed shows yet again what a fraud this ‘listening exercise’ is. We are not invited to challenge the wholly specious claim that ‘competition’ – that is, handing over chunks of our health provision to profit seeking companie is unquestionably a good thing.
Since the introduction of the internal market, administrative costs have gone up from 4% to 12% of the NHS budget. ‘Competition’ is an inappropriate way to run the NHS, it isn’t (or shouldn’t be) a market. When we need is co-operation and co-ordination between local GPs, Hospitals and other parts of what should be an integrated and seamless service that doesn’t spend all its time sending itself invoices.
As far as choice is concerned, mine is that I want a GP within walking distance who has the time to see me promptly and when necessary I want a local hospital a short bus ride away that is properly resourced – including A&E, maternity and ICU. I don’t want to have to choose between several hospital that are all closing wards and dropping specialisms.
I completely agree with this statement. The way these questions are framed assumes the changes have already taken place.
We don’t want or need any NHS restructuring.
I am a patient. I don’t want choice. I REALLY don’t. I just want everywhere to provide the same level of service, and for this level of service to be as high as practically possible.
Your questions in this “listening exercise” are some of the most transparently leading questions I have ever read. They’re practically a textbook case of how not to ask questions, or how to force people to appear to agree with you even if they don’t. Having read these questions, I will have no confidence whatsoever in the results of this “exercise”.
I totally agree with these comments.
When people are ill they want good quality care wherever they are and not to be faced with having to assess and decide on different options. This is difficult when you are well but even more difficult when you have health problems.
The ‘listening exercise’ is shown to be a complete sham because the questions in this case assume that people want increased choice without asking if they want choice at all.
I can remember the so called consultation at the launch of the green paper on “The Future of Social Care” we were given 3 options to choose from. But there was no consultation in arriving at those three options, they were decided on behind closed doors at the DoH.
So government was simply asking us to endorse what they had already decided on.
What sort of consultation was that?
What a terrible question. How can it be a listening excersise when the question is:
How can we best ensure that competition and patient choice drives NHS improvement?
How about a question asking whether we want competition to drive the NHS?
I don’t want it.
I’d just like to echo the sentiments of some of the above posters regarding the blatantly leading questions of this ‘listening excercise’. The question above should be asking us whether we want ‘choice’ at all.
Choice isn’t always a good thing – particularly not where health is concerned. What’s best for most is a universally sound service that people can have faith in when they are in need. All choice does is give many people the opportunity to make bad decisions – particularly those whose financial situation predetermines their ‘choices’ for them. This dressing up of free-market ideology as ‘choice’ is a joke.
From what I can see the “listening exercise” (so right it is inverted comments) is a paper exercise by the government to paper over the cracks in the NHS Bill. Why have we had a referendum on AV which nobody was concerned about, and we are sleepwalking towards a privatised NHS. The Con/Dem government did not feature any of these proposals in their manifestos, there is no desire for it yet we have no voice in the change.
Perhaps the result of the 2015 Election (if Labour can get their act together) will send a clear message to governments that they ignore the will of the people at their peril.
Enforced competition will only serve to destabilise high quality integrated health care. If it down to who shouts loudest and pays most the most vulnerable will be denied high quality care, because the vulnerable are often the most expensive to treat.
One area where local choice should NOT apply is which treatments the NHS will support. Deciding the efficacy of medecines and treatments is highly specialised, which is why it should be determined by NICE. Making NICE only advisory, with actual decisions taken locally, means that (a) decisions will usually be less well-informed, (b) decisions will be open to influence by local pressure, often with heart-rending accounts about particular patients, (c) less-rigorous local decisions will lead to money being wasted that could be better spent on other patients, and (d) it leads to a post code lottery.
The greatest concentration of scientific expertise is in NICE, which was set up for the purpose.
A dreadful question. As a nurse in the NHS, I have heard that our service’s contract is up for tender and that the commissioners are ‘keen to welcome new entrants to the market’. This is happening aside from the Health Bill and under the radar. Patient care will get worse in my area if the proposed changes go ahead (yes, I can provide sources) and there will be deaths (ditto).
Competition is NOT what is needed in the NHS: collaboration is, with a decent standard of all health services wherever you live, and no matter how unprofitable it may be for those who provide you with those services.
Your government’s desperate love of free-market ideology, and your greed to speed this ideology into play as soon as possible is so transparent it would be laughable if it weren’t so tragic: at least now more and more people are becoming aware that you take money/perks from the private healthcare providers and other big business who want to eventually strip the NHS bare, so are really listening to them, not us.
This is what is really happening.patients are being admitted under a diagnosis.The hospital receives a tarif.When the money runs out,the patient is kicked out.The Gp is then asked to do the tests that the patient should have had in hospital (so they are not paing for them) and then refer the patient to the outpatients which will attract a further fee. Each step is very competative on price.Shame about the patient. Oh and so much for choice.If the patient chooses to go elsewhere the whole process has to start from scratch.
That’s a very good point. Many commentators here seem unaware of the competition you describe, which happens already throughout the NHS. The question is not whether it’s a good or a bad thing. It’s a fact of life. The question is how to put it to better use and make it drive improvement.
i do not want choice, i want good care local to where i live. i do not want the NHS that i have gratefully grown up with irrevocably destroyed. Mr Lansley – leave the NHS alone. you do not have a mandate to destroy the jewel in our crown.
Scrap the entire bill. No mandate for it, vast majority of health professionals aganist it, the public are against it.
Lansley has the arrogance to think he knows better than all the experts ? He doesn’t realise that the GBP hold the National Health Service concept as precious and something this country is proud of.
Competition between private providers and NHS will cause fragmentation of services, reduce quality and prevent integrated working. It will also delay procurement, as we are seeing already with NHS London Pathfinder support, which has been severely delayed by procurement rules and is now having to spend scarce time and money on this problem
I agree with the other posters who have commented on your leading questions – this is a textbook example of how NOT to write a survey! I believe this survey to be biased and, as such, I have no confidence that you will make a balanced decision. Basically, we are being given a choice between privatisation and privatisation; an impartial survey would also have considered a ‘Do Nothing’ approach – this should always be the starting point when planning a new project.
My answer is that I don’t want a choice. I’m not medically trained and I want to be able to trust that my GP will make an informed decision on my behalf, in which money is NOT the deciding factor.
I find it laughable that the public is being offered a ‘choice’ regarding health care, yet the ‘Vote No’ campaign was based on the premise that we are all too thick to understand AV! Please make up your minds – do you think the electorate are intelligent or not?
choice – i work in mental helath services – choice is important however sometimes the rapid access to services and the level of risk would mean choice is not an issue; access is needed quickly and crisis teams through local services work hard to maintain people in the community. people with mental helath problems often given the choice would not engage – how does that fit with the new proposals.
access to IAPT services is where choice is peorhas needing to be available however quality and level playing fields are important.
How can we best ensure that competition and patient choice drives NHS improvement?
in mental helath services – competition should not be allowed to happen – private mental helath servcies would and do cream off the profitable and easy to operate services. they contribute little to the training of staff prior to taking them into private sectors and also appear not to have to operate to the same level of governence.
there should be no clear competition as such otherwise we will return quickly ot the days of poor mental helath servcies and this will fly in the face of the governments mental helath servcies proposals.
The NHS cares for people who in most cases are not well. You cannot treat them in the same way you would treat products on a production line. the NHS is not perfect but it still has it’s heart in caring for people.All competion will do is harden the attitude towards already down trodden people.
This government seems to have its heart on destroying our NHS. We are the envy of the world with our health system.
The Americans health system is in a deep hole and trying to claw its way to a better system for all its citizens, but our coalition government just can’t wait to jump in and join an American like-wise system, the haves and the have nots!
Ask the older citizen’s in our society what health care was like before the NHS and how wonderful it was when it was born.
This government is digraceful!
The amount of patient choice that was present in the NHS is sufficient: patient’s having a choice of GPs within a geographical location; having a choice of which A and E to attend for non-critical conditions; having a choice, informed by their GPs, of which local hospital and which consultant at that hospital to be referred to; having a choice, guided by their hospital consultant of which tertiary referral specialist to be referred to. Beyond allowing that, the government’s role in patient choice is to ensure everyone has timely access to reasonably located health services irrespective of postcode, which has more to do with improving quality and networks than improving ‘choice’ and competition.
True, there is quite a lot of patient choice already in the NHS. But that isn’t the question. The question is how to use that patient choice to drive improvement.
One way would be to ensure that patients’ choices are better communicated. For example, if a patient chooses between hospitals, those hospitals, and commissioners too, need to know why the choice was made so that they can improve services. There have been cases of substandard services shunned for years by local people in the know, without anything being done about them until a story appears in the national media. Fixing that is the challenge.
Choice and competition is good for the NHS with limitations. Poor NHS practice has been allowed to thrive with little governance or scrutiny such as Mid Staffs, however allowing private companies a wide range of oppertunities (local pay negotiations facilitate this) by making the ‘buisness more attractive’.
The choice should be between good NHS Trusts and NHS Trusts who have partnered with Third sector orgs Not Private companies that have one eye on the patient and one eye on profit.
The key to a good NHS is better governance and scrutiny rather that focusses on outcomes for all patients (including those facing persistant and worsening health inequalities).
Once Private companies compete (being subsidised by other parts of the buisness) the NHS will diminish once reduced in capability what stops these private companies increasing cost as the NHS wont be in a position to compete.
Talking about “patient choice” is an utter nonsense. When I’m unwell, I haven’t got the mental focus to ‘choose’ medical treatment as though I was shopping for a new frock. All I want to know is that I can trust my GP’s recommendation for treatment and that I’ll get it at my nearest hospital. This is convenient for me to get to, and also for my friends and relatives to visit. And, it should all be provided from public funds. This will always be cheaper than using private providers.
I don’t want choice I want a functional NHS. I’m not saying that the NHS is perfect at the moment but changing it on the misplaced ideological belief that the market knows best is not going to help anyone except the corporate fat cats who will undoubtedly profit from cherry picking the most profitable parts of the NHS, regardless of any measures put in place. History has shown many times that corporations move far quicker than governments, and that these measures are quickly circumvented if there is money to be made.
I don’t like seeing the Conservatives using a GLOBAL economic downturn as an excuse to strip the most important and envied part of the welfare state.
The NHS has for many years been organised around acheiving shorter surgical waiting lists and acheiving waiting time targets for treatment. The people however that use the NHS the most are those that have chronic disease and it is time that the NHS organised services accordingly. The current primary versus secondary care divide is artificial and distorts care with unhelpful and disruptive competition. Commissioning decisions should – as much as possible – be removed from those who might have a vested interest in favouring one part of the NHS from another. Those that make commissioning decisions should aim to minimise overall costs whilst providing optimal care and value for money to the patient. In many cases providing the best treatment even if slightly more expensive may be cheapest option in terms of overall health and social costs.
Expensive operations and hospital admissions are likley to be more often required when there has been a failure of chronic disease management. Focussing on the optimal management of chronic conditions by designing pathways of care, championed by specialists in partnership with GPs has to be the best way forward.
If you really want to listen, then listen; NOBODY voted for this reform as it wasn’t in any of the parties manifesto’s. 42 GP’s and private medical companies aside, NOBODY wants this; not the doctors, not the management, not the surgeons, not the nurses, not the patients, not the the public, not Labour, not the Lib Dem conference, not even doctors on the Tory backbenches. I’m not sure which part of NOBODY you fail to understand but you say you want to listen, well this is what the people are saying
Couldn’t agree more but this isn’t a listening exercise it’s a cooling off period. The government are simply hoping those of us who object (i.e. the vast majority) get bored or distracted by other things so that they can implement these massive and damaging changes under the radar.
Why don’t we expand the use of the NHS so that it is not centralised through GPs?
If for example the patient knows they need to go to a physiotherapist, why can’t they go to a physiotherapist on the NHS without having to go through their GP.
Sometimes the GP is not the best person to do the diagnosis considering they are jacks of all trades and experts of none. For example, I personally have been to A&E got 1 diagnosis after a period of time that they said to then go to GP, i went to a sports injury clinic & they diagnosed it differently & suggested I needed an MRI, after seeing 3 GPs (both in Scotland & England) only after the 3rd GP have I been put forward for an orthopedic review, which there is an apparent waiting list of 8 weeks.
Had I been able to go to the private sports injury clinic and had they had the power to put me forward for an MRI, this would have been over months ago instead of a year after the injury not actually knowing what is actually wrong.
People want good, reliable services, as local as possible (allowing for specialisation). We want collaberation between care services and information to help us make decisions. For that to happen, we need clarity and accountability from those providing services. It is not clear how that will happen with the government’s proposals for change in the NHS. Where is the detail? We do not want another rail privatisation fiasco where tax-payers have now ended up paying far more so that private companies can choose how many trains they’ll run!
My MP says that choice is a priority and an overwhelming concern amongst many patients. I disagree. The majority or ordinary people want their GP to decide where best to treat a problem. The last thing we want is an internal market in the NHS. Or are you using the rail industry as a model?
Don’t believe the management consultants. They are the people who audited the banks!
Who wants fragmentation of the NHS, prevention of staff working collaboratively in multi-disciplinary teams and hampering of the delivery of integrated seamless pathways that deliver best outcome for patients?? Who wants a competitive environment in the NHS to make it harder to share good practice? Who wants private companies to cherry pick more profitable NHS services? Who wants the result of a competitive environment in the NHS to lead to a race to the bottom in employment terms and conditions, pay and pensions in order to cut costs? Certainly not me and I am not alone. It is all about money, money, money,cutting costs – not a thought for PATIENT CARE. “Listening Exercise ” this might be, but is anyone at the DOH actually going listen, PAY ATTENTION and act upon the huge responses from all the different health care professionals and their professional bodies???
When I need medical assistance I want to be able to contact a health professional who is local to me, whether it be my GP or somebody at the hospital. I want this person to be able to recommend the best course of treatment that is going to resolve my ailment in the quickest possible time regardless of the cost. I do not want a cheaper alternative that is going to be less effective.
How we achieve this I do not know, I would guess that the people at the sharp end (the GP’s and the Dr’s and nurses in hospitals) would be the best people to guide us on this. However this should be a national service free at the point of delivery, so that it is available to all regardless of their own financial circumstances. If we want a more efficient and quality service perhaps we should look at models in the not for profit and charity sectors who in the main deliver an excellent service on a shoestring as opposed to big businesses who provide a much lower standard of service to their customers and are more concerned with keeping their shareholders happy.
I would be interested to learn how competitions rules apply in a service that has gatekeepers (GPs) and where gatekeepers are also providers.
Choice and competition are simply means to an end, not ends in themselves. Presumably the ‘end’ (as the SoS keeps telling us) is better patient outcomes. Neither choice nor competition are necessarily needed for better patient outcomes, so the focus upon them is misplaced.
There may well be a role for competition in agreed and appropriate circumstances, but to spend tens of millions setting up Monitor to promote competition is ridiculous. And even where competition might deliver some cost-savings in specific areas it may have harmful effects on other related services especially in hospital settings.
The main challenge facing the NHS is older people with long-term conditions – many of them complex. What is needed to address this is not competition but integration; not choice but confidence that someone is taking responsibility for designing and delivering a care pathway within which there will be choices. Maybe we do need a new Monitor – not to promote competition but to promote integration. What DH needs to do is ensure financial incentives promote an integrated health and wellbeing journey rather than fragmented episodes of care.
Our NHS is a public service, not a market economy. Market forces have no place here so leave the private sector out of it!! We do NOT want to end up with a two-tier system as in the USA, with superior healthcare for those who can afford it.
As for devolving healthcare completely to local GPs — it’s easy to see how standards would then depend on where one lives. An affluent area would enjoy great health facilities, while a more run-down place …
Surely the aim of the NHS is equal treatment for all, irrespective of where a person lives, not a postcode lottery? We should be able to access the same standard of healthcare at the surgery/hospital/clinic nearest to us.
At a time when the U.S. is trying to move to wider health coverage, we want to smash ours into a thousand compeating shards. The GP’s will be both providers and commisioners of healthcare, surly a conflict of interest.
How much does it cost to train a GP? We then want to turn these people into pen pushers, stuck planning and resource meeting all day. Eventually this role will be outsourced, then GP groups will join up to save administration costs and within 5 years and many billions of pounds we will have reinvented the primary care trusts, without the oversite we have now.
I am horrified at the prospect that the private sector are ready to swoop on yet another public sector area. If the NHS is inefficient then get to work fixing it not selling it off so that the wealthy can again profit. As we have seen with most privatised industries and PFI schemes we the public get less service at inflated costs – far more than the cost of inefficieny. We are then help to ransom with little, no competition or choices that are a complete stitch up. You only need to look at our public transport, schools and utility companies to see this. Savings are also often made by employing staff on lower wages and worse terms and conditions, who benefits from this? certainly not society.
Start to fix our health service and not dismantle it at the expense of all and the profit of few – you have no mandate to do this.
Patients want high quality local services not choice and competition. Perverse incentives and the conflicting budget priorities of GPs, commisioners and hospitals caused by the current financial flows do not help. These propsals will make this situation far worse. Introducing more private providers who cherry pick off profitable services whilst leaving the difficult and complex cases to what is left of the NHS is a sick joke that only an ‘i’m all right jack’ tory would believe is a good idea.
In my experience the only winners in all of this will be the private firms, the consultants working in those practices and the wealthy.
Empower local front line staff to improve thier own system, focus on quality, invest where change is needed (e.g. rapid support and social care for old people to keep them out of hospital) and we could have an NHS that is higher quality, patient centred and much much cheaper.
I agree with Dr. Sims description of the NHS as a monolithic nationalised industry, the dream has died – new ideas are urgently needed.
Considering the amount of Taxpayers money poured into the Health Service, and the army of specialist people it employs, one would expect that the health of the Nation would be excellent, or, at the very least, improving – sadly, this is far from the truth. The Health Service needs to rethink its blind faith in the greedy self interested pharmaceutical Industry, and give training to doctors in Natural Ways of Healing.
I think that competition is driven by cost, not quality. Cost is an easy measure, measuring quality is much more subjective. High quality healthcare should be available to everyone. This is not a commercial commodity Mr Lansley, this is peoples lives. Invest the money put aside for these changes into frontline services. Concentrate on reducing waste, and endless middle manages. Efficiency will result in better services, but competition will put services on the scrapheap. I joined the nhs 20 years ago as a nurse, to make people better. Now the nhs has lost its main aim, and this government will be remembered for getting it very, very wrong.
The bigger question and answer should not so much be choice and competition. How can you have improved choice with less cost? The system does not work… Patient choice is only at the point of regional service – what someone can choose (or is available) in one part of the country is totally different to choice for treatment and care in even a neighbouring town….. This is fundamentally wrong and is the greater issue that needs to be addressed. It was supposed to be addressed years ago but has got worse instead of better. We still have a system of huge postcode lottery despite people paying an equal percentage in relation to income via NI contributions. We don’t work in a REGIONAL Health Service. Lets actually make it a NATIONAL health service where treatment and choice for both patients and staff is equal throughout our Nation.
The large majority of patients just want the guarantee of high quality care and an ideological obsession with choice is likely to lead to wasteful duplication of resources and increased costs.
There is scant evidence that large-scale private involvement in true public services actually leads to reduced costs, particularly when the service requirements put strong constraints on the amount of competition that is really possible. For example, we have probably the most expensive railways in Europe, but they are little better than under British Rail and provide the worst service of any of the more affluent countries. Air travel performs much better on price but shows little inclination to provide a proper public service. In fact, one does not need to look beyond health care; the USA has notoriously expensive health services but recent evidence shows that the health of Americans is generally worse than that of UK citizens.
Cherry-picking by private providers would be detrimental to the core NHS services where private providers will have no interest – specifically accident and emergency and most other areas where there is a real danger of patients dying. You have only to look at the state of the Royal Mail to see the future of the NHS core under the proposals. Yes, there are good commercial courier services but they have taken much of the more lucrative business from the Royal Mail with obvious consequences for the universal postal service and the Royal Mail itself.
Opening the service to ‘any willing provider’ will be disastrous because it will result in competition law requiring tendering across the EU with increased bureaucracy, wholesale fragmentation of the service into many private providers, and an inevitable loss of control of the service by local management.
Some services could be provided by private companies, as they are now, but only when local NHS management deems that to be appropriate on grounds of service quality. Simply give local NHS management the same sort of discretion as universities have and voluntarily exercise for example. There certainly should not be a general move to open up all services to ‘any willing provider’.
I don’t believe that creating a purchaser provider split has helped health care. I don’t see how competition will drive up quality, in fact I believe there is more risk of driving down quality. It will merely increase the variance we have been trying so hard to eliminate.
I am a little concerned about the focus of the debate from the Department of Health. It seems that there is a consensus that choice and competition are good. Unfortunately the evidence suggests that the benefits of choice and competition may be somewhat overblown.
We currently use 14% of the NHS budget to support a choice agenda and the White Paper heralds an increase in choice. Over the next 5 years whilst the NHS struggles to cope with a £20Bn gap as a result of a freeze on funding we will be blowing £70Bn plus on choice.
If I exercise choice it means that some less articulate (even than me) person will be left with a less good option. This cuts against the equality suggested in the title of the white paper.
Most people want to have choice in their healthcare but only a tiny proportion exercises it. The effect of competition and choice on healthcare performance has been disappointing. We could really do with different penalties for the worst performers both in primary and secondary care and be prepared to close down those that are not able to reform.
If I were unwell I would want to be managed by a local integrated system that focussed on keeping me well with evidence based care. Perhaps I should move to Torbay from my dotage so that I can experience a Kaiser Permanente system that works hard to keep me well and out-of-hospital.
Suppose I don’t like the way the police operate in my neighbourhood – I’m not going to dial RentaCop – I want the local constabulary to respond to national and local democratic views and deliver accordingly. The same should be true of the NHS.
INVOLVING ALL CLINICIANS AND PATIENTS IN RATIONING
Could there not be price & quality competition between NHS Trusts, e.g. we could commission a neurology team who were prepared to give strong reassurance rather than order a CT. Such tests could always be performed on a private basis. GPs are currently more comfortable in operating like this but I would suggest their needs to be a culture change. One quality measure would be the speed at which clinic letters were dictated. What we must avoid is taxpayers money being lost to shareholders and in red tape and contracts.
I think we need to collaborate more in efforts to reduce costs and waiting lists for those who do urgently need specialist assessment. In Cambridge we are trialing email advice from Consultants or setting aside timed slots for Primary & Secondary care clinicians to speak on the phone. Then I think we can truly share care and responsibility. Surely some of the time currently spent seeing follow-up patients might be more profitably spent speaking directly to a GP who knows their patient inside-out?
I wish Consultants would try to manage conditions slightly outside their area of expertise by having a chat in the coffee lounge rather than inconvience their patient’s by making an expensive cross-referral.
Where there is dissent about the benefit of a certain treatment then I would propose this is brought to an exceptional case grant panel.
I think a larger role could be played by patient representatives on these panels, and I wonder if county counsellors would be well practiced in this role. If we truly work with those we serve in deciding priorities / QALYs then GPs are less likely to be blamed if it all goes wrong. Most guidance should come from a national level and NICE have a role to play in this.
If we are to maintain a free NHS then we have to have these difficult conversations with our patients. In my practice we bring all such decisions to an in-house panel and think we manage to maintain our relationship with our patients. I tell my patients that in the situation that they need urgent treatment, then I will go the extra step to ensure they are seen soon.
Many NHS hospitals are saddled with PFI agreements that commit them to high fixed costs for many years to come. I would like to know what will happen to PFI contracts and costs in the scenario where a private provider of health care services is successful in winning contracts for patient care that leave an NHS hospital with depleted revenues. What is to prevent the extreme scenario of the tax payer ending up paying for health care services twice over, once for PFI payments on an empty hospital and secondly to the private health care provider?
The role of choice and competition for improving quality: The NHS is a health service, not a commodity. It cannot give everyone real choice for two reasons. One is because very often patients are not in a position to make a truly informed choice. It takes a huge amount of time to give someone enough information to make truly informed choice. The NHS can function because there is trust from patients and integrity from doctors. This means not everyone has to go to medical school in order to make the right choice. Secondly there is limited money in the health service and sometimes that means people can’t have what they want because that might mean someone who is more ill going without. All the evidence collected from social researchers about this subject repeated finds out that patients want a single effective good quality service far more than they want choice.
Competition: Competition when using financial rewards does not improve quality. Again this has been shown by researchers repeatedly. Quality is improved by integrated working, trust and openness. When general practices within one borough are showing how their colleagues are performing, this will drive them on to improve the quality of their own service and to try and find out how they could do it better. If money is the driver, people become secretive and they often lose their integrity. Money is a very powerful motivator and may override doing the right thing.
How to ensure public accountability and patient involvement in the new system:
Openness will ensure public accountability. Consortia should have to publish why they are driving a particular path forward and to justify it in terms of patient care. Patient involvement is difficult. Patients are not a homogenous group – they are all of us. We all have different motivations to be involved in health; these may be personal motivations and can result in destructive or constructive involvement. Some patients (people) are reasonable; some patients (people) are not. Clinicians must not have to jump to the whims of individuals or groups with a particular axe to grind or with a particular interest to put forward. I do think that service users can gain a particular insight in to the workings of the NHS that is very valuable though. So I think that people wishing to represent patient interests should be interviewed and selected for their ability to be objective and constructive.
How new arrangements for education and training can support the modernisation process :
Education and training seem to be very neglected in this white paper. I can only see the picking apart of the service having a negative effect on education. Education is not cheap. At present many of us support education even though it is a ‘lost leader’ because we think it is important. That is less likely to happen if profit becomes the sole motive for involvement in the NHS and if there are hundreds of local consortia across the country. Furthermore the NHS as an academic organisation leading in research will suffer because it will be far more difficult to collect research data.
How advice from across a range of healthcare professions can improve patient care :
Clearly this can be helpful. Again though there has to be reasoned careful thought about the value of services, evidence that they are effective or not and objectivity. If all services are struggling to make an income then clearly they will all insist that their way is right. This is why there has to be collective responsibility and why the ‘any willing provider’ model is so destructive.
Which are the types of services where choice of provider is most likely to improve quality?
Continuing from my previous comment, I think this question is a red herring. Rather than obsessing about choice improving quality, why don’t we find out what does improve quality and work on that? Choice is not the answer. Quality will improve if the service is properly funded in the first place (we know that driving down costs eventually destabilises services). It will improve if the people who provide the care are given the responsibility to improve quality (working with management support but not being told by managers how to do it). Harnessing the effects of the providers pride in the service will drive up quality (harnessing the human desire to be the best). Ensuring that users also have pride in the service, care about it and use it responsibly would help. Quality will also be increased by collaborative working. We know that people working collaboratively together are better than people fighting. So why not do it?
The other real difficult with choice in an organisation that has to deal with surges and lulls in demand is that if you try to staff the service to deal with the public efficiently all of the time you have to overstaff. Sometimes we have to accept that in order to prevent a lot of money being wasted with staff not being fully employed all their working hours, there will be times when people have to wait for a service. If you have multiple services trying to offer a responsive service and they have to compete on response times as well as cost, either it becomes very expensive or costs and quality deteriorate.
What is the best way to ensure a level playing field between the different kinds of provider who could be involved?
Well again, why do you want to do this? The more providers there are, the more money is dissipated in to running costs and transaction costs. In other words, choice is expensive. The government keeps telling us costs have got to be kept down and the NHS needs to be cost efficient. Multiple providers is hardly the way to do it. Governance arrangements become more expensive because there are more providers to visit and assess. Financial arrangements are more expensive, transaction costs increase. It is absurd. The NHS is one of the cheapest most effective health care systems in the world still (contrary to what the government wants to tell us). All the evidence is there. The NHS can do this because there are NOT multiple providers involved.
What else can be done to make patient choice a reality?
Patient choice is not a reality and never can be. This is a chimera. So you could choose to go to one of two companies providing chiropody for example. They should be as good as each other and offer the same services, no problem if they want to do it differently but since surely the NHS would want to ensure they are of equal quality why would it want to pay to run two services where it could run one? I think that there should be a chiropody service in every borough and the improvement in quality should come from comparisons between them and as i have said, professional pride then driving up quality in each borough (and clearly having governance arrangements where that is not happening). That way quality improves without more money leaching from clinical care to other things.
It is possible that there may be in the foregoing jumble of suggestions, criticisms and prejudices some useful ideas to improve the NHS, but even if there are it is unlikely that anyone will read through them all to find them. Muddled thinking will prevail as usual, but let me make a few simple points, and hope that someone will consider them:
Quality can be defined as goods or services which are fit for their purpose, free of defects, reliable, value for money. Do not confuse quality with grade, luxury or expense. A match that strikes and burns evenly then is thrown away has quality; a gold-plated lighter that fails to function does not. Japanese cars, cameras, tvs etc. have quality built in at competitive prices, so they dominated world markets.
So. specify the needs and desires of the end user. Do it precisely, then take the cheapest price, holding the supplier to his promises.
The same principles apply to services in the NHS. Any doctor or surgeon knows you must first diagnose the patient’s complaint, then plan the remedies. The most economical are obviously the best – so long as they do the job effectively and reliably.
< There is no conflict between quality and cost. Defective goods and bad service are always more expensive. But your quality must be
defined.
Results must be recorded and analysed, so faults and failures can traced back to source – then eliminated. Prevention is better than cure.
There are proven systems for achieving this, widely used in both manufacturing and service industries: the international standard ISO9000 series. Quallity, properly defined and measurable, is the basis. The techniques rely on precise specifications, accurate records, statistical analysis and preventive remedies.
Plan, do, check, amend… Calculate the cost of faults and failures, then eliminate them so that in future that money is available for better purrposes; make everyone responsbile for the quality of his or her own work, give them the support and training that they need.
This kind of quality control is not created by inspection and supervision; it must be led from the top by example and exercised at the lowest level feasible. All employees should understand that quality is their first duty. The job of management is to create the conditions in which employees can give of their best.
Quality is not expensive; cheapness alone is. ISO9000 – it’s all there.
Will anyone take any notice in the great ramshackle sacred cow of the NHS? Probably not. The fundamental ideas are simple, but applying them in practice means thinking, working, leadership and persistence.
Thus spake the Prophet
Managers are, in a sense, the servants of their staff.
No “competition” in Nhs please. Save nhs from competition. Please.
It seems counter-intuitive to be striving for a system in which “patient choice [is] a reality”. This suggests that we are pushing towards a state of fundamental inequality of provision. I realize that not all providers can be equally resourced, but, rather than accentuating differences through the potentially damaging forces of competition, we should be increasing the efficient sharing of resources and of best practice.
If I am afflicted with a serious health condition, I do not want to be faced with a choice between rival providers, but rather to be directed towards the most effective care through a co-operative and clearly communicating organization.
By instilling the principles of competition in an organization like the NHS, you encourage an environment in which individual performance is valued over communicative and co-operative mutual benefit. It is fundamentally against the inclusive spirit which makes the NHS our greatest national asset.
“Patient Choice” is not the right terminology to describe what a majority of people want from their hospitals.
I want to be able to trust the local healthcare provider to have my best interests at heart.
I want to be able to trust that my local healthcare provider will give me sound advice and to keep me well-informed.
I want my trust to be well-placed. But I also want to be able to trust that if my faith is broken that whoever is responsible for breaking that trust will be held to account so that lessons can be learnt and mistakes avoided in the future.
We should be voting for “Patient Trust” not “Patient Choice”
Patients want information and choice over specific care management decisions e.g. drug therapies suggested by their GP not who provides that care. Increasing “choice” by farming out services to the private sector who will make a profit out of them is a false economy. the market system has already cost the tax payer millions in contracts, billing, legal fees administration and transaction costs and is only set to cost more. If I was asked to choose I would choose a single local high quality health care provider which is not trying to make a profit, who’s sole duty it to me as a patient and not shareholders and which is free at the point of access. That’s the NHS as it should be and I choose to support it. The health and social care bill is destroying it.
The first step on the choice agenda is for the NHS to stop discriminating against mental health services. The NHS constitution gives a right to choose the organization that provides their treatment when they are referred for their first outpatient appointment with a consultant-led team. The Department of Health now appears to discriminate against people who are disabled by their mental disorder, and needing elective care, as “mental health services” are specifically excluded from the legal right for choice of referral. It is true that many referrals for mental health services are emergency, but a significant number are not. This includes patients who perhaps fail therapy within Increasing Access to Psychological Therapies (IAPT) service or secondary care and should be according to various NICE guidelines be stepped up to a specialist service. This is often not done and patients are denied access to effective services within the NHS. An example of this is in OCD or BDD, a condition which, because of the sufferer’s obsessional doubts, fears, and compulsions, can over many years lead to severe disability such as the inability to work or study, becoming housebound or being dependent on carers. I have had communications with many people with OCD or BDD (or their families) who are severely disabled, and who want to be referred to our service at the South London and Maudsley Trust because of our reputation and results. Our patients often seek to travel to our unit when local care has failed. They may be seeking an assessment for out-patient treatment or for admission to a residential unit. However because they may not be able to obtain a referral, it means individuals with mental health disorder are unable to obtain elective care at a hospital of their choice. Choice is important to some people as they have not made progress locally and more specialist input or intensive therapy is required.
I worked in the private sector for 40 years. The aim of every company is to maximise its profit. Corners are severely cut, ridiculous risks are taken, morality is forgotten, all to maximise the bottom line.
The aim of trying to privatise the NHS is to make money out of it.
My MP, Sarah Newton, has failed to reply to my questions e-mailed to her on 25th April, which are repeated below:-
Dear Mrs Newton,
Thank you for your letter in reply to my e-mail routed through 38 degrees. I am not reassured.
Firstly – you say “supporting NHS is my top priority …” – but Lansley says that too and his proposals would wreck it, in my view. So more attention to detail is needed, especially in relation to the two major concerns which I set out in my earlier e-mail.
Firstly – the way in which competition is organised and encouraged. This needs to be in a way which does not endanger or slough off major parts of the NHS to private companies which in later years will be able to raise prices in a way which causes big problems and raises dangers of a two tier health service. (In passing, note how some of these practices have played out in USA with costs of health care per head double what they are here – with a worse health outcome – due substantially to private providers and insurance companies taking a cut).
Secondly – the speed of change. The NHS is subjected to major change, imposed from the top, year after year and it diverts enormous energy from patient care. The complexity of managing the health service – human resources, technology, best practice, budget, and many more, means that hurrying the process will inevitably bring a worse long term result than one that has been carefully worked through. This requires systematic, (not token or politically driven), steering from grass roots – patients, clinicians of all disciplines, and health managers, and independently evaluated by a competent body such as the Kings Fund.
Lansley’s statement to The House of Commons, (which you kindly enclosed), also is at a level of generality that glosses over the two points above which I am most concerned about. Turning to one piece of detail, he says “The coalition government is increasing NHS funding by £11.5 billion”. This is £11,500 million and pro rata should give Cornwall £115 million. Your quoted figure for Cornwall (£7.5 million) appears to show that this county is being very substantially short changed, again.
I do support the joining up of adult social care with health services, and a shift from secondary to primary care – but to have an impact, far more money will be needed. To illustrate from my own recent experience: during extended hospital stays at RCHT it was apparent that many patients, who had genuine and sever health problems needing in patient treatment, also had social care needs especially by virtue of dementia. The level of staffing in nurses and auxiliary nurses was so low that I was constantly having to intervene by day or night as one or other confused patient started to remove their cloths, go to the toilet in an inappropriate place or to walk away from the bed while attached by pipes or wires to his bed. My intervention might be by ringing a bell, suggesting to my neighbour that a wait for the nurse might be a better idea or sometimes, going to hunt for a nurse. The point is that my life as a patient (with severe illness) was not improved by interrupted days and especially nights because the staff were fully committed elsewhere. So £7.8m on joining up services is deeply unimpressive in the face of substantial demographic change and existing unmet needs. When I spent 3 weeks in a (first class, NHS) tertiary centre, it was very clear that the poor levels of care at Treliske were by no means unique – in fact what I describe above is typical for secondary care.
It is for these reasons that I hope you will support the NHS by seeking for the bill to be withdrawn altogether and rethought – from the bottom up. I am quite sure that the changes that result will be a great deal better than those which come from a Lansley down process.
Yours sincerely,
James Robinson
Having read through most of this thread it seems obvious that somewhat of a consensus is forming. I hope the powers that be are taking note. Fundamentally what we want is an NHS that provides the most appropriate, high quality services, as quickly as possible, locally, and free at the point of use. We aren’t interested in choice for the sake of it, just quality healthcare when we need it.
The comments from healthcare practitioners seem to be in agreement that co-operation and sharing of knowledge and best practice are what raises standards and that competition between providers isn’t conducive to this. There also seems to be consensus that, particularly financially driven, competition isn’t appropriate in a healthcare setting where any kind sub-standard care is completely unacceptable and possibly dangerous. It would seem to me that there is already sufficient ‘competition’ to drive up professional standards in the sense of the prestige earned by for example being a pioneer of an effective new treatment or other such service motivated outcome.
Communication between the practitioners and services required by a patient needs to be clear and efficient to avoid delays and important information being missed, and this is more effectively done when those services aren’t provided by different organisations with varying priorities. (It seems to be difficult enough already sometimes for the necessary communication to take place between departments in the same hospital let alone different organisations altogether…!)
Regarding the issue of ‘choice’ I did though want to point out that there is one sense in which I don’t think anyone would want to relinquish the ability to choose. And that is were specialist services are concerned. To be an an expert in something requires experience and experience for medical practitioners working in a particular field means seeing patients with that particular problem. For less common conditions it may not be practical to expect there to be a specialist practitioner working in every local hospital as these individuals wouldn’t see enough cases to gain enough experience. So to have access to the highest quality care may mean choosing to be seen at a specialist centre, which may not be local. This of course already happens and if having some choice makes it easier for patients to see specialists when they need to all the better.
I think what is really being said is that patients aren’t so concerned about being offered a personal choice between several general hospitals or A&E departments at the point at which they are acutely ill or seeking treatment for a relatively common condition, there should be a standard of care/service maintained accross the board. However, they expect to be able to rely on quality advice from their lcoal primary care practitioner to help them decide on a course of action and access the most appropriate care for their particular circumstance, and if that means seeing someone not based at their nearest hospital then that shouldn’t be a problem.
Finally, a couple of people have alluded to those with chronic conditions. There are a couple of issues here.
1. Sometimes individuals suffering chronic conditions may actually know as much or more about what’s best for them than a primary care practitioner and in this case their voice needs to be heard. The comment above about physiotherapy is a case in point where if you know you have e.g. sustained a muskuloskeletal injury (experienced tennis player say) or an old condition flares up that you know benefits from a particular treatment, would it not save time, appointments and paperwork to self-refer direct to the appropriate practitioner?
2. The NHS is excellent at dealing with acute problems but does shy away from much follow up or preventative care, which while perhaps perceived as being an unjustifiable cost (the patient is not completely incapacitated) may actually help prevent future expense. E.g. someone complaining of back pain (how many hours of lost work due to that??) may feel better in the short term after taking painkillers (cheap) but actually might prevent future or worsening problems if they can see a muskuloskeletal specialist (expensive) quickly to investigate the cause and address that.
Choice is generally regarded as being about choice of hospital.
I suggest that the first level of choice is about choice of GP practice, and within that, which individual GP I want to see. As the profession becomes more part-time, more multiple role (including now commissioning) excercising that choice (for continuity of care) is becoming more difficult. The recent Kings Fund report on imrpoving quality in general practice re-emphasised the importance of continuity of care as bein equal to that of access, and even more so for those millions of people with one or more long term conditions. (it is rare to have just one long term condiition)
As to choosing a GP, there is insufficient innfromation available. Currently all GP data relates to a practice, not the individual even though in parts of London the GP population are nbow >50% not partners. Most of taht data says nothing about the core skills of a GP – consulting, diagnosing, communicating, empathy, compassion, diligence, teamworking. Indeed the instruments that were available that started to address some of those (GPAQ and IPQ) have now been discontinued in favour of the far less detailed (in terms of individual GPs) patient surevy.
There is a prospect in future of not only being able to choose a GP practice, but also of choosing which commissioning consortium to belong to, with a further risk of erosion of equity. The commissioning board will have the power to “disband” a consortium and effectively with that theconstituent GP practices. How exactly will the patients of thoise practices be in volved in that decision?
Registering with a GP practice remains a challenge in parfts of the country. Few rely on NHS Choices, with most people going by word of mouth recommendation.
The idea of being able to register wherever you live with any practice is totally mad, driven by the perspective of MPs living in two places most of whom access private healthcare anyway. The old contract mechanisms of temporary residents, immediately necessary treatment and emergency treatment atill valid, still available and even more effective with the advent of on-line patient acces to their won records. All that is needed is to make patients more aware of this and to access them more, and also challenge those practices that have not yet implkemented it.
Choice of hospital provision is only appropriate in my view for elective procedures. How realistic isit to suggest “hmmm I wonder which air ambulance helicopter to call, lets check out Trauma Advisor….”?
More publicly available timely and accurate data are needed – not simple league tables please but something that shows confidence intervals or addresses the issue of comparing apples with pears.
Long term conditions (whichy is where the really big money lies in terms of potential savings / gains) requires integrated multidisciplinary teams serving a long term population of educated and supported patients. My preferred model would be not “Any Willing Provider” with the fragmentation and duplication that would inevitable ensue; rather, “Contested Collaboration” – integration of locally based teams, but tested out for safety, value for money and effectivenes and patient experience.
The whole excercise is looking at the NHS through the qwrong end of the telscope. We need integration not fragmentation, continuity not a discontinuous provider landscape, collaboration not competition, professionalism not profit (as the sole driver).
I work in the NHS and have seen a major shift away from partnership working because of the competition element. Local community services and hospital services are in competition with each other. Collaborative working has all but disappeared. GPs are also ‘clubbing’ together to provide certain services with the support of big drug companies and competing with local already established services. GPs are independent business men and not directly employed by the NHS. The end result is fragmentation.
I think that our NHS can be more efficient and effective but introducing this level of market forces is destructive.
Totally agree – how can we work together and compete?
The introduction of competition is superficially attractive in order to drive improvement in services. If done properly i.e. opeing up all services to competition this might work. However, the considerable down side to this is the loss of co-operation between organisations and the lack of strategic planning. In addition, the damage to education and training in healthcare is likely to be considerable, with employers choosing to poach staff from other organisations rather than invest in training themselves.
Throughout my career I have found politicians to be wary of full competition and as a result we have endured various “fudges”, such as the internal market, which leave NHS providers with the more difficult, time consuming and generally loss making work, whilst independent providers are able to “cherry pick” the more lucrative work.
Although I am naturally inclined towards competitionand personally would welcome the opporutnities that it would provide, I would also acknowledge its downside. If the people of our nation wish to have comprehensive, joined up and well thought out healthcare I would have to accept that this is probably best achieved with an overarching organisation such as the NHS. To make services better, however, their organisation should be devloved to local bodies with public and patient involvement, and those bodies should be invested with real power. PCTs could be evolved to do this, and in my view are better placed than GPs to take an overall strategic view. The DoH should be reduced in influence probably doing no more than providing a national service specification of the minimum level of services that the publich can expect. There is also no reason at all why such local bodies could not make use of independent providers if they wish to do so.
If choice and competition worked then hospitals like Mid-Staffs would have no patients. But they do. For many choice isn’t option – many admissions are as emergencies, plenty of peope can’t or don’t want to travel (and frankly why should they?) and most people don;t have the knowledge to make an informed choice. Most of us just want a decent local hospital and accept we might have to travel around our region for specialist care.
Private healthcare companies exist to make a profit. They exist for no other reason – why would they want to provide care that makes them no money? Many services in the NHS (some specialist cancer care for example) operate at a loss – the NHS needs the routine work to pay for this.
It’s already been said that private companies will make a killing (in more ways than one) if these reforms go ahead. Patient satisfaction with the NHS is higher than ever – why are we risking our best ever achievement to put more money into the grubby hands of the super-rich?
Who is going to look after the patients that won’t make a profit?
Stop these reforms now, before it’s too late and we realise how good we had it. Save our NHS.
I think the questions asked in this listening exercise are completely bogus. They start from the assumption that choice and competition are definitely a good thing. I am far from convinced of this. I genuinely think what most people want is a good local GP, a good local hospital and the ability to be referred to world class specialist services if they need them. The NHS is not perfect but the ‘evidence’ the government uses to convince us wholesale reform is based on incorrect interpretations of the literature. The claim that 5000 deaths from cancer could be prevented if we had outcomes as good as Europe for example – the research this is based on actually says 7000 deaths could have been prevented if we’d had European mean cancer survival rates in the 80s and 90s it does not apply to 2011. Cancer survival has improved year on year in the UK since 1995. One of the areas that really does need improvement is care of the elderly. What is needed for this is societal change in attitudes to older people and an improvement in the status and work conditions in this area so experienced dedicated staff want to work in it.
Is there anyone who would honestly choose a health care provider that prioritises profits over one that prioritises the best outcome for the greatest number of patients? I don’t think so.
Private health care can provide a better service than the NHS for very specific sets of patients, but only because they can select their patients very carefully. If you want to be ensure a good health service for everyone, you need the NHS – and let’s not forget that the NHS is one of the best health services in the world.
Bringing competition into the NHS will in theory remove complacency and drive up quality in the NHS itself but runs the risk of cherry picking of services unless every provider tenders on the same basis. To create a level playing field in competitive tendering either a factor for training costs has to be removed from NHS costs or an appropriate contribution to NHS training costs has to be included in any tender from a private company not contributing directly to NHS training. In addition the private sector must meet the full cost of all treatments it chooses to take on and if not provided by the original service provider the NHS must be able to recharge for all care provided as a result of complications of that treatment especially high cost critical care. Only then can we be sure we have a true competitive market and I suspect we will find reduced interest from profit making organisations if they have to carry high cost risks as the NHS already does for much private health care.
Reading through these posts, the overwhelming majority from well informed (many directly involved) people is coming out against this proposal.
As a number of health professionals have pointed out competition naturally makes loss making ventures harder to justify and as by its nature most health care is loss making, expensive and to some extent inexhaustable, simply hiving off cheaper operations to be carried out by private (profit making) companies is not going to help. It simply creates profit for private companies.
On the question of choice, many mothers don’t have the choice of natural home child birth or water birth because there are not the midwives or expertise in their area. So will these proposals really benefit patients to have ‘better’ choice or ‘more’ choice, because actually isn’t it a question of ‘any’ choice for some right now?
The government did listen to the public over forests, again regarding the reforms to the NHS they are being told TO STOP THIS BILL. I very much hope they will listen and act with reasonable sense rather than costing us a lot of money creating havoc with a system that is working well. Rather than rushing into these massive changes from on high, they could consult with GPS, nurses and those working in health care and groups of patients/citizens with a real need first, to make the changes that will benefit all.
It seems to me that patients most want to be seen by effective and caring professionals at locations they can reach with relative ease. That’s what I want as a patient!!
We in Speech and Language Therapy are constantly reflecting on ways to address patient access and making service adjustments because we recognise that equality of access is a very real issue and one that our NHS with its roots in social justice values has asked us to look at – this is a value we readily identify with and it leads to real changes and choice for patients because it is based on clinical understanding and consultation with patients. For example, people who stammer can use email and text to contact the specialist therapist as phones are often a barrier. We offer evening appointments and evening groups because many people who stammer are at work or in education which keeps them busy during the day.
Companies that have shareholders to whom they are ultimately accountable do not have the right values to be able to design and deliver truly patient-centred care.
Also, as others have said, private companies will cherry-pick the straightforward conditions, and ones that can be ‘cured’ in very easily measured ways, as the target for their provision. Who is going to care for those people – who are many – who have complex and/or enduring needs, to put in the time and effort required to work as a team? Certainly not private companies.
The Matrix report from the Royal College of Speech and Language Therapists shows the cost benefits to the taxpayer overall of providing speech and language therapy for children and adults with communication difficulties. Private companies won’t care about that. Why would they?
I think too that fragmentation of services, and the constant changes that one provider winning a contract and then in a short time another winning it that will inevitably result from endless tendering out of services, seriously threatens the development of consistent and co-ordinated healthcare.
When things go wrong for individuals in the area of health and social care it is nearly always a breakdown in communication that is found to be a major contributing factor in the failure of the services to meet the person’s needs. If we are constantly changing providers the scope for poor communication is manifestly going to increase and so more people are going to have more frustrating experiences and inadequate care.
I work in a Strategic Health Authority and also provide consultancy on health matters to Barnardos . It is becoming increasingly difficult for the very skilled practitioners in the third sector to influence the NHS modernisation agenda for transitional arrangements or to inform the planning phase going forward with regards to establishing GP Consortia and the other structures in the reforms. One of the reasons being given by NHS Consortia Development Teams which results in excluding the major charities leading to them being absent from the table is that there is a ‘conflict of interest’ and an ‘unfair advantage’ if the charities are included in discussions. This is nonsense and does not acknowledge the amount of work that the charities undertake directly with children that is directly linked to improved health outcomes. It shows scant regard for the knowledge skills and experience of the voluntary sector workforce in providing very complex services to children and their families. Strategic planning and service design is (and should be) entirely different and seperate from the tendering and procurement phase which happens much further down the line and on a level playing field. It is the childrens charities like Barnardos that are best placed to advise on ‘patient participation’ for the large populations of children that form a GP patient base. It is disgraceful that children do not seem to have a focus in conversations about the reforms – they are conspicuous by their absence in the planning documents.
How then do we give children the choice? How can children evaluate what they are receiving? The medical (and nursing) professions are not seen as being hugely skilled in working with children and this becomes even more noticable with hard to reach children living in vulnerable families. Please listen to the Charities such as Barnardos to get it right for children and to give them a voice. I would suggest Consortia (and Clusters) need well informed advice from the Charities on how to achieve children’s engagement and advocacy from primary and preventive care through to specialist provision. I would suggest that choice for children will depend on advocacy through skilled engagement. Representation for children by children is important on several levels, for example for the HWB to produce a good JSNA (for children), for service redesign and evaluation, for public health campaigns and to secure a voice for children as part of Health Watch. Please make sure the third sector is properly invloved.
Competition on price, such has been proposed by Andrew Lansley’s bill can never be a good thing for a national health service. Inevitably it will lead to private firms taking the “profitable” areas of care – elective surgery in the young and fit for example – and leaving the NHS providers to fill in the gaps. Why is this a bad thing? Well quite simply because providing the “profitable” care provides surpluses which the NHS uses to subsidises the care commisioner (ultimately the government)’s tariff for the loss-making care; typically care for the elderly, chronically ill and those with complex interactions of multiple conditions. As such by creating a market where the private firms can leach capital from the NHS into their shareholder’s pockets, NHS service provides trying to complete the services for their populations will be left running a deficit. Furthermore it seems to be the intention that should a service be left running a deficit they will be allowed to fail! What then for the unprofitable swathes of healthcare? Will the private firms magnanimously step in to take up the slack? Why would they? It’s only going to hurt their bottom line – at the end of the day they answer to their shareholders not the patients.
But I guess that’s alright seeing as the duty of the Minister for Health (oh wait is that Lansley?) to provide a Universal Health Service is being quietly chopped at the same time.
Whatever the NHS’s failings (chronic underfunding being a major cause of these but that’s another matter) this proposed stealth privatisation is most certainly not the answer to create a truly world leading health service! Healthcare can never be a place for profits – look at America if you need any evidence for why this isn’t a road we want to go down.
So my constructive criticism would be quality is where it counts. Address areas such as hospital food, staff morale, cutting the bureaucracy which stifles innovation, see the value of prevention and quality rather than cost (a little more money spent now can save patient suffering AND tax payer’s money down the line – the ceravix vs gardasil choice is a prime example of how this has been got seriously wrong in the past!).
I work as a consultant in child and adolescent psychiatry in the NHS in Andrew Lansley’s constituency, specialising in work with multi-problem, high risk youth who have serious substance misuse problems, alongside psychiatric comorbidities, offending, educational failure and frequently histories of past or present neglect or abuse as well as frequent exploitation. This patient group represents some of the most vulnerable youth in the UK, and long term studies demonstrate that their lifetime prognoses (across domains of health, employment, offending and relationships) are desperate, and very expensive.
Firstly I am concerned in relation to clinical care and risk management: One of the key problems that services for my patient group face is the fragmentation of care, with multiple workers from a wide range of agencies (youth work, health, mental health, social care, youth justice, Connexions, etc.) approaching these “hard-to-reach” young people to deliver more or less specialised interventions. As frequent inquiries over many years have shown, poor inter-agency collaboration is a particular problem for these youth; one that is associated with poor, even fatal, outcomes.
Whilst there are many difficulties implicit in communicating effectively about these young people under the best of circumstances, I have had direct experience (and very frequent feedback from professionals I have trained in many settings) that suggests that when the several agencies involved do not have an explicitly and exclusively collaborative relationship the risk of miscommunication is dramatically increased. Introducing or increasing competition between the care-giving agencies that are required to knit together an integrated multimodal package is a recipe for poorer, less integrated care, with increased risk to these young people, and potentially the general public. I have myself had direct experience of working for two organisations which were pitted against each other in forthcoming tender bids, and I have no doubt about the impact of this upon effective patient care.
Secondly, I have real concern about the deleterious effect on innovative and sustainable local service developments if they are to be placed on an ever-revolving ‘wheel’ of tendering contest after tendering contest. I have direct experience of the importance of staff retention in small innovative services that rely heavily on networks of human knowledge (of allied services and personnel) and relationships across a geographical area, as well as (conversely) the toxic effect of uncertainty upon staff retention in the anxiety-provoking year leading up to a new commissioning tender. Quite apart from this, the amount of hours that a small team is required to put into putting together a tender bid is extraordinarily burdensome on top of day to day clinical commitments. Under these circumstances really innovative practice, and practice that is focussed on long term goals (as opposed to short term commissioner-led targets) is increasingly hard to sustain.
Thirdly, as has often been stated already, there are very real concerns about the capacity of a largely decentralised and de-regulated system such as I see proposed to provide the robust commitments to provide clinical experience and training for new clinical staff (doctors and other health professionals.) This is potentially devastating to the longer term development and sustenance of healthcare provision in the UK.
Fourthly , I should now be old enough not to be surprised when the political rhetoric about avoiding muscular change-for-the-sake-of-change in the NHS fails to materialise. I am most disappointed that this massive reorganisation was in no way put to the vote in the General Election.
Finally, as a ‘coda’ to these points I want to attest to the fact that, contrary to much of the rhetoric that would have it cast as, at worst, an example of centralised paternalism, in many senses the NHS is in fact more representative of many of the most desirable features of the “Big Society” that this government seeks to promote than almost any other setting on the UK. It is mainly driven by an unsung army of low paid workers whose motivation is evidently not financial but instead is simply to “make stuff that works better”; many NHS clinics and innovative services run just because an individual or small group of individuals has a passion to fix something.
I have long argued that what most predicts a patient’s or client’s sense of value in a service is the gratuitous – that which is freely given; the staying behind to explain something again, the making of a cup of tea, etc. For my patient group, who traditionally have been seen as ‘failing’ to attend appointments, or being “hard to reach” by conventional services, this kind of attention to “treatment” in the widest sense of the word is particularly important. This is hard to legislate for, I warrant, but I think that, without wishing to idealise the organisation, the NHS is the place where it happens more than most.
I would also argue strongly that the NHS (and this is undoubtedly so within my own specialist field of work) has a far stronger record of innovation in health care technology and delivery than the private sector has.
So this is the baby that risks being thrown out by your bathwater change; one that introduces (or at least dramatically increases and cements) competition as the principal driving force for change in the NHS. I strongly reject the notion that competition in this arena is a purging force for good; surely it is the extent to which the government can help to set the conditions whereby purposeful collaboration can take place (rather than competition) that will determine success?
Patients do not need lots of choice they need goof quality cost effective care. They need the service that meets their needs not anything they want
Which are the types of services where choice of provider is most likely to improve quality?
This is what is known as a leading question. It makes the assumption that private providers will inevitable improve quality. I would like the evidence for this assertion? To date having read extensively on this subject and as a British trained GP who has worked for 6 years in the system, I failed to be convinced. In fact many private providers, which have now been commissioned to provide simple operations have in fact been subsidised by the British Tax payer. Ironic but true. This is because they are guaranteed a minimum income and often did not generate this income by undertaking enough operations. Therefore they were paid for “Under utilisation” of their service. That appears to my eyes to be very inefficient. Secondly there is no after care? When operations are unsuccessful or have troublesome sequelea these centres do not provide any review service. Thirdly they do not train doctors and make no contribution to the cost of doing so. Fourthly they will only do the simplest of procedures, so where do we send the more complicated patients? As if the proliferation of private providers continues unchecked, and “see everyone clinics” in hospital are down graded there will be a proportion of patients that who the private providers deem unsuitable who no one will see. Perhaps it maybe easier to use a case to illustrate this point. A lot of hernias can be done by laproscopic surgery which is cheaper as it often requires less recovery time for the patient. However a number of hernias are unsuitable for this type of procedure , however now we have a private provider who only does laproscopic repairs. The hospital no longer sees hernias as they all dealt with by private providers…… where do you send the patient? If your in your 70′s you don’t want to travel to a hospital 200 miles away which provides some specialist services. So in reality the cherry picking of private providers not only provides a chance for private companies to profit
but will ultimately result in a reduction of available services.
I have never understood why the duplication of administrative services and and services in general leads to efficiency .
What else can be done to make patient choice a reality?
Patient choice has been held up as the most important tenet of health care? Is this really how most patients feel?
Very often when I have explained various options for ongoing treatment. Often at great pains to educate and empower people allow people to make a valid choice, they ask if you were in my situation what would you do? What most people want out of the health service is the best care that can be provided, they do not want 100 different types of hip operation , they want the one that works. Fragmenting a system which has been set up to provide a high standard of care, into lots of different services all basically aiming to provide the same thing, seems that it avoids the economy of scale that come from a unified service. Secondly it makes it very hard for the clinicians performing the service to gain enough skill to excel in their jobs. I also wonder who is going to inspect all these private providers and ensure they provide the same high standard of care that the NHS does?
A lot of work has gone into setting up the Deaneries in their present format. The Deaneries are work well and have trained staff to support the recruitment and training of junior doctors. Where is the sense in dismantling something that is working! This is not just about staff it’s about disruption to doctors education and training processes as a whole.
As a GP, I am obliged to offer choice to my patients when I refer them to hospital. The vast majority want to go to the nearest hospital. Other factors are public transport routes, parking and whether they have already been seen at that hospital. This bears out much research that if offered “choice”, most people will not say no, but when they have to rank it against other things that they want (eg. good service, local etc) then it comes low down in the priorities.
Choice is only advantageous to those who have the financial means to travel. We have seen in education that it is now schools who choose pupils, not parents who choose schools. Private healthcare providers and insurers are only interested in low risk patients. I recently saw a middle aged patient refused insurance because of her moderate hypertension. Private patients are transferred to NHS hospitals as soon as things go wrong: it is too expensive to provide the ITU back-up and expertise. One of the reasons the NHS can provide such high quality care at a reasonable price is risk pooling – the risk and cost are spread over a large population. The fragmentation which the Bill proposes will limit this, and hence increase costs.
Academic health economists have shown that competition and choice in healthcare do not improve standards and do not lower costs. Quality, insofar as it can be measured, is driven down to keep prices low, but overall costs go up because of the transaction costs (e.g. monitoring and managing contracts and tendering processes). Hence healthcare in the USA, the most marketised system in the world, is 2-3 times the per capita cost of the NHS, with worse overall outcomes. Informaticians tell us that competition only works for discrete and identical units, eg baked beans. I resent me or my family as patients, or me as a doctor being treated as baked beans! The care I give and the care I want to receive is individualised!
One of the reasons disadvantaged groups find to difficult to access primary care is that PCTs, following central diktat, conduct “list cleansing” exercises, where they send letters to registered patients. If they do not reply, they are deemed not to exist, and deregistered. How are the homeless, travellers, migrants etc meant to see a GP? And this occurs under a system where PCTs have a responsibility to their populations; how much worse it will be if the Bill is passed and consortia only have responsibility for their registered populations? I cannot see how any profit driven organisation will have any interest in taking on these expensive patients, nor any mechanism in the proposed structures which could ensure such groups are offered appropriate services. Abolishing practice boundaries will also risk further increasing health inequalities – see the RCGP submission.
Lack of information remains a significant problem, not only for those patients who do wish to exercise choice, but for mangers trying to evaluate services or clinicians who want to look at their own performance. All the IT effort seems to have been spent on the largely pointless and unwanted “spine” for sharing patient records, instead of useful things like improving data collection, or local links between GPs and hospitals. Quality in healthcare is hugely difficult to measure, and subject to so many confounding variables that it is difficult to interpret. But even those things which are measured are not fed back to clinicians, services are mostly unevaluated, and huge changes such as those proposed here are not even piloted!. It is very frustrating for clinicians trying to practice evidence-based care to have politicians imposing assertion-based policies upon us.
But is measuring quality is so difficult, perhaps we could just ask patients? Overall satisfaction with the NHS is at an all-time high of 64%, and satisfaction with General Practice routinely runs at over 90%. How many politicians have such ratings? Perhaps they are jealous? It certainly does not seem a good basis for embarking upon the fundamental changes envisaged in the Bill.
Other possible reasons for the changes are the supposedly poor outcomes of the NHS (this was well and truly exposed as false by John Appleby, Chief Economist at The Kings Fund), and the Nicholson Challenge. The latter is undoubtedly a problem: better drugs and technologies mean healthcare is ever more expensive, and as there are more older people, there are more people requiring that care. However, as has been shown repeatedly, more choice and competition can only reduce cost by driving down quality. Most people do not want this.
As the psychiatrist, Dr Dickon Bevington, explained so eloquently in his post yesterday, healthcare works best when it is integrated and collaborative. It is a win-win situation, as such care is also the most cost efficient. But is no good just mentioning integration in press releases when the whole Bill works against collaboration. The vast majority of those who work in the health service do so not only for their salary but also because they believe it is an important job, and should be done to the best of our ability. In a truly national, tax funded, system, we all have a stake in making things work. Philosophers have argued that the very existence of the NHS makes us better people. The Health and Social Care Bill should be withdrawn and David Cameron should get the drafters to start again to produce a bill with collaboration at its heart.
I fear however this may be yet another sop of a consultation, with the submissions largely ignored (as last summer) and all the time and effort we have put into it wasted, when we could have been learning he new NICE guidelines or even seeing patients….
I am deeply concerned about the focus on price. I for one am not particularly concerned about the cost of the NHS – I regard good general health of the nation as being worth paying for. In the NHS there can be no substitute for a comprehensive and quality service – price simply shouldn’t be a factor. When you introduce profit making organisations the bottom line will inherently be a consideration – we need regulation not competition. I don’t want to be able to choose between different local service providers, I want there to be a single, well funded, efficient and responsive service. Already privatisation in the NHS (in cleaning and catering services and in grounds management) has led to a significant reduction in standards of patient care and (some studies suggest) the rise of the hospital superbug. We need to roll back, not roll out, competition in the NHS.
I do not think we should ever consider Health and its provision as a business. Human beings are not commodities. Choices are for those that can make them and there are plenty of people who cannot! By providing choices we will alienate a great part of society and as usual the poor and less fortunate will suffer! Are we really going to become a country where you need private insurance, like the USA, to ensure that we get the treatments that should be available to all?
I have experience of working for many years in both the public and private sectors (not healthcare). I know from experience that the idea that the private sector runs things better and more efficiently is pure myth (I have worked for large, global companies). The NHS will not be better / more efficiently / more cheaply run by private providers. They will, in any case, cherry pick – have you ever heard of a private ICU?? Instead of wasting money on contracts, monitoring contracts, picking up the pieces when the contracts go wrong, why not just look at the layers of management in the NHS and redistribute resources so that we have less chiefs and a lot more indians?
I don’t want choice. I want a good hospital within reasonable distance of my home. Nationally I would like hospitals to share best practice rather than compete.
As far as is possible, I want health care from people who want to take good care of me, not people focussed on turning me round and pushing me out a.s.a.p.
Choice and Competition is what was promised for the privatised railway.
What have we got. Any choice? No. Any competition? No.
Biggest cost in the history of our railways? Yes!
Don’t ruin the NHS with this silly ill thought out plan like you did the railways.
It won’t work and everyone knows it.
The doctors don’t want it, the nurses don’t want it, but most important – the users of the the NHS don’t want it!
I find trying to discuss the proposed NHS reforms difficult in the 4 catagories set out. They all interlink and one has an affect on another.
For example one of my concerns regarding the notion of “any willing provider” is that with all the extra choice of service hosts, WHO chooses which provider is best for the local population and HOW is that decision made. It has been mentioned by Dr Julian Sims that poor management can occur as a result of promotion of good clinicians to managerial positions “which they are ill equiped to serve”. Is this not what the government are pusing GP’s to do? They maybe excellent clinicians who can make all the right decisions about their individual patients’ care, but what experience and training have they when it comes to commissioning the best services for a large population and how to budget 80% of the NHS finances. With increased competition and more providers for GP’s to choose from – will the promise of the best possible rates be looked at first and the quality of care second? In order to be competitive, all providers will slash their rates to make themselves more attractive for the new commissioning bodies – and will the cheapest option the best one?
Competition makes you work harder – yes, but it is only fair if everyone is on an equal playing field. However, the NHS is already on the back foot. The only way acute trusts can make money inorder to make improvements is by winning commissioning contracts and treating increasing numbers of patients. With increased competition, patients will go elsewhere, less will be treated in the local hospitals and with less demand for services – services will stop! The difficulty is that the acute hospitals have no other way of making money – even fund raising is highly policed. For example, a physiotherapy out patient dept might be able to fund raise for equipment, but if they raise more than their equipment costs, that surplus cannot go towards anything else, eg: staff training, uniforms, computer equipment, payment for extended services etc, their hands are tied. Trusts are being cornered into cutting their prices in order to maintain their competitive edge and patient appointments that would normally be paid at £40 per hour are being paid at £10 per hour. Yes this undercuts the private sector – but how long can you run a service like that and how much does it devalue the work of the excellent clinicains providing that service!
The NHS is THE PLACE to learn if you are a health care professional. Where does the government think that the Dr’s, nurses, physiotherapists, pharmacists and social workers got their experience? Have they thought about who the people are that provide private services at present – NHS consultants are normally the leaders in their field and predominantely work in the NHS, but they would most certainly have trained in the NHS. They are ones who take the private clinics and run the private theatre lists along side their normal NHS jobs. It is a common occurrance that if you have a private Physiotherapy appointment, your physiotherapist will probably also work in the NHS, and if not they would have trained there.
If as a result of the proposed changes to the NHS the acute trusts disappear, where will the training happen? How will the training of our future health care clinicians be regulated and where will they be able to get the fundemental experience in practice if these precious resources go? what is your plan there Mr Cameron?
I second the views of many people who have commented before me and state that in a democratic society – let the people choose – we chose you to govern us, now you do the descent thing and let us chose how we should be cared for, stop assuming you’re doing the right thing for everyone and ask us instead! A referendum about how many boxes to tick on a piece of paper seems greatly insignificant in comparison, yet the nation were asked to vote about that! The information you are getting from these message and e mails are important, but you cannot for one minute think that it is a fiar representation of the population as a whole – we need a referendum about, we should be able to tell you what we think and KNOW that it counts!
thanks you.
The government should stop worshipping the false god of ‘patient choice’.
No patient I have met who is ill wants a choice. They all want, and need, a top rate, local hospital which works in close collaboration with primary care, investigative services and social services. Competition and choice risks fragmenting these services, reducing collaboration and integration while only giving the individual patient the luxury and an illusion that they are having some ‘choice’ over their care
There is no real evidence that choice and competition improves services or reduces costs. The NHS is one of the most efficient health care systems in the world. In this world of evidence-based practice the only changes that should even be considered are ones that are proven to improve outcomes, not ones that promote choice and competition simply because they are part of the ideology of the government who happens to be in power at the time.
Our Communities need local services and value best thathas served them effectively over the years. This is “Choice” at its best and allows for interaction and onward improvement. The “Level Playingfield” must not be so over-regulated by the “System” that it destroys this “baby” yet again. The cycle of “Change” in the NHS is beginning to look more and more like a downward spiral at this time and great care is needed so that “more for less” does not squeeze the last living breath out of an efficient locally based health care provider. This will definitely give our Community less for less and it will be the fault of the “System” and seen as such. The emerging GP Consortia must be able to show that they have consulted in a full range of forums to support the best that can be achieved in each of our local health care areas. Too much change can be very confusing and no one wants to waste their time if they foresee that they will be going round in circles. These “Changes” must be seen to be meaningful and solid enough to be built upon and influenced by politics as little as possible.
I feel that the introduction of private companies into a competitive framework will shift the emphasis from delivery of best patient care to profit. I think that the previous and deplorable example of private companies being paid for surgical procedures not done is a disgrace and could happen on a greater scale if private companies with a profit motive become a part of the NHS per se. have no objection to a greater role for for Not – For – Profit organisations and charities becoming involved more in the care delivery process as they bring to the system an altruistic and not fiscal motivation. Intrinsically I feel that the patient’s identified and expressed need should drive the process of commissioning.
patient choice is not necessarily linked to the marketised competition between services and such competition may in fact lead to less choice, particularly for the most vulnerable in need of care. Having a range of small and local providers is the best way to improve choice in delivering healthcare.
Recommendations:
• To increase choice women’s organisations, who provide specialist services, or women-only provision should be available in existing services to ensure that women’s needs are met.
• Special licence conditions should include support for existing women’s services.
• The ‘mandatory services’ obligations should include women-only services and specialist services to marginalised women.
• Women’s organisations that provide health services should be commissioned or given funding if they are working with the health sector.
• Where communities facing discrimination make up a very small proportion of a local population local authorities or the NHS Commissioning Board could commission specialist borough-wide, regional or national services for them to address accessibility or cultural issues.
• There should be a condition in the licence for providers to ensure that antichoice providers refer women on to other local services and do not create barriers to services.
• There must be a focus on long-term and preventative strategies as these will lead to future savings.
• Clear guidance is needed from Government on how to commission health and social care services from the non-statutory sector.
• Commissioning processes must involve women’s organisations and women to ensure that gender-appropriate services are part of the landscape of providers.
• GP consortia must have sustained and meaningful engagement with the women’s voluntary sector to ensure that the services it commissions accurately meet local needs.
• The voluntary and community sector should be supported by Government and commissioners to fully engage with GP consortia and commissioning processes.
Competition in the private sector seems to mean undercut on price. As we all know cheaper is not always better. Robust governance will be required to prevent substandard care being delivered as a result of profit driven efficiencies with private provision.
Choice is fine but must come with a contract that if you make a choice you will be fined if you do not attend your appointment / admission / day surgery.
Competition in healthcare is a distraction from the provision of services focused on safety and quality towards those that place efficiency above all else.
There is room for substantial improvement to be made within our state healthcare system and I would support change, but not change that undermines the hard won gains that have been made predicated on safety and quality.
In the debate on choice, it seems to have largely gone unremarked that the doctors that staff the private sector are mainly the same ones who staff the NHS, (with the partial exception of one or two big cities). Financial rewards are better, of course, working privately. Expanding choice by expanding private provision threatens motivation towards providing the best NHS care as incomes become more reliant on the private sector for some staff. Nobody is going to be enthusiastic to go the ‘extra mile’ if a longer waiting list will guarantee a bigger income in the private rival. Choice for some compromises standards for others.
In my experience private providers main concern will be profits,so will put in low tenders to try and ensure they get the contract and then worry about how they will deliver it,I know of providers (for outreach services)who cannot ‘support people’ as they have not included in their tender, enough money to take into account travel costs,thereby people in rural areas do not get seen as often as they may require, if at all.
I am concerned that increased choice refers only to choice of provider. The NHS is currently able to offer patient-specific choices within a healthcare episode. I’m worried that with the implementation of so-called ‘best practice bundles’ – & who has determined this is not clear to me – what we actually may offer patients is one package of care, take it or leave it. Whilst this may demonstrate better outcomes to a population, it does not necessarily allow variation for patients to optimise the patient experience.
Whilst I feel that patients should be able to choose, many would just prefer to use local services – and they should be able to get the same service in whichever area they choose.
Do patients really understand what it is that they are choosing between?
I am concerned that the choice for patients would not be equal across the country effectively leading to pockets where patients cannot access services they need.
Patients will get the best service when they receive an organised service from a company not operating for profit.
Patients are most likely to choose hospital or in-patient settings rather than community based services.
Women in the area I live have the choice of many hospitals to have their baby. At the moment one hospital is very busy as women are choosing to give birth there and the staff under real pressure with the sheer volume. While the other has many empty beds but is still providing sub standard care. Over a number of years the hospital with spare capacity has not had a good reputation in the community but has done nothing to address their problems in a way that filters down to the care of mums when they have their baby. I’m not sure choice has served anyone very well. Effective management, transparency and meaningful user feedback that is acted on may help. The real issue for maternity care is to tackle the bullying in the work place and for staff teams to have the time and the training to care for mothers in a kind and professional way.
when people talk about patient choice, I often wonder what they really mean. how many people out there can actually say theyknow enough to make the appropriate choices in what they require about their health. I consider myself as a knowlegeable person in the area of health. however, the experience i had recently with my health, i realised how little i knew about what choices i was able to make. my GP needed to refer me to a rheumatologist and he did. but had he asked me to make a choice, i would never have known whom to choose. i wonder if those less knowlegeable of health issues than i am would have faired better. to have a choice is a good thing but only if the service users understand what choices there are.
I think that insurance companies have no place in the national health service. The american model is disasterous unless youre rich. We need to move away from that model not towards it.
I am an allied health professional working in a hospital setting providing rehabilitation to patients. I work as part of a group of professionals including Occupational Therapists, Physiotherapists, Speech and Language Therapists, Nurses and Doctors to provide specialist treatment in order to promote independence to patients and enable them to return to live in the community. It is vital that I liaise closely with social services and housing associations in order to ensure all aspects of the patients needs will be addressed. In the last couple of months I have seen a dramatic change in my working practice taking me away from my clinical role and further towards that of a case manager.
Because of the dramatic cuts in funding for local authorities the number of Social Workers has markedly decreased which has led to the Occupational Therapists having to carry out tasks social and other local authority workers would have previously completed, for example form filling on behalf of patients and chasing up with regards benefits and housing. As a result this leaves less time for the therapists to provide patients with the treatments that they are trained to do.
The reduction in funding has also led to the closure of numerous community groups which provide ongoing support for patients with long term conditions and are often a life-line to reduce the impacts of social isolation and possible further ill health. Loss of such services would be detrimental to public health and lead to further costs to the NHS and the state through admissions to hospital, increased care needs and the reduced likelihood of the individual returning to work.
As such services do not necessarily provide immediate, measureable results, I am concerned that they will not be considered as important by the commissioning bodies and therefore are at risk of further cuts. As a result of this, existing clinical services will be at risk of being judged as poorer quality in the outcome measures because of the increase in time taken to discharge a patient because a lack of available community services. Already health professionals find it difficult to source funding to enable individuals to access community resources and the proposed changes to funding community services would make this even more difficult and even more time consuming. Most importantly this limits patient choice and their right to a better quality of life.
If we believe in devolving power and decentralising decision-making then why is the coalition government proposing that primary family health services (eg GPs, dentists, opticians and pharmacists) are commissioned nationally rather than locally.
There has been a lot of public debate about the commissioning of hospital services by GP consortia, which to my mind has over-shadowed the question of who commissions the GP consortia.
Currently GPs, dentists, opticians and pharmacists are commissioned locally by the primary care trust, who will have the local knowledge about gaps in services, poor provision etc and take action to deal with them and have a degree of local accountability.
With the proposed abolition of the primary care trusts, why has this been centralised. How will the NHS Commissioning Board in Leeds know what services we need in Bristol (where I live)?
Just as responsibility for public health is being transferred to local councils with a ring-fenced budget, why not transfer responsibility for commissioning GPs, dentists, opticians and pharmacists to local councils as well. There seem to me to be very strong arguments for this:
1. Integration with public health
2. Integration with adult and children social services and health services already provided by the local councils
3. Councils have has experience of commissioning services – health and social care, children and young people, drug services – which could be developed with expertise from the PCT.
4. Less disruption as the relevant staff and expertise could be transferred from the primary care trust (as with and along with public health).
5. In the longer term there are opportunities for better co-ordination with other local services that are based in the community such as housing, community safety and parks and sports services (eg prescribing physical activity instead of drugs)
6. Local knowledge meaning better targeted services, more appropriate services. greater sensitivity to the needs of local communities and greater local accountability
I have six monthly dental check-ups, see my optician every year or so and, being generally in good health, perhaps see my GP once or twice a year on average. I rarely have to go to hospital (well at least not yet). So it seems bizarre to me that it is only the expensive hospital treatments (that fortunately only a few of us need at anyone time) that will be decided locally by GP consortium – while in future the primary health services that everybody uses every year will be decided hundreds of miles away by some national quango rather than locally. Where is the patient choice in that?
Choice in itself, is not a bad thing but benefits and drawbacks to the NHS need to be carefully considered to ensure the whole is not compromised by the part. There are very few issues with choice between NHS providers, as this should drive up standards within the NHS as each hospital/clinic/service strive to offer something different over their rivals. This should definitely continue under Choose & Book. The issue that is continually mentioned is cherry picking the easier procedures by private providers that rarely cause complications or indeed litigation. This maybe could be addressed by licensing private providers only if they carry out all procedures within a particular speciality. For example, I imagine (I’m no clinician) that ingrowing toenails is a quite straightforward procedure but if all chiropody issues were included in that private providers service to qualify for NHS funding, with appropriate ratios of easy to hard, this could perhaps mitigate the issue.
e.g. Hard/Very Hard 20:100 ; Standard 20:100 Easy/Very Easy 60:100
If this is palatable or difficult to police what about just having choice between rival NHS providers with private providers being included in NHS funding only when the NHS providers cannot reach a certain standard whether that is timescale and/or outcome? Patient choice is still present, it gives the NHS first call but, crucially, if they cannot achieve a certain benchmark, private providers are invited to pitch. Standards are driven up, the NHS has some protection but the safety net for continued quality is available.
These reforms are misguided and driven by ideology.
The well known Conservative mantra is that everything must be private. It seems that the Government intend to give control of the money to the part of the NHS which is private i.e. the GPs. This is ideology.
We need an NHS which is free at the point of need, works efficiently and provides the best possible care within the constraints of the resources available (i.e. the cost the taxpayers are prepared to pay), but I am far from convinced that these proposals will provide this. Instead the service will become fragmented which will increase costs and result in a more unequal service. The suggestion that patient choice will automatically improve things is an illusion because most people do not have the knowledge to make an informed decision. There will be the suspicion at least that the G.P. is basing his advice on the greatest benefit to his practice rather than the best interests of the patient. Even though more information may be provided most people are not in a position to assess this. In addition, with more private companies involved we will see increasing amounts of advertising designed to persuade (i.e. mislead) patients into choosing a particular provider.
While I can understand that involving clinicians in the design of services could lead to improvements, wholesale change such as this are unnecessary. People love the NHS and levels of satisfaction have been very high – lets keep it that way!
Choice (of provider) has proved illusive for a number of reasons, many of which are described above. In addition to those comments it is beyond doubt that choice requires an excess of capacity over demand to enable sufficient providers to stay in the market at levels of utilisation below what is assumed in the national tariiffs. If the price (tariff) does not include a margin for excess unused capacity those providers will shrink and eventually close thereby defeating the objective. Add to this the requirement to provide care with limited access times the balance between capacity and variable demand implied by choice becomes almost impossible without redundant capacity that has to be paid for.
An extension of this argument also applies to the scope of choice. There is little evidence that the independent sector has been allowed to/ is willing to enter the provision market for unscheduled care or for the higher specialised services that often require infrastructure support way beyond what an independent provider would be able to provide unless they entered the complete provision world. If this artefact, undisclosed separation persists, the acquisiton of marginal elective activity by new entrants to the provider market will remove the financial contribution made by this activity to the infrastructure required to support the other essential services of the current NHS providers. This is being played out in micro with the desired rebalancing of activity between hospital and community where the infrastructure cost coverage becomes a real and difficult constraint, but manageable. If there is a further range of threats created by alternative elective provision with no transitional funding to bridge the time taken to reduce infrastructure reduction one of two things will happen, NHS providers will become non-viable and close or they will cease to offer those services that depend on available infrastructure (high cost imaging, critical care, Consultant expertise, laboratories, education and training) leaving the population who need these critical services with no choice.
The business with Southern Cross also should provide a lesson. The consequencs of that organisation folding or exiting the UK market or demanding a significant price increase are unthunkable but now harsh reality. There is a failure regime of sorts for NHS providers but none (in terms of continuity) for the independent sector. What wouild happen to supply continuity if significant services which have become an accepted and necessary part of NHS provision decide that operating margins reduced by successive imposed effieicency gains (price reductions) that have no evidence base are sufficient cause to exit the provision market or use the threat to force prices up?
I wonder if any of these consequences have been thought through? In simple terms there is nothing wrong with choice made available by competition so long as the market is fair, the impact is considered and managed and there is no excess costs associated with making it possible for what the vast majority of users seem to be saying is not an issue.
Working as a nurse, with vulnerable groups in my locality who lack capacity to make informed choices. There appears to be a potentially increased health inequality developing here. The NHS perhaps working better for those who have greater capacity to understand it?
I can’t help but feel it is crucially important to have local health services, thoroughly scrutinised to ensure they perform as they should for all. Local NHS commissioners should be included in this scrutiny to ensure that the needs of all groups within any given community are appropriately assessed and on this basis, local services should be designed and developed.
Shifting expertise out of area and creating market forces that are driven by those who shout loudest is in my view, in danger of segregating communities and potentially overlooking the most vulnerable groups in our society.
Re-organise the NHS based on more thorough needs assessment of entire populations using services, not on what appears to be the opinions of a few relatively small stakeholders and consultations. That’s a mistake.
The difficulty I have with choice and competition is that it admits that some parts of the health service are better or worse than others. I cannot believe that we have allowed the situation to get so bad that we need choice and competition to drive up performance or to ensure that funding is made available due to a higher demand for services in one trust over another.
I agree as a current patient in the NHS System, that choice has worked for me, and has allowed both I and my spouse to receive treatment at the hospital located closer to our residence, rather than being obliged to travel longer distances to hospitals, where such services have been centralised.
The ethos from the foundation of the Health Service was to provide an appropriate level of care, at a local level to where people reside. This approach has long since been abandoned and services have been removed or relocated obliging people to travel further for Accident and Emergency services in my own area and for Maternity Services further afield.
Another issue of choice and competition is the post-code lottery approach now adopted by Health Trusts to providing treatment on the basis of cost, rather then its efficacy for the patient. Aided and abetted by NICE, whose charter seems to be to withhold new medicines on the basis of affordability, rather then their life enhancing or even life prolonging efficacy. No longer is saving life or providing the best treatment the mantra, it seems to be save money at all costs so we can employ more managers.
I appreciate that money is always short and that someone has to decide on priorities, but the inhumanity and lack of compassion involved in these decisions, which in the main, ignore Clinical Opinion, just seem to me to fall into the category of murder by withholding resources.
Young Diabetics disadvantaged by QUOF payments
The current prevalence calculations have financially disadvantaged our population of young Type 1 diabetics this financial year. We run an in house specialist shared care clinic for out population of 42 type 1 diabetics within our University Student Health Service. We achieved more QUOF points (81/100) than last year (76/100) and yet our QUOF payments have dropped from £ 21,706 in 2010 to £1,724 in 2011. This means that we can no longer afford to continue providing the level of care within the practice and will now refer all the patients back to hospital for their consultant care which has to be a retrograde step.The reason for the altered prevalence figures may be related to our very low number of Type 2 diabetics ( currently 2 patients) which makes us very different from the average general practice. Surely Type 1 and Type 2 QUOF payments could be considered separately in order that the funding is equitable to the amount of work done, and to allow clinically excellent care to continue in a community setting?.
I do not believe that either competition or choice can “drive NHS improvement”. Nor am I reassured by the Prime Minister’s claims that there will be no cherry picking by private providers. With “any willing provider” how is this to be avoided? Private health companies exist to provide profits for their shareholders, so are bound to take the most profitable services, leaving the NHS to deal with the more complex and expensive – and to step in when one of their patients proves more complicated. I strongly object to private profit being made from health and care. As for choice, how can any patient, especially a seriously ill one, make an informed decision about where to find the best care for his/her particular needs?
Dr Richard Taylor, formally an Independent MP and Health Select Committee member, has written:-
“The most important battles the NHS should be concentrating on now are:
Improving efficiency and value for money while cutting the NHS deficit,
Improving safety and quality of care across the NHS,
Improving patient and public participation in decisions about NHS services nationally,
Strengthening commissioning, especially for quality of service provided, and as part of this improving communication and co-operation between primary care and hospital doctors.
These apparently conflicting aims, when successfully addressed will all lead to improved health outcomes and can be effectively implemented by strengthening existing NHS organisations and initiatives rather than creating new ones.”
My views on choice is that there is not really a choice when you are constrained by travelling distance, unless we are going to waste serious amounts of money funding it.
Otherwise we are going to ensure a two tier health service where those who can afford it can procure the best in the health service whilst those who cannot have to accept what they are given. Or even within existing departments in local hospitals you may end up with popular consultants overwhelmed by a huge workload whilst his colleagues are sat around twiddling their thumbs, hardly the best use of resources in either scenerio
Another constraint for choice is the cost of scanners etc, these cannot be placed in every single health facility they are simply to expensive, and where is the sense of having one standing idle whilst the other is being used 24/7
So then we come to competition. You cannot have a free market using public money within the NHS it will not work unles you privatise health provision something I am vehemently against unless providers do not take over existing equipment paid for by the public, particularly if it is to be used for profit, but they provide their own equipment thus increasing competition and choice. Otherwise the whole exercise is pointless. Then people can make an informed choice whether to use the publically owned NHS or opt for private companies
Companies bidding to provide services cannot cherry pick, if they are going to set up a general surgical hospital then they must undertake to perform all procedures currently done by a District General Hospital, or a regional speciality Unit. In short they provide services in parallel with current services, thus truly increasing choice and competition.
Competition will narrow choice because healthcare will be about cutting costs in order to be competitive, and this will mean that quality of care will suffer. We know that privatisation doesnt work for the people of this country. It only works for business. If these plans go ahead, the gulf between rich and poor will widen, and this will have devastating consequences on society. Wales and England have rejected these plans at government level. These plans have been rejected by the English citizens, and our citizens in Wales and Scotland are helping us with this fight. The Condem government will not win this one. This is our NHS and the government has no right to destroy it.
There is NO conflict between quality and cost, so long as the quality required is accurately and precisely defined and measurable.
Goods and services must fulfil the needs and expectations of the end user by being
< fit for their purpose
< free of defects
< reliable
< value for money.
Do not confuse quality with grade. An earthenware cup must have the
above qualities just as much bone china. It is idiotic to use a gold-plated lighter in the kitchen when a cheap throwaway might serve just as well for less money. Total user costs must be known and measured.
Do not buy something cheap if it costs too much to run and maintain.
Quality must be defined precisely by the buyer, guaranteed by the supplier,and delivered reliably. The only question then is – price.
All faults and failures must be recorded, costed and traced back to source (defective materials, faulty procedures, lack of training, wrong definitions or measurements?); the faults must be rectified at source. Systematic prevention is better than cure.
This kind of quality management pays for itself, and shows a profit because the savings go directly to the bottom line.
There are systems for achieving it, namely ISO9000 series (based on BS5750). All suppliers must be certified to this as a minimum requirement. The improvement of quality must be constant and measured.
Many goods and services companies practise this kind of quality management. It was advocated by the Government many years ago, but never thoroughly practised.
Start doing it NOW.
Most patients will coose local services above anything else, and in my experiece service users are usually happy with the service provided. Most services that patients have direct contact with are run very well and patient satisfaction is high, despite being under huge financial pressure. Money spent in the NHS continues to be wasted in many areas by constantly re-inventing the wheel, the competition brought about by this change will dilute quality as people strive to provide the same service but at less cost. In the long run this will result in more money being spent on new people being trained to do a job that a team was already very competent at.
As a Consultant Child and Adolescent Psychiatrist working in East London with children, young people and families where a child has learning disability and/or autism, I am witnessing the dispersal of a long fought for and recently formed small specialist CAMH service. There will be no specialist service for this population group to reduce the risk of serious mental health problems developing and worsening, never mind a decent choice. The idea of promoting competition and choice where there is no money to develop even one decent and properly integrated service to meet complex health, social care, education and additional needs for children born with a complicated mix of developmental disability/illness seems a particularly cruel joke. The children I now see (many of whom I believe I will in future have to turn away until their mental health difficulties become massive and acute) have complex needs and disabilities which usually span multiple different ‘care pathways’. Unfortunately parents are usually ground down and exhausted by the challenging circumstances they face and the 24/7 care they have to provide, so campaigning to meet their complicated package of needs is difficult. As a result little ‘noise’ is made and little interest taken by the public media domain, until tragedy strikes, as for example when a parent sets themselves and their child on fire, as happened not so long ago in Leicester. My question is this “Forget competition and choice, just show sufficient compassion to prevent unnecessary suffering. Please fund and provide just one baseline decent provision, to work across and integrate care pathways and achieve the best possible physical, emotional, family, social, educational and quality of life outcome for every child born with complex disabilities.”
Payment by results for psychological therapy is an exercise completely ignorant of the complexities of mental health services, the problems service users bring, and the diversity of service user groups that services need to be available to. Psychology waiting lists are currently untenable and putting increased pressure on services will result in those most vulnerable and therefore less able to access services being marginalised from NHS services.
Measuring mental health is impossible as what will be a huge leap forward for one individual may only be the first step for another. Each user of psychological services requires specific individualised treatment. Reducing therapies to a common ‘currency’ is disempowering and implies that mental health professionals need ‘incentives’ to put their patients first.
have worked as a doctor for ten years and feel passionate about the
NHS. I have just been appointed as a consultant in emergency medicine.
There are two things I would like to see develop in the white paper.
Stopping evidence free expensive ways of reducing emergency A&E
attendances which do not work, but instead integrating GPs into A&E, so that
inappropriate attenders get seen by GPs. I would also like to see an
expansion of A&E consultnats. This would reduce admissions and length
of stay as the patients would get expert help on arrival to hospital. Often the sickest patients are seen by the most junior doctors especially out of hours and at weekends.
The role of monitor in encouraging competition and not co-operation. I
fear this will destabalise hospitals and risk the future of hospitals
emeregcncy department. The risk in going forward [with the bill] as
it is, is It would lead to some
hospitals not being able to continue as they are. If you were to say
‘we’re going to go out to competition for vascular surgery services’
and my hospital lost the contract to a private company, we wouldn’t
be able to run our own
trauma centre, for example, because you wouldn’t have the staff and
the skills on site to do things and the volume of procedures needed to
ensure clinical standards remain high.” A&E depend on the specalist behind us and if they no longer work for the NHS but for priavte companies doing routine ops, they are not there for us in an emergency. Monitor must ensure co-operaation and not competition.
kind regards
Dr. Rob Galloway MBBS BSc MRCP FCEM PGcMEdED MAcMedED
P.s. I would really appreciate an actual response as opposed to a
computer generated yer yer yer Mr . Landsley is listening. I would be
delighted to meet him please can you publish when and where we can meet.
This proposal is not about choice. It’s about profit. The concept of choice is just a smokescreen.
Some of the comments from fellow NHS professionals beggar belief. Have they actually experienced other healthcare systems? Most in Europe are dreadful. To suggest healthcare is better in France or Germany is drivel. The NHS is extremely effective, of a very high standard and in my humble opinion, cost effective in many areas. Introduction of competition will fragment healthcare and increase “managerialisation”. Market forces just do not work in healthcare; yes, they create wealth for many “cherry picking” providers (I suspect some of the posted comments originate from these opportunists) at the expense of the central government and population most at need, proven time and time again in the States for instance. If there really were a better system out there it would’ve been noticed! Furthermore, very few patients want “choice” of provider, but prefer guidance as to whom it is best to see and where, largely from their GP. Quality is always more important than cost, surely. Competition will erode quality and result in a multi-tiered multiply-managed and ultimately more expensive system that will take years to evolve. Ignore the sharks….they want to line their pockets. I am in a position to make a lot of money from these reforms yet am strongly opposed to nearly all of them. I want to preserve our NHS, which can be improved I’m sure, and we should strive to do this through other reforms after consultation, not blind instinct. DOH, wake up and smell the coffee!
This government like previous governments say competion will bring greater choice, value for money and better services. One only has to look at the privatised Utilities to see that this does not and will not be a valid argument, I refer to the Thatcher era. Change for change sake is not valid, this is being done to FORCE people into going private, to make some ex MP a vast amount of money, shoot the lot of them the quicker the better, I will do it for free.
The NHS is a free government run service which has been running along fairly nicely. Trying to make it look like a private medical care facility is to ask for the impossible. GP run primary care and consultant led secondary care are poles apart….GP training and qualifications, consultant training and qualifications are also poles apart. Asking one group to control another is a bullying approach. Already the Government has caused the training system to deteriorate badly from a first class one to the second rate one where nurse and junior doctor training is concerned: the cornerstone of respect for consultant authority is currently replaced by that for managerial authority: this does not augur well and trainees will not find themselves beholden to such authority and training already suffers producing mediocrities in place of excellent trained finished products as existed. All the time new and often silly plans are hatched by managerial staff to justify their existence and expand their authority and consultant bullying: the question lies in whether anyone of these measures led to improvement is patient care: the answer is no. The costs on admin bureaucracy is spiralling while keyline recruitments as nurses and doctors, are sidelined. To say that the Government is unaware is absurd but its time the rot was halted. Patients are happy with good medical care that existed before and it was reasonably priced compared to constant tales that are fed to show how wonderfully well managers have improved NHS!! At what cost? Where did the money come from? How did it really improve choice and what is competition and is there a need for it amonst government run organisations? Is there a need for so many targets? Just cut the bunkum and get on with the job!! Secondary care can be easily improved by giving senior nurses and sisters the teeth to keep their wards clean: there was no MRSA until the sister’s were sidelined and managers came!! Likewise the biggest risk is that doctors training is suffering and once this country allows medicrity to take the place of excellence this country will be doomed, thanks to the unbridled power of managers and not professionals. Often choices are imposed down the patient’s throats , they are made to travel huge distances whilst some dam’nd lie of a statistic is produced to show how efficient managers are whereas in reality its a load of bulls!!
In the current context, the concept of introducing competition ( or choice) is rather like Sophie’s choice. Competition suggests that there is a overprovision of services from which a competitive exercise might ensure survival of the fittest. However, nothing is overprovided within the NHS.
With the advent of cost savings and in particular the massive reduction in management cost, the procurement exercise in itself will consume virtually all the current resource.
Although the rhetoric is all about quality, I have yet to see a quality proposal ever win againsts a qquantity proposal. On top of this, any outside provider, or at least most, are motivated by profit and will wish to see a margin on their investment from what is already an underinvested service. The concept does not stack up.
The concept of Monitor forcing organisations into competition is riseable.
Choice and competition are nice words, but what we need is a public health service free at point of use. Not a state healthcare insurance provider. Privatising the NHS will mean worse care that is more costly than it is today. The NHS has its flaws, but it does tremendous good- and privatisation will ruin it- and give us the disgusting illness based bankruptcy that many in the US suffer from.
The NHS was brought in back in the 40′s mostly against the wishes of many in health at that time, has anything there changed?
Ask any British man,woman or child and they will tell you that good health is more important than money and in this respect the NHS is of paramount importance, far too important to be left to the whims of andrew Lansley and David Cameron.
Privatisation just means PROFIT.
This whole choice in public services thing is completely daft. It has made a complicated mess of the school application system and it is likely to only cause problems for the NHS. I don’t want choice of services, nor does anyone else I know- I simply want the service I need that is geographically closest to me to be to be of a good standard. That’s it.
I don’t think any kind of competition or privitisation is going to manage that because the focus of a private company always has to be on profit. Without that drive to cut corners a public service in the public sector is always going to be better.
The only part of the NHS that would benefit from competition and choice is hospital food. That should also however include the choice for the patient to have their own food brought in and reheated if necessary.
I agree with K Sidaway-Lee in that I do not want choice. As a prostate cancer patient 4 years ago, I received first class treatment from my GP and the specialists I was referred to. If I had to choose, I do not believe I have the competence to do so and would finish up sticking a pin in a list! From my own experience the NHS in my area works well and does not need to change
This is just political ideology there are many ways to improve service. Everyone wants better and cheaper services. We can all work together as one big team and make a difference for the sake of improving peoples health. This all sounds remarkably top down. How about a real bottom up approach where feedback is sort from patients, nurses, doctors, all staff (no politicians!). Then during regular team meetings you have a quality section where the feedback is discussed and improvements made where appropriate.
Purchaser/provider split is a waste of money. There is no evidence that it has improved health or saved money. Thousands of staff are involved in contracting; their salaries could provide more health care. “Competition” is a sham for dismantling NHS. “Choice” is meaningless when there is little spare capacity; choice is difficult to come by except in a major metropolis; most people don’t have the knowledge to exercise choice, which effectively is done for them by a doctor. So let’s return to the pre-Clarke NHS.
I have worked in the NHS over some 10 years, it is not choice or competion that is needed it is fewer managers with clipboards and more professionals to do the job they trained to do instead of endless paperwork and trying to meet targets, all of which do nothing to help the backlog of patients. And lets face it privatisation just means more costs so shareholders can get a return and even more paperwork.
A patient or patients family will always seek for the best at any cost and not be willing to step back for the best of another patient with a higher need. As long as personal and financial resources are limited, this empowerment of patients must lead to a dislocation of rare ressources. The demanding smart patients will block the workforce of the very specialized most excellent doctors who should be spared for the most complex cases.
Gatekeeping and vetting is essential to maintain an efficient healthcare and individual egoism must be balanced by independent decionmakers.
For years doctors have warned of the dangers of increasing the use of private companies in healthcare provision. In other countries healthcare outcomes have worsened when the market is brought in to healthcare. Fragmentation of care occurs with many different providers involved in episodes of care. Costs increase when private companies move into the healthcare market – it isn’t cheaper or more cost effective – it costs the taxpayer more.
Private providers have their eyes on the profitable, easy to perform aspects of healthcare. They don’t want to be involved in patients with many illnesses or those who may need extensive postoperative care or even intensive care – that is left for the NHS to sort out. The worry is that cherry picking these ‘straightforward’ aspects of care may destabilise local hospitals and also crucially diminish the opportunity for training our future GPs and consultants.
The Government says they ‘never privatise the NHS’. This is a bold statement to make but it is misleading. The Health Bill may not lead to privatisation as we saw, for example, with the railways or water, gas and electricity companies in the 80s and 90s. What the bill does though is open the door to private healthcare providers and allow them massive opportunities to offer their wares under the banner of the NHS. The ability to use the ‘brand’ of the NHS is much sought after. Yes I understand the private providers offered services under the last government but this was on a much smaller scale and the NHS remained the ‘preferred provider’.
By any other name this is a privatisation of the NHS in my opinion.
Why break what does not need fixing? Patient satisfaction is very high with the NHS.
Competition is all very well, but it leads to a post code lottery for patients, because administrators play chess with provider outlets, playing the ‘my facility will be the best’ game, forcing patients to travel long distances for treatment to supposed ‘centres of excellence’.
As an NHS patient I want good healthcare within 30 minutes travelling time from home, because I would be ill enough without makiing things worse for myself and/or any visitors and family members.
I don’t want a myriad of private providers muscling in on what should be a vital service to the public, because with private providers comes inequality of access, and health for those who can pay the most.
Unum health insurers can take a running jump, and keep out of British healthcare, we don’t want American style healthcare here, because it disadvantages the most needy and vulnerable – the chronically ill cost too much!
It is all very well having patient choice, but it doesn’t always work in practice, and the general public are not likely to know much about the providers, to make a valued choice.
All we want is good care everywhere at a point of delivery within 30 minutes travelling time of home.
But of course that is too much to ask, isn’t it?
This is a sham!!
A recent YouGov poll found that 95% of the public have no idea how to get involved with this “listening exercise”.
How does the Government propose to engage with the elderly, frail or sick who do not have access to online forums?
The reforms proposed to the NHS are heinous enough but to exclude the majority of NHS users who are unable or prevented from expressing their views is devious and underhand.
As a GP involved in commissioning I fear that nhs contracts and nhs commissioners (managers and clinicians) lack the sophistication required to ensure that the private sector and their lawyers do not threaten integration and collaboration. I have witnessed the same service being interpreted quite differently by an established nhs provider versus another AWP, with the latter being far more costly. The result was the contract was pulled for both (to ensure fairness) and to in order to ensure that we do not trip up on any issues around competition in the future the service now has to be fully tendered. If the nhs is a public service let’s demand an open accounting system for both nhs and private providers and make certain that any legal fees are also fully disclosed. The no win no fee system has often resulted in more costs going to the lawyers than are won by the claimant. If we are required to achieve 20 billion in efficiency we cannot afford to divert precious resources to the legal system
Clinical professionals endeavour to practice to high standards underpinned by evidence based knowledge and skills in the best interests of individual patients before them, and appropriate referrals are ideally in the interests only of a better patient outcome and also based on evidence. Understanding scope of practice also defines a professional way of working as does having confidence in the abilities you have.
Using every available pound for healthcare makes for financial efficiency and good clinically led management is about doing this.
In the current system over the past 30 years gradually more and more healthcare resources are spent on other things, top slicing e.g. the predictably I’ll fated national IT project, transaction costs have risen, SHA,s and DH interfere in what should be locally and professionally determined. The legitimate function of private enterprise is to get best return on investments to make profits, the function of NHS is to provide most efficient and effective healthcare for the voted funds – they are different objectives.
Abolish constant top down meddling, increase professions say in running NHS suported by fewer but directed managers and spend precious resources fully on quality health not for profits
of independent sector or the bureaucracy to support a Market legitimised by notions of false choice.
Change, but for the right reasons, not churn.
To continue, the inflencing moves towards marketisation relies on assertion over evidence, opinion presented as facts. A flourishing Market in amy case needs over supply, without it there is no real choice. In healthcare increasing marketisation means incentivising cheaper services and cheaper services in my experience means lower quality. Despite the pause SHA’s are still filming Carry On Regardless – the sequel – the worlds of the clinical professional and those that want to consign clinical services in the NHS to the same sorry fate as contracted out non clinical services collide.
The NHS is supposed to be free at point of use and to meet needs whatever they are, irrespective of patient’s financial circumstances. In such a situation demand is potentially infinite. Increased patient choice, even where the patient can rationally choose does nothing to address this dilemma. Insofar as patient choice is appropriate it exists already.
Of I am supposed to comment on competition. We have seen what a disaster this has been in the US – incredible waste of money and humiliation for patients. Leave it out! Introduce a Total Quality approach instead. This involves trust, and competition is the enemy of trust.
There is a lot to be proud of in our NHS so why do we need to dis-assemble it? Having worked in Social Services for many years I have seen first hand how the move from an in house home care service to tendering private companies has created a culture of profit above quality of service.
I am highly concerned about the government’s plans to introduce more competition into the NHS. I believe that this will undermine every patient’s right to access a good health service. I also believe it will increase bureaucracy and cost in the long-term. As a trainee health psychologist I understand that the NHS is under financial strain from the increasing number of people requiring care for chronic illness, however I believe that a collaborative approach between patients, doctors and experts across the spectrum of health and social-care will provide the best solutions, and this forward looking approach is at odds with free-market thinking, which marginalizes and compartmentalizes patients, professionals and departments. Please rethink the reforms.
Simply put I don’t want choice and competition in the health service, I simply want a good health service. And to be frank I really don’t see where patient choice can actually be of benefit to the patient. I had a tumour removed last year, it was found and dealt with promptly, which is how I think it should be. I was not an expert in any way on the medical details and fail to see how I could be expected to make informed choices on any aspect of my treatment. If for example I were given a choice of hospitals or surgeon for my operation on what basis should I be expected to choose between them? Would it be on the basis of statistics on success rates? If so, I don’t see how useful that would be, since no two operations of the same type are ever exactly the same and any statistics would be easily distorted since a hospital or surgeon who is perceived as being better would be oversubscribed and could cherry pick the easier operations.
We engaged in a tender as a GP practice, this cost us 10,000. It is shocking to think that if this process occurred 250 times for Darzi Centres that a huge amount of money was wasted. If you are a GP in an area, then you are investing in your practice and doing a lot of work for notheing, also you are building up relationships with that community which have huge gains for healthcare. You cannot market this sort of phenoma, and there are not a pool of spare doctors and nurses. NHS organisations are value for money and often run on a shoe string. COmpetition can only push up the price and create a more mechanical service. This is not what we need with an aging population. Please drop competition and support professional culture.
On the front line we hate choose and book. Choice is an informed choince about your health not necessarily a mechanical computer process. Not all commercial things fit well with health. In fact this has broken Dr networks by putting management in the middle. Please can we have healthcare with less red tape. What evidence is there that so much monitoring is at all efficient or motivating or better for the patient
The question about which are the types of services where choice of provider is most likely to improve quality is a dishonestly leading question, because the question itself tries to trick people into thinking that “choice” of provider is itself “likely to improve quality” – it isn’t. The “any willing provider” aspects of Mr Lansley’s White Paper will actively undermine treatment quality, because willing providers are not necessarily the best qualified, and because the Bill’s provisions will compel providers to under-cut each other and compel GPs to award contracts to the cheapest providers.
The question about how to ensure a level playing field between different kinds of provider is also a dishonestly leading question. The question NHS patients want answered is how to ensure quality of service, especially considering that the NHS is, considered in market terms, a health insurance scheme our families have been paying into for generations. The numerous forms of tax UK citizens pay have helped build-up the NHS over many decades, and this is a historic investment that we are entitled to draw upon when we are sick or injured. No-one wants “Free” healthcare. We want the health services we’ve already paid for.
The question about making patient choice a reality is yet another dishonestly leading question. When patients visit their GP they prize an optimum quality service more than they prize the hassle of having to choose a rival service if the first is poor. The “choice” the “any willing provider” and lowest-price competition aspects of the NHS reforms are designed to encourage is the government’s hope that more patients will “choose” to pay extra (in addition to the tax they’ve already paid) and go private, because, as a direct result of their White Paper, NHS services will for many patients have become intolerably poor.
The idea that Cameron’s privatisation of services is in the interests of patients is complete rubbish. A report this week suggested the costs of administering the myriad companies now running the Railways is about 5 times the price it would have been under British Rail. The shareholders, lawyers and PR sharks are the main gainers. Passengers are an inconvenience except by paying spiralling fares.
On railways, they have cut trains, cut out stations, inflated fares, and generally optimised to maximise income based on the very limited set of rules that are in their contracts. That is what private companies exist to do. The model was wrong and idealogically driven for the railways, it is wrong and immoral to use people’s illness as profit lines in this way, and with healthcare we will collectively pay for this waste.
We know that the US insurance driven healthcare model is hugely inefficient and costly. But it seems that US Healthcare companies have been in on the design of the new NHS, will bring ‘expertise’ to GPs in exchange for a share of their profit, and we, taxpayers and patients, will be far poorer as a result.
I have managed mostly to avoid the NHS as a patient so far, I will want efficient local and integrated care when i need it. As a taxpayer I want minimal money wasted and syphoned off, and as someone who has worked across all NHS health settings, I want the NHS frontline empowered, not just GPs who are often parochial and myopic when it comes to specialist or non medical clinical and support services. Oh, and with their hands in the till.
The whole emphasis is wrong, it has been so under successive administrations, driven by the mandarins in Whitehall.
Competition? The only competition seems to be bed managers who are not medically trained against nurses and doctors. Remove the bed managers, save the money.
GPs already filter patients and restrict choices: further GP power will REDUCE the service delivered and remove patient trust.
Creation of more internal markets will create more roles for staff who push money around rather than push and care for patients.
How about finding some more funding for cleaning the hospitals?
How about stopping the building of PFI buildings that we pay more for over the long term? There’s a nice MOD building in Bristol (Aztech Park) that is going to lose jobs – maybe convert that palace – which it is – for medical health needs?
The main competition should be each hospital with itself, to improve its own services. As soon as competition between hospitals occurs, the focus shifts from the patient to the target, be it financial savings, “outdoing” the rivals etc..
Choice should be part of a patient’s right, but in my experience most people want a service they can access easily – i.e. a local one. Psychological reassurance is often provided by swift action, especially in emergency situations; the patient feels safer because they’ve reached a hospital within 10 minutes rather than 30 and care can begin more quickly. Even if a transfer to a specialist unit is then required, at least the patient has had a better chance of being stabilised and reassured that something is being done for them.
choice should provide the best care for patients.However private companies will put profit before patient welfare.This is not good.
Patients, nationwide, should have a level playing field of care…when ill, especially in an emergency situation we need the advice of the experts not to be asked ‘which hospital would you like to go to?’It is crazy to think that privatisation will produce a ‘better’ service more cheaply as any private company will be in the business of making a profit. We need to reassert the National in the National Health Service. Post code lottery care is absurd in this society.
Competition:
1. The costing of an individual procedure is arbitrary: complications can arise at any time, requiring supervision of a senior consultant; transfer to another department; etc. These costs cannot be accurately considered on a per-patient basis, and in the NHS the services are costed to cover these situations and so help to fund other activities within the hospital when things run smoothly.
2. So, a private provider could use low-grade staff to provide a cheaper service short term, but when things go wrong they will require that senior member of staff, or that other ward to transfer the patient to. Of course, the money that in the NHS would have provided these additional services has gone into private profits. Also, the patient is not in a hospital, so the new system requires transport between providers in emergency situations. This amounts to a poor quality of care.
3. With a lower patient throughput in hospitals, these lower value services could not be justified because economy of scale diminishes, and the money allocated to these tasks with the overheads of senior supervision becomes depleted also. So, funding for senior staff is diminished, junior staff do not have roles as these have been lost, and the hospital is no longer a viable healthcare provider at all. This is a slippery slope!!
4. I do not believe competition is in the interest of patient care. The only driver we see behind competition in any market is profit. Utility companies underwent the same process of introducing competition. Safety has always been compromised, and illustrated by our recent oil disaster involving BP.
Choice:
1. There has been no survey to my knowledge asking patients whether they want to have to choose to which healthcare provider they go to, when they become ill. NHS doctors often wear a private doctor’s hat and take provide care for private patients within NHS hospitals anyway!
2. Patients are not educated about healthcare.
3. Doctors are.
4. Doctors should be free to provide the best healthcare available to those patients who need it.
5. Patient choice should be limited to whether to accept or refuse the treatment solution(s) offered to them by qualified doctors.
I quite agree. The health service does not need competition which will drive destructive wedges between people where collaboration and co-operation would be far more efficient in cost and resources.
As others have said, as a patient I want quality above choice, as locally as possible.
It amazes me that the assumption appears to be that only competition can improve performance. Organisations in the private sector may be subject to competition but they do not deliberately seek competitors in order to have a reason to improve their processes. They look for ways to improve their processes in order to fight the competition that is there. Transferring funds to pay external providers will only weaken the NHS and make it more difficult to put the necessay effort into process improvement.
I do not think that choice and competition will improve the NHS . What will improve the service will be good knowledge and interaction between NHS staff and the patient.
Competition will not provide better Health Service as competition is about contest of resources.
I don’t want arbitrary choice. I would like a quality service for my individual health care needs, reasonably local. I would rather this was not provided by private companies whose main concern is profit. These companies tend to only provide care to those who are actually fit and well. If you are ill, or infirm, you will probably find the private companies don’t want to treat you, as it is too expensive for them. They take out all the “easy” jobs from the NHS, leave us to deal with the needs of everyone else and then when it comes out that a service more expensive in the NHS, they just assume it’s cos we don’t know how to be efficient like a private company does! We’re not treating like for like.
‘Choice’ means that the ‘alternative providers’ can cherry pick the straight forward cases at tariff rate, leaving the NHS to pick up the complex cases. Teaching hospitals need to have striaght forward cases in order to train future surgeons.
Competition, by it’s very nature creates massive waste – it means multiplication of virtually identical services so that there is a fictional ‘choice’ between them. On top of this it requires money to be spent on promoting the benefits of one ‘choice’ over the other, money that could otherwise have been spent directly on patient care.
The NHS should not be in the business of advertising and marketing, it should occupy itself with the provision of healthcare. The introduction of more and more profit-making organisations also means that the NHS is being parasitised, with money being extracted for shareholder profit, that should also have been returned as patient care.
The phrase ‘different kinds of providers’ implies that more of these profit making companies will be making their way into the NHS, cherry picking the most profitable procedures, and leaving the real NHS to pick up the unpopular areas – the oldest people, the most complex cases, people from the least affluent backgrounds collected together to be given a second class service. Rather than thinking about how to make a ‘level playing field’ for providers, we should be making sure there is a ‘level playing field’ for patients, so that the oldest, sickest and poorest are not left behind.
More important than ‘choice’ is QUALITY. We should be enabled to access the best quality healthcare. Also implicit in the notion of ‘choice’ and ‘competition’ is the idea that people with more money can access better services. This is inimical to the philosophy of the NHS.
I read this after writing my response – you said it so much better than I did. Wish I could have that on the front page of every newspaper.
Your questions are loaded toward the response you’re seeking: There is no evidence that competition in the NHS has ever driven improvement. If there were, I’m sure Andrew Lansley would have repeated it ad nauseum. In fact, there is much evidence that it does not. I have worked in the NHS for 21 years, and have been witness to many and varied attempts to bring the market into the health service. I and my colleagues are clear that, quite aside from this kind of organisational upheaval which costs millions, causes untold misery and disruption to staff, the introduction of ‘competition’ between say, hospitals, does nothing demonstrable to improve the service to the patient. We need less private involvement, not more.
We are aware however, that there is very clear evidence that this government is keen to place our health service in the hands of their supporters in the private healthcare market. Care UK, KPMG, United Health, to name a few. Care UK – who already have control of all prison healthcare in England were contributors to Andrew Lansley’s election campiagn. This is the kind of issue which colours public perception of this government’s ‘initiatives’. Services owned and by shareholders, with the profits going to enrich them instead of back into the service of health provision can not possibly improve the service to the public. Only to the friends of the government.
Choice of provider is not something that I have ever heard patients refer to as improving their perception of the service they receive. However, length of wait for an appointment, quality of care, and professional and kindly interaction with staff is something we hear lots about. Choice doesn’t come into it. People don’t want choice. They want a reliable, friendly, effective service at the closest point to where they live. Ask the patients. I haven’t seen a scrap of evidence that the government have asked the public anything before drafting this Bill.
The widening of private sector involvement into the national health service ensures that it won’t survive as a national health service. There are many of us who see this move as an ideological project pursued by those who don’t use the service, to increase the revenues of their friends in private health companies – for example, McKinsey, who are well documented as pursuing their ‘right’ to have a slice of the lucrative health ‘business’ in this country, so that it ends up looking exactly like their US service. I could go on. The government seems to think that this information escapes the public. And the fact that Mr Cameron has hired McKinsey as part of his ‘forum’ is, to us watching this unfold, incredible, and demonstrates the lack of insight, and even common respect for the public, that this government is capable of. No wonder the nurses recently gave a vote of no confidence to the Health Minister, the BMA voted to oppose most of the Bill, Lord David Owen published his critique – ‘Fatally flawed’, and even Tories are asking awkward qeustions of the government.
How have these 2 things become part of the NHS? Most patients want a reliable, reasonably efficient service which provides the care they need. Choice is only applicable in certain areas anyway and competition should be totally abandoned. Perhaps a return to the old principle of cooperation would serve as a better model.
In my own recent experience in an NHS hospital the one area where standards fall far below the required level was the ward cleaning. This was in stark contrast to the scrupulous bed and furniture cleaning carried out by the nurses as part of their infection control regime. The cleaners were perfunctory and no furniture was moved or beds cleaned under, that I saw, during the week I was there. I believe this was a resource put out to private tender and I would suggest that in all probability the lowest bid was accepted. This would inevitably lead to the cleaning company having to pare costs down to the absolute minimum, paying their employees as little as possible in order to turn a profit and encouraging the cutting of corners. Opening up other areas of the NHS to competitive bidding is more than likely to lead to similar problems.
Further to this a number of questions arise relative to the fitness of MPs to be involved in this bill. For example: How many have direct experience of NHS hospital care? How many MPs have connections and interests in private health care companies and /or rely on them for any serious medical care? What provision is being made to eliminate the possibility of contracts being awarded via the ‘Old Boy’ network?
Whilst there are undoubtedly areas for improvement in all parts of the NHS, our NHS has undergone tremendous improvements over the past 15 years.
My family and I have not had wait months for a referral, which was the case in 1996, for several of us.
Surely it must be possible, at a time of falling real terms budgets, to transfer best practice form one place to another, without reverting to GP commissioning and changing the instutional structure so radically?
Can’t the exisiting governance arrangements be relied upon for all Health institutions to stay within budget, whilst focusing on the outcomes necessary?
It’s not broken, so why do we need politically-led changes that take us back to the bad old days, when the culture of partnership working in our best practice areas are there for all to see in service improvement?
How much will these reforms cost and where is the evidence that such widespread instiutional change is necessary, or will actually deliver the improvements claimed?
My personal view is that the Coalition have this badly wrong in even having a debate about the NHS. It’s fundamentally OK, and change can be made without making fundamental changes, for example in GP commissioning & competiton. Neither partner in the Coalition even got elected on a platform to radically change the NHS.
I for one would hate for us to go back to the days when GP’s tried to guess because of the cost implications of referring for an X -ray or to a specialist. That would be to revert to the National Sickness Service we had then.
Please don’t make the classic politicans’ mistake of thinking that changing the institutions will change the culture of the poor performers. It simply creates uncertainty in the best ones. For example, we already are seeing a flight of staff from PCT’s.
As I patient I find this to be a leading question in order the government can pull out part quotes and use them in their favour. So I will simply state the idea of competition in health care is unethical and goes against everything our NHS stands for. I overwhelmingly choose to go to an NHS hospital where all depts under one roof incase of complications (journeys from private clinics to HDU etc could decide whether you live or die), where staff are professional, properly trained and their to help you. Not a private provider where they may serve nice tea but they view you as a profit making commodity. Recently unbeknown to me was sent to private part of local hospital and was horrified. Not by their standards but by how the consultant spoke to me. I am not backward in coming forward to complain but this incident was so personal and awful I feel I can’t even report it. Yet had I been in the NHS part firstly I am sure it would never have happened and secondly their would have been a strong network of other health professionals about they would have picked up on it and complained on my behalf. The ideal level playing field in my eyes is boot all the private providers back to USA or emptying bins and stick with and build upon our NHS- Cameron did say prior to election the system works and we would be sticking with it and so we should.
In response to the three questions:
1) type of service most likely to improve quality – easy pickings e.g. minor and routine surgery – where risk is low.
2) Level playing field: NHS organisations contribute to training and manage expensive high risk treatments e.g. ITU. To have a level playing field all organisations would have to be able to contribute to the costs and overheads and appropriate governance associated with these. They would also have to be a very large provider. To be fair to the taxpayer they would have to be not for profit and closely monitored, if not managed by government.
3) Choice, equity and quality can be in direct conflict. Patients want quality rather than choice. A tax funded system has a duty on equality.
I am terrified by the idea of competition: I don’t see how this can possibly help people with costly, minority, difficult-to-treat conditions that are already poorly understood and badly handled by existing systems. I am especially concerned about the impact competition will have on the treatment of trans* people, which is already woefully inadequate. And, as someone with chronic health conditions, I’m concerned about long-term support and decision-making: I’m currently on non-standard off-licence medication that is lots more expensive than the “standard” treatments but *actually works*.
All of which boils down to: I am extremely concerned that quality of care (which is not easily measurable) will take a back seat to cost of care if the NHS (which is).
(And I’m upset that the listening exercise is set up in such a way that I am feeling guilty and disenfranchised for simply not having the energy to read all other responses to this post before commenting!)
Whenever I hear words like ‘choice and competition’ bandied about, alarm bells start ringing. Yes, on the face of it, they sound like a good idea – but really it’s the language of laissez-faire capitalism. What you actually end up with is the consumer (patient, in this case – which is even worse as it could be the difference between life or death) having to pay escalating costs for a worse service. For previous examples, look to energy supply and train travel. And how do you feel about going to the dentist if you’re not lucky enough to be on the books of an NHS one?
The Tories have promised the NHS to the vultures that fund and support them. They know it offers rich pickings and hate the original socialist principles it represents. They have no mandate or right to take this action and must be stopped at all costs.
. I don’t want to wake up in a country where I’m worried if I can afford to be ill. I suspect the few doctors who support these proposals will be those on the gravy train afterwards. LEAVE IT ALONE.
Extracts from the paper New Health Horizons submitted to the Department. “We therefore suggest that the Department should explore the investment of more focused resource to develop a limited number of “Fast Track” Pathfinders that would develop a number of new models for wider Consortium adoption… This approach will help to surface issues that need to be addressed: for example, how best to ensure a balanced “trading relationship” between commissioners and providers such that desired gains can be achieved but without prejudicing the financial and clinical performance and viability of either side in the short term. …All parties will need to work together in a way that enables the Provider community to become more efficient without putting vulnerable yet essential Providers at risk of collapse…. The Fast Track Pathfinders should reflect the broad categories of different conditions that exist across the country…. At its most obvious level, a key difference will lie between largely rural areas and densely urbanised areas such as central Birmingham. http://www.newhealthhorizons.org
The fiction of choice: Emergency cases, rural dwellers, those without easy access to relevant data … will in effect have no choice. Choice is non-existent for many (most?) parents when they are seeking school places – is there any good reason to think health care provision would be different? I cannot see how.
Competition: I fear this means competition to hold down costs whilst maximising profits rather than to provide high-quality health care efficiently and effectively.
Managerialism is one of the biggest ‘drags’ on the system. Deal with that problem first. The NHS is a publicly funded body for the benefit of all and we have every right to expect government to sustain it until we have mandated you to do otherwise. Indeed there is more than enough data to show that we expect that.
I am against these proposals. Look at the mess “choice” of schools has caused in education – millions of unnecessary journeys and disruption for children to distant schools at a higher cost to families and the authorities – plus unnecessary extra road congestion and accidents (Having driven school buses I can vouch for my claims. I had one Mum in a hurry bury her car (with two small children in) in the Back of my stationary bus, 8’3″ wide, 11′ high and with it’s lights on!) In my day, we all went to our nearest schools and the overall standards were mostly superior to today’s schools, stricter disciplined, healthier, cleaner and no infantile political correctness wasting the budgets. (It is the latter that is eating public service budgets at an alarming rate)!
Private contractors fail to provide quality services now! As witness huge costs of temporary agency staff and the awful quality of hospital food and extremely poor standards of cleaning and hygiene.. Walk around the back of a hospital, Ministers and poke around!) When I was a National Serviceman I dined in a mess feeding over 1,000 hungry people, three times a day, but the lady Flight Sargent in charge served up food of such quality on a tight budget that there was always a rush for “seconds”! If she could do it, why not hospital Kitchens?
If the Government reformed NHS management, reducing all salaries to a maximum in special cases of what the Prime Minister is paid for leading the whole country, we might start to improve cost effectiveness. I am amazed at the huge sums paid for much lesser responsibilities than being PM and the huge obligatory pay off’s to such “higher Management” staff when they fail or are dismissed! The number of non essential jobs on good salaries being advertised in all public administration is truly alarming! Stop all this “celebrating diversity” and pandering to staff’s personal ideals, lifestyle choices and whims and get on with the core tasks.
Some areas I have been to are very well and efficiently run, others are not. I have had what should have been clinical decisions about follow up appointments taken by unqualified staff on the grounds of “pressure” on resources. But if we cut the unnecessary administration, insist on quality and value for money from contractors seeking contracts – things can be improved and that “pressure” might be reduced.
I see all this improving “choices” and “private contractors” as an admission that public services cannot be run effectively with existing well paid Managers. Surely this is not the general case? So I think what the coalition government it really trying to do is hoodwink us into agreeing to creating more opportunities for private companies to get their hands on more taxpayers money.
I am all for reform, but without the privatisation angle. I would end private health care using NHS trained staff and facilities – without stiff leasing costs, that would level the playing field! After all, the NHS invests most in the training and takes back all the “difficult” cases, so why not charge more for it? If we are all really “in this together”, lets see everyone relying on the NHS and stop the wealthier in society from plain and simple queue jumping!!
In all honesty I am not looking for a greater choice of healthcare provider, I simply want my local health authority to be well funded and staffed. I am not living in some fantasy land though, where I am not a high earner but I would certainly be willing to pay more taxes to maintain standards at my local hospital.
I have a couple of problems with the notion of increased patient choice as I’m not entirely sure what the supposed benefits of this choice are for the patient. Firstly, as somebody with no medical training, making a choice about which “provider” will best serve my medical needs, would be slightly ignorant, arrogant and possibly detrimental to my own well being. Medical experts are paid to make these recommendations as they have undergone the training required to do so. Secondly, I have no idea what health related misfortunes await me in the future. I imagine I’ll find out when they arrive. Maybe I will have time to spend reading up on my ailment and assessing which is the best available provider to use but chances are that I will not and in those circumsances I will want my local health authority to have at least a good chance of providing me with the care I need.
This is supposed to be about choice and competition and I object to those being linked. We need co-operation not competition which may drive standards down.
I already have a choice of NHS hospitals in the area where I live which is South of Manchester. I know which hospitals specialise in certain treatments and I can check their waiting times for less urgent conditions.The NHS hospitals provide a fantastic degree of specialisation, research and education. If we want to have private providers then lets compare like with like. I know of no private hospitals that do the research and training – in fact they clearly depend upon the NHS to train their consultants.
It is an admitted fact that difficult cases are transferred from local hospitals to specialist hospitals and it is also therefore agreed that the recovery rates for these difficult cases is less than for the simpler cases that local DGH’s treat. I fear that private hospitals will cream off easy cases, not have the overheads of research and education and therefore their cost effectiveness will look very good when compared with NHS hospitals- better recovery rates at less cost.
How about offering a referendum on these non requested and unauthorised by the majority of voters, radical changes to OUR NHS.
This would be choice.
I would like to see cooperation , not competition , to be the driver of the NHS
1) Some patients will be discriminated against as private providers will inevitably seek to select patients that provide the best financial return and refuse to treat the more complex and risky cases
2) Financial competition will force some hospitals to close – a decision which should be made strategically, not at the whim of the market. The bill enforces the logic of competition that only the fittest should survive. It reduces financial support and effectively allows hospitals to fail before steps are taken to save core services. The bill makes no provision for the loss of non-designated services
3) A recent BMJ article backed the view that the bill is effectively a one-way door to privatisation, as it will force the NHS to follow EU competition rules. Private providers have publicly stated their intention to use the courts to reinforce their right to bid for any area of NHS work There is therefore no protection against the domination of the private sector in the supply of healthcare to the public. Many would call this privatisation, most would not support it, and there must be a change to the bill to prevent it
4) Professional bodies have highlighted problems with the standard of care at some private clinics treating NHS patients.] However public scrutiny of these companies is shrouded behind commercial confidentiality. Privatisation of the out-of-hours GP service has produced several tragic incidents resulting in the deaths of patients. The regulation and safety of large-scale private sector provision for the NHS patients is at best unproven
5) The costs of competition have been massively underestimated. International experience suggests the transaction costs will be substantial[10]. This burden will include not just the cost of the new competition regulator Monitor, but huge spending on lawyers for bids and contracting, as well as fees for accountants, management consultants and on marketing. NHS hospitals and GPs will be increasingly spending public funds on these unnecessary, non patient-related fees. Commissioning already consumes 14% of the English health budget, but expanding competition could force up transaction costs to 30% of all health expenditure – as in the US.
The bill should protect the values of the NHS not undermine them. It places business motives at the heart of the NHS and passes control in to the hands of commercial companies that will be difficult and expensive to regulate. As the new budget holders, GPs will become “rationers” of care and will likely be compromised by their business interests. The relationship between doctor and patient will change and some trust lost. Services will be more difficult to plan around patients’ needs. Many medical conditions require considerable cooperation between agencies to achieve a high quality of care, but the bill will fragment provision between competing businesses. Quality, value and fairness will all be undermined. The values of the NHS will be eroded and eventually the public’s trust will fail too.
As a consultant surgeon working within the NHS I feel strongly that the plan to open up a free market in healthcare and ‘ show no mercy’ to the NHS i.e. not allow local NHS Hospitals to be a ‘preferred provider’ would be disastrous. This would ultimately lead to an American system which would be twice as expensive, encourage unnecessary treatments and ultimately leave some patients with little or no care. Bevan’s unified NHS Hospital network with Hospitals and clinicians collaborating ( not competing ) to get the best results for patients is a key feature of our fantastic NHS.
The government does not have a mandate for allowing market forces to destroy our key NHS services and the process of allowing foreign profit hungry private companies to have lucrative ‘cherry-picking’ contracts whilst NHS Hospitals take on all the difficult cases and complications (and also deal with all the emergencies and training ) has to stop.
When I see a patient I am only interested in getting the best result I can for the patient within the resources available. My decision is not swayed by financial considerations but is based on clinical merit only. Where necessary I should be able to refer the patient to another NHS consultant without having my decision vetoed by a panel of bureaucrats. GP’s and Consultants do not support the Governments proposals to marketise our Health service or sell it to private companies. Lets keep our NHS public. Mr Clegg has got this one right.
Do we learn nothing? By choice and competition you mean privatisation. Is that because it worked so well with “outsourcing” the hospital cleaning contract? Oh no, actually it didn’t did it. Huge increases in hospital acquired infections because the cleaners are loyal to their employer and not to the hospitals. When they’re told to cut costs to ensure shareholders get their money, they cut corners.
Ask any sick person who has had the misfortune to endure a Work Capability Assessment by a “healthcare practitioner” about how the private sector put money before anything else. They have to, they’re businesses – and if a business doesn’t make money it goes out of business fairly quickly. I can’t see what’s so difficult to understand about this. A private sector company only has one target and that’s quite simply ‘profit or bust’
The private sector is the backbone of the country, they need to make money and on the whole they do it very well. But their place in the National Health service should be confined to providing goods and services at the going rate – not cherry-picking the most profitable of the services the NHS currently provides. Remember WE have paid for this service already through National Insurance and tax.
I do not want providers to compete for me – I just want to be given a decent service. The government has already been shown (by independent research it chose then to ignore) that allowing private providers to ‘compete’ for services which deal with the vulnerable (in that case it was with job seeking) doesn’t work. The private companies cherry pick the profitable cases and leave the hardest to deal with to the diminishing state services to pick up. If the NHS isn’t supported to provide a comprehensive service it will collapse – and then we will be left only with private companies providing for lucrative services, and the sort of costly ongoing services for the most vulnerable (poor, elderly, people living with longterm conditions and disabilities) will be left by the wayside.
Considering we have all been paying into the NHS all of our working lives I find it incredible that Lansley has the audacity to even suggest what he has – and to press ahead with it when nurses and doctors have voted overwhelmingly against both him and his proposals is just arrogance beyond belief. To then pretend to have a real ‘listening’ period just twists the knife in further, when most of the ‘listening’ events go unadvertised and have taken place before anybody gets to hear about them, and staff in the NHS are being told to press ahead with implementing the changes.
We criticise ‘leadership’ such as Gaddafi’s – but tell me please, when innocent people start dying because they can’t get treatment, precisely how does Lansley’s style of leadership differ?
And one final question – how do we get proof that Lansley has actually listened to all of this? I will be certainly be awaiting answers to my questions before any of these reforms go further…
Choice in the realm of competition is not an appropriate model to base the NHS on, full stop. Competition, I fear, would mean the result of holding down costs whilst maximising profits rather than providing high-quality health care efficiently and effectively.
Many people end up losers under such a system, and like many doctors and nurses say, many in deprived or rural areas would have no choice anyway.
Patient choice already exists and this has already led to services competing in some areas. Where patients are dissatisfied with a service they should be encouraged to excercise their choice as well as raising their concerns, this will drive improvements in services that need it. =no need for the reforms that are being forced through
patient choice already exists. patients hould be encouraged to raise concerns when they are disatisfied with services and also to excercise their choice. this should provide sufficient ‘drive’ and competion to ensure services continue to improve.
Competition will lead to cherry picking by Private Providers who pick off and provide those services that are more profitable. high demand and high cost services such as A&E will not be attractive for independent providers for obvious reasons.
Developing a competitive market will only drive costs up – having tendered out health services in the recent few years in my role – transaction costs are high for e.g. tupe of existing staff to new providers is costly, time consuming.
often patients dont want a choice of who provides their treatment they want high quality caring health services that they trust in. they want to be able to choose their appointment time and date and maybe which consultant sees them. you dont have to have competition to provide this choice.
As an accountant can I point out that the transaction costs associated with running the proposed convoluted and inefficient GP led commissioning system will end up being enormous and will far outweigh any ‘savings’ from shedding (albeit at huge expense and probably temporarily) the current staff in SHAs and PCTs.
If, as I suspect, the real intention of the reforms is to fragment and ultimately privatise the NHS then this may well be a price the Coalition are willing to pay.
We need to stop running huge unproven ideological experiments on a treasured and much envied public service and operate the NHS as the multi-billion pound business that it is.
We need common objectives, set by the Public Health professionals, and clear targets that people understand and agree with. Let’s operate as one organisation rather than perpetuating the loose confederation of semi-autonomous self-serving organisations which the internal ‘market’ has produced to date and which will only get worse under these proposals. Healthcare should be more about co-operation than competition.
We are in danger of producing a generation of leaders and managers who can only function in the chaos of continual re-organisation and who spend more time competing against their peers in other organisations than helping the NHS become more effective, economic and efficient.
If we really want to save money, to pay for our ageing population and the increasing costs of drugs, follow the lead of the Scots and Welsh, and abolish the un-proven (even after 20 years) purchaser/provider split which I suspect adds little but cost to the mix.
I would suggest we need to Simplify and Save rather than Complicate and Cost!
Patient satisfaction with the NHS is high, waiting lists are low, and massive sums of money are being saved by acute Trusts up and down the country. I am not a stupid woman, but cannot understand why we need yet more unnecessary, expensive, reformative turmoil, nor why these proposals were not outlined in the Conservative manifesto, nor why the LibDems are supporting them, nor why Labour aren’t voicing any meaningful opposition.
After 30 years in the NHS I can honestly say that I have never seen morale so low. Even our GOLD-PLATED PUBLIC SECTOR PENSIONS are under attack – strange that nurses didn’t face this pension envy in the 80s and 90s, when we were always being told how marvellous we were for doing such a s*** job for so little reward.
This listening exercise is based on ridiculously leading questions.
“How can we best ensure that competition and patient choice drive NHS improvement?”
This starts from a position that competition and patient choice will lead to improved outcomes – where is the evidence for this?
The majority of the evidence I have seen suggests that competition leads to increased health inequality and reduced access.
The mantra of ‘no decision about me without me’ is a great one. However, it should be remembered that when this phrase was coined in the late 1990′s it was all about ensuring that patients were involved in treatment decisions. It didn’t have anything to do with competition or choosing between different providers.
There is a great deal of evidence of the benefits of shared decision making. The WHO has conducted and collated a lot of research in this area and has shown, for example, that shared decision making results in increased compliance with medication regimens and can also lead to improved patient satisfaction. Patients can only make truly informed choices if they believe that they and their clinician are working towards one clear goal – patient health. If patients believe that clinicians have vested interested in certain treatment or providers then this will ruin this relationship.
As for competition, there is, as far as I am aware, no evidence that competition results in improved patient outcomes. As someone who has worked in health research for many years the idea of competition between providers is anathema to me. Healthcare is a team game – we improve by collaborating, sharing best practice with eachother and seeking second opinions when we need to. We do not compete – we work together.
And as many others have already said: The NHS belongs to the British people. It is not yours to sell Mr Cameron.
I don’t want “competition” or “choice”, I just want competent doctors who can treat my mental illness without me having to go into massive debt about it. This is what most ill people want. Choice is for things like “do I want a blue jumper or a green one?” and competion is for sports and the like. Stop trying to make a profit out of society’s most vulnerable, you bunch of vultures.
Taking each question in turn:
In many areas there is, in terms of hospital provision, only one choice, and often only one GP surgery. This is, therefore, a false – and leading – question. Most people I know are not concerned about choice (which, ineveitably, will bring with it bureacracy associated with contracts, prices etc.). They are concerned about having faith and confidence in local services and local practitioners. There is a need for transparency about the quality of these servcies, and the performance of practitioners, but arranging some sort of management consultant-led and designed “market” will not provide transparancy – quite the opposite.
Again this question misses the point and does not address people’s concerns about, a) the proposed reforms, b) the need to improve certain aspects of the NHS, such as elderly care (to take this as an example, the need is for local discipline and management, not national reorganization and the organizational disruption which will surely follow from the proposed reorganization). Politicians of all hues appear to be wedded to the idea of large-scale – strategic – management change, rather than the less exotic but managerially logical apporach associated with incremental chaneg based on the assessment of needs within, eg, a particular discipline (eg oncology) /area (care of the elderly).
Patients do not necessarily want choice. They do not appear to be asking for it. Where on earth is the evidence that this is what people want? Why this preoccupation with choice? Is it because the providers of choice will come from the private sector? Where is the evidence that the private sector is somehow best (we are, after all, living in the aftermath of private sector failure in the finacial sector, and the evidence from, eg, the US Commonwealth Fund, suggests that insurance-based healthcare is better than socialised healthcare.
Please listen to the people you serve (and I don’t mean the private healthcare providers!). The SoS does not have a monopoly of wisdom or experience, and his party does not, in reality, have a majority or a mandate for these changes.
Patient choice is important when they have been given all of the facts so they can make an informed choice, have the capacity to make that choice and have not been overly influenced while making the choice. But all too often no information is provided to patients about the options they have, they are given at a time when they have other more pressing issues to hand (keeping well) or have influencing factors which may not enable them to fully understand their choices. Which independent body will provide the information – correctly and accurately, giving up to date information on all of the services available to them and how can private companies be prevented from looking like the better choice through their slicker advertising and offering of unrealistic outcomes. In Neurological rehabilitation – one of the many forgotten parts of the NHS – patients have a wide range of private options already – but do they need it and have clear outcomes or just want it because its there? Evidence so far would suggest a lack of monitoring of this issue.
Taking each question in turn:
In many areas there is, in terms of hospital provision, only one choice, and often only one GP surgery. This is, therefore, a false – and leading – question. Most people I know are not concerned about choice (which, ineveitably, will bring with it bureacracy associated with contracts, prices etc.). They are concerned about having faith and confidence in local services and local practitioners. There is a need for transparency about the quality of these servcies, and the performance of practitioners, but arranging some sort of management consultant-led and designed “market” will not provide transparancy – quite the opposite.
Again this question misses the point and does not address people’s concerns about, a) the proposed reforms, b) the need to improve certain aspects of the NHS, such as elderly care (to take this as an example, the need is for local discipline and management, not national reorganization and the organizational disruption which will surely follow from the proposed reorganization). Politicians of all hues appear to be wedded to the idea of large-scale – strategic – management change, rather than the less exotic but managerially logical approach associated with incremental change based on assessments of needs within, eg, a particular discipline (eg oncology) /area (care of the elderly).
Patients do not necessarily want choice. They do not appear to be asking for it. Where on earth is the evidence that this is what people want? Why this preoccupation with choice? Is it because the providers of choice will come from the private sector? Where is the evidence that the private sector is somehow best (we are, after all, living in the aftermath of private sector failure in the financial sector, and the evidence from, eg, the US Commonwealth Fund, suggests that insurance-based healthcare is better than socialised healthcare)?
Please listen to the people you serve (and I don’t mean the private healthcare providers!). The SoS does not have a monopoly of wisdom or experience, and his party does not, in reality, have a majority or a mandate for these changes.
Taking each question in turn:
In many areas there is, in terms of hospital provision, only one choice, and often only one GP surgery. This is, therefore, a false – and leading – question. Most people I know are not concerned about choice (which, inevitably, will bring with it bureaucracy associated with contracts, prices etc.). They are concerned about having faith and confidence in local services and local practitioners. There is a need for transparency about the quality of these services, and the performance of practitioners, but arranging some sort of management consultant-led and designed “market” will not provide transparency – quite the opposite.
Again this question misses the point and does not address people’s concerns about, a) the proposed reforms, b) the need to improve certain aspects of the NHS, such as elderly care (to take this as an example, the need is for local discipline and management, not national reorganization and the organizational disruption which will surely follow from the proposed reorganization). Politicians of all hues appear to be wedded to the idea of large-scale – strategic – management change, rather than the less exotic but managerially logical approach associated with incremental change based on assessments of needs within, eg, a particular discipline (eg oncology) /area (care of the elderly).
Patients do not necessarily want choice. They do not appear to be asking for it. Where on earth is the evidence that this is what people want? Why this preoccupation with choice? Is it because the providers of choice will come from the private sector? Where is the evidence that the private sector is somehow best (we are, after all, living in the aftermath of private sector failure in the financial sector, and the evidence from, eg, the US Commonwealth Fund, suggests that insurance-based healthcare is better than socialised healthcare)?
Please listen to the people you serve (and I don’t mean the private healthcare providers!). The SoS does not have a monopoly of wisdom or experience, and his party does not, in reality, have a majority or a mandate for these changes.
Well Said Gordon Morris I wish I could put it as well as you and others Have This is realy about directing tax payers money into the pockets of the conservative party’s rich freinds and funders my experience of the health service has been good I would not be here without them and their dedication ,if BT had not been privatised we would have superfast Broadband, please do not let the same happen to our health service
Patient choice will depend on availability of providers and services between which to choose. Today the children’s minister said that the NHS is failing to support vulnerable young people – supply of speech therapy and basic equipment for children with special needs has become a postcode lottery. “A six-month wait for speech and language therapy can be critical; an 18-month wait can be really critical.”
How will the commissioning support children with severe or multiple health and learning disabilities?
How will local authorities and commissioning consortia work together to deliver the new single care plan covering schooling, health and social services from birth to the age of 25?
Where is the evidence that competition in the provision of Health services will improve those services? I understand that transaction costs per procedure will increase from 10 to 20% of the NHS budget – one fifth of the whole budget going to administration of the competition laws (ensuring that no-one has an unfair advantage by being better at providing a service – rather than cheaper), filling the pockets of lawyers – what a waste of public funds. Such a shame, when there are dedicated people willing to collaborate – who willl be prevented from working co-operatively by the new ‘Monitor’ organisation, in case multinational companies are disadvantaged. How appalling – make improvements by all means, but don’t make health care about profit only..
I do not agree that choice of “provider” is necessary to enable patient choice.
The NHS is already able to provide a choice of services and hospitals or treatment centres. I do not believe a further choice of providers is necessary or desirable.
If different providers are introduced there must be parity of quality and cost for treatments. This should be regulated by an independent body e.g Monitor. It would also be vital that services and resources for staff (e.g. training) working for different providers, are the same across the board to ensure that providers do not attempt to cut costs in this area.
Choice of Provider could actually lead to a reduction in patient choice as service providers are unable to forecast patient numbers and thus will have to operate with some spare capacity. Some excellent small service providers may find that this situation makes it impossible to operate (and go bust) as their income fluctuates in an unpredictable way. In addition it seems perverse that services will have to run with spare capacity at a time when the NHS is trying to reduce spending.
Research which has already been submitted to this consultation and others on the NHS White-paper by UNISON has shown that patients do not desire a choice of provider. They want a good, local service, free at the point of use. I.E. the NHS.
I am concerned that those without the financial means or personal health to be able to travel would find their choice restricted.
The idea that further cuts within the NHS will result in improvement is dangerous.
For many years the NHS has been asked to accept cuts and we are again being asked to do the same. We are now in a position where all savings that could have been made have been made, so any further changes will directly affect frontline services.
The idea that a private provider will produce a more cost effective service is also dangerous. Private providers will offer the minimum of service as they are in business to make a profit. (Remember hospital cleaning services being privatised?).
As clinicians within the NHS are asked to do more, their will to remain in the NHS providing an excellent service dwindles. Then the burden of doing more with less resources is left to those who believe in the NHS and who have stayed in post so far but these clinicians get to a point where they find the situation unbearable. The current freeze on recruitment does nothing to help this situation and so the circle continues.
Mr Lansley is correct the amount being spent yearly on health care is increasing every year – it always will do as the number of new treatments available increases yearly as does the ever-aging population (this is not news).
NHS staff have been asked to put up with the following in recent years:
Pay freeze for the past 3 years
Pay freeze for the next 3 years
An increase in the number of years they have to work before they can now retire
An increase in payments to their pension
A reduction in their final pension
Morale amongst NHS staff is at an all time low.
Bear in mind if you continue that strikes are a real option throughout the NHS. Where does this leave the politicians then when patients aren’t being seen? Remember the next election will be here sooner than you think.
Re: competition.
The Conservatives added competition to the rail network, with awful results. Now our railways cost much more than other countries. Now the same party wants to add competition to the NHS. I fear the same result will happen. Only this time, it is lives at stake, not just transport.
I can’t see any direct benefit to me by adding competition. I just see a race to the bottom, with big business gouging profits out of sick people. That’s the last thing Britons want – some sort of half-baked “competition” ideas. My advice: run the NHS properly. Don’t think that some political “competition” dogma can do that for you – you just need good people who know what they are doing.
Re: choice. More political dogma, I’m afraid. Just give me one good thing, rather than a wide choice of half-baked ideas. I just want the treatment, not some puzzle dreamed up by a right-wing free-market zealot. Choice is a “nice-to-have”. Good treatment is a must-have, and I’d choose it over more “choice” every time!!
There is enough competition in the private sector. The NHS may not work for everyone but it is a viable alternative to paying for treatment. Right now the public has a choice, pay for treatment privately or use the NHS, if you remove the NHS you remove one of the choices, how does that help?
As a country we NEED the NHS, we also need politicians who care about EVERYONE, not just the people who have lots of money.
The majority of the people of this country do not want to lose the NHS because we know that without it we are doomed to the kind of health system actively failing the majority of American people right now. There, if you have insurance or can pay privately you’re just fine, if you haven’t you go without and maybe die! Why the hell would we want that here?
You only have to ask Americans and they’ll tell you they would love a NHS like ours. I am not blind to it’s faults, I know it needs improving, but it works hard for us and it is a free service provided by the country’s people for the benefit of it’s people.
It needs saving, not scrapping.
GET YOUR HANDS OFF OUR NHS!!!
I was about to remind the listening excercise of the recent research provided to the government by Unison. I was about to point out that most patients’ choices are based on two simple questions “how close to home?” and “how soon”. But Hannah Walter puts it so much better than I could.
The notion of ‘choice’ is not about giving taxpayers and vulnerable, infirm and elderly patients what they want, it is about giving private healthcare companies the greater share of the ‘market’ of healthcare they and their shareholders want.
The proposals which are intended to open up the NHS to private profit is the most dangerous of all these damaging proposals. The result of allowing private firms into the health system would be to destroy the integrity and patient-centred approach of the NHS, where devoted employees work hard in the interests of patients. It would replace this with a profit-centred system, and would spell the end of care available depending only on need.
It is well known that US health care costs approximately (people argue about precise figures) five times British health care, but in the US, only 60% of people receive it. All international surveys show that the current British system (with its inevitable problems) is far and away the most efficient way of providing care. The US system does not simply give more competitive provision; it simply adds a whole system of fees, charges and percentages between the taxpayer and the care system, in the form of insurance salesmen and their costs.
It is beyond belief that the government should be trying to move the most cost efficient and comprehensive service in the world towards the least efficient and selective system which operates in the USA.
‘Competition’ may result in organisations trying to be more efficient, however, there is the possibility that inappropriate goals or targets are set as benchmarks for success. For instance, a speedy pathway for a hearing aid fitting might be seen as appropriate, yet this follows the outdated biomedical approach to healthcare – where you are simply attempting to address an impairment of an organ. Instead, the World Health Organisation recommends following a biopsychosocial approach, whereby you consider the individual in their entirety and the impact of the problem (e.g. hearing loss) and how this limits their life. When one does this, it is clear that a broader rehabilitation approach is necessary and not simply the application of a device. This is based on evidence and the government should take time to review the evidence-base for intervention, particularly for long-term conditions. Thus the fitting of a hearing aid, although speedy in a competitive market, will not provide the additional necessary support in order to facilitate increased participation in everyday life as defined by the individual. If we are driven entirely by competition, we will lose sight of the World Health Organisation’s principles and revert to an archaic system of healthcare delivery where faulty organs are ‘fixed’. It just isn’t possible. Keep the NHS as the primary provider – it follows evidence-based approaches and includes rehabilitation as a necessary part of healthcare.
Is there any way that patients can break free of the post-code lottery and choose where they recieve outpatient treatment with the hel[p of their GP? This should improve services and reduce complacency of local services (with protected A and E and services that people can only access locally like routine treatments for chronicly ill patients with a need for many contact hours with nhs services)? But there’s also a danger to it – what if there’s collusion between GPs and consultants? How would this be monitored and prevented? Without any controls in place it’s a pretty risky move?
I wonder what will happen to all of these comments when the listening exercise concludes. Will anything be published? Since the “Liberating the NHS” consultation finished, I haven’t seen any documents that tell me the outcome of the consultation: the views or concerns expressed; the government just pushed ahead until the rising furore prompted the current pause. Who does a consultation and then doesn’t publish the results?
The government have tried to bamboozle us with economically-driven arguments for change. In fact, the NHS is internationally recognised as offering excellent value for money, is envied by many other countries, and has been working hard to save money as part of its QIPP programme with truly spectacular savings. Now, organisations are being told to set aside all those savings to pay for all the redundancies they’ll need to make (so that’s morale-boosting, natch), and the infrastructure support people who like everyone have been instrumental in making savings continue to be villified by the politicians (though less so than previously now that clinical areas have lent their support). The proposed changes will cost a fortune to implement. “Liberating the NHS” was never about saving money: it was all because a few politicians bought that boloney that was spouted in the USA in response to Obama’s proposed health reforms, that a free-to-use, socially-funded, non-competitive and non-profit health service is somehow “being a bit Commie”.
Government, if you really are listening, listen to this… If it ain’t broke, don’t fix it. The NHS was performing better than ever before you started meddling, and was in the process of leaning and saving money without your ridiculous idealogical and unaffordable crusade. Bear in mind that if you manage to destroy the NHS your political careers will be forever tarnished, probably terminally. Oh, and please publish the findings of your consultation.
(By the way, for the record I’m not the same David Robinson as wrote the “NOBODY” email earlier on: we are a common name I guess. Just wanted to clarify these are two different people, not the same person banging on
But I firmly endorse the views of my namesake)
I am really worried about plans to involve private companies in healthcare provision. I don’t believe that introducing competition into the NHS will improve services and I also don’t believe that it is what patients want. Much the same as with schools, we just want to know that we can use our local GP practice or hospital and get a decent service.
While there may be some areas of public policy where competition can improve effectiveness, it would be a disaster for healthcare as circumstances in the US demonstrate. I fear that companies will cherry-pick the profitable parts and let the rest go hang. I think that voluntary organisations will not have a hope of competing against the tendering power of big multinational companies intent on extending their reach into public services.
I think these ‘reforms’ are more about promoting an extreme market-based ideology that does not have mainstream support among the British electorate – hence the fact that the Conservative Party was not able to secure a majority in parliament. I don’t believe the NHS can ever be safe in the Tories’ hands and I think the proposals now being discussed show claims made to the contrary during the general election were lies.
I think the government should be governing for the people who elected it, not for business interests. And I think these pernicious proposals should be scrapped.
If the principle behind competition in the NHS is to improve services then ‘groundrules’ need to be fair to all parties. In a growing number of cases qualified/willing providers are employing NHS medical and clinical staff on a sessional or cost or case basis, as additional to their full time substantive contracts with local NHS Trusts. As such the Trusts carry significant overhead costs for training, education and clinical management, in addition to the emergency service rota. If willing providers wish to employ NHS staff then as a minimum they must pay a contribution equivalent to the NHS Trusts. Without this their ability to under cut tariff rates is an unfair advantage on NHS Trusts. Given the commercially confidential nature of these arrangements, it could be argued that clinicians should not be allowed to work for directly competing organisations without explicit agreement of both parties. Examples are emerging where clinicians employed by alternative providers to provide ‘pile them high, sell it cheap procedures’ are undermining the viability of their employing Trust and its ability to provide a comprehensive range of services to the local population…..that certainly does not sound like improvements in services to me ….rethink needed fast !!!
These changes are the opening of flood gates to privatization of the NHS, and is a stealth tactic being employed to get us towards the US system of HMO fat cats. Do we really want poor people dying from preventable diseases, families being bankrupted to pay for treatments and people working until their dying day to pay for medication, because that what happens in the US and its what will happen here. These changes are a terrible risk and it will be a tragedy if they go through. I have written to my Lib Dem MP (Simon Wright) asking him to vote against them.
Pursuit of financial sustainability alone (without environmental and social sustainability) is not …. sustainable.
An excellent way of creating choice and competition for the NHS is to ensure the social and environmental impacts of products/services are reported in a transparent way by healthcare providers. This will drive up the quality of healthcare by enabling patients to make ethical decisions and commissioners to purchase sustainable products/services. For example, contract wording could state: “the Provider will ensure a process and system is in place to measure, monitor and reduce carbon significantly across the organisation”.
Procurement in the NHS is responsible for 60% of the entire NHS carbon footprint. Making sure that carbon reduction is addressed systematically across the service will help reduce this percentage dramatically, drive up quality and reduce costs.
Measuring and reporting on sustainability is an important element to measuring excellence and quality while providing choice and competition. The more information and choice patients and commissioners have, the greater the competition. An ability to assess the sustainability credentials of an organisation means users can choose services more ethically, something which the public is increasingly demanding.
This must be sufficiently sophisticated to take account of the circumstances of each patient. For example, a hospital in Inverness may score 10/10 for carbon management, but clearly that doesn’t mean that the most carbon-efficient choice for every patient would be to travel there to receive treatment. This also accords to some extent with the wish of many people simply to have confidence that their nearest hospital provides a friendly efficient and evidence-based service. However in cases where care can be delivered remotely, then carbon-efficiency becomes location independent. Any mechanisms that would accelerate the development (and patient acceptability) of remote care services would enable wider competition independent of location, and more carbon-saving.
I believe that public health should also be working more to identify how choice and competition can be better fostered in areas that can achieve multiple benefits in cost, carbon and health. For example, introducing more transparency into the market for private renting, by ensuring more full information on the energy efficiency of lets, would enable tenants to put more weight on this when choosing a property, ‘nudging’ landlords to improve the efficiency of their properties, thus addressing fuel poverty, improving a difficult part of the housing stock and reducing national energy demand.
Competition is a massive waste of taxpayers money. The reality, especially for those who need the NHS most such as the elderly, is that they need local services to be as good as possible. Billions and billions of pounds are wasted on managers and commissioners which could be spent on clinical services which are at breaking point. Scrap the expensive, wasteful, purchaser provider split, scrap the market, invest in clinical services, cut the wasted billions spent on management, scrap foundation trusts and measure and publish outcomes and make service users groups compulsery. Much much cheaper, miles better and doesn’t involve privatising the NHS.
I seriously doubt the effectiveness of competition within the health service. I think that cooperation is actually the way to go in order to provide safe, efficient and effective care and choice for everyone.
I do not agree with either of the words (choice or/and competition). These are not words of the National Health Aervice. They are the Conservative weasel words for greed and selfishness. Private enterprise is in the business of
(1) making Money
(2) killing off the competition.
I will put up with this make believe farce with regard to transport and utilities.
I will not put up with it when it comes to the NHS.
Lansley and other shades of government must realise that the NHS belongs to the people and not business.
I will not condone any structural change which interferes with the concept of the NHS and will do all I can to fight profiteering from illness and death
Private companies should not be part of service provision. The NHS has improved greatly over recent years and there are many good examples of improving efficiency. Let the Foundation Trusts drive efficiency and quality forwards – the mechanisms are already in place with incentives to do this. Centralisation sounds attractive with presmued economies of scale – but does not necessarily work in a labour intensive CARING organisation like the NHS.
Please stop using the NHS as a political football and allow it’s empoyees, clinicians and managers to do what they do best and continue the good work of recent years.
It shouldn’t be about competition but rather best practice and helping to elevate and improve care across the board, by introducing competion you end up with hospitals trying to be out-do other hospitals rather than mutual cooperation in becoming the best they possibly can. Introducing market forces can only lead to a deteriation of patient care.
The NHS is not perfect, it has too many managers and there’s always a new government coming along trying to show off by changing it – usually for the worse. The NHS is world leader in healthcare provision, and even today 65 years after its’ inception the NHS remains unbeaten. It works, and it works well – more often than not at any rate.
Scrap the plans and keep our NHS out of the hands of private business.
This is a typical Tory tactic, sell to the highest bidder. The NHS may not be perfect but it does a fine job. The last thing patients want when they are ill is to have to decide where they want to receive treatment. Most people want to be close to home so family and friends can visit. Look what happened when energy was privatised; prices soared and now we have a confusing nightmare of different schemes by different companies all out to make money. It may have given us more choice but it certainly hasn’t made energy any cheaper by encouraging competition, quite the opposite.
I have family in the States who thought private healthcare was great until their insurance company didn’t want to insure them anymore because they became ill.
David Cameron wouldn’t have got a look in had people known what they had in mind when we went to the polls. He should tell Andrew Lansley to leave our NHS alone. People have long memories and this government will never be forgiven if they destroy the NHS.
Cameron says he will not gamble with the NHS but that is exactly what he is doing. Privatisation and competition may well have some benefits but is also has the capacity to do major harm, destabilise other services, “cherry pick” easy cases and leave high risk expensive cases untreated. It will take time to work out how to maximise any advantages and minimise the downside, by all means run some pilot projects but wholesale, rapid privatisation is a wreckless gamble which will cost millions with no guarantee of a better service at the end and a good chance of a worse one.
I would like to say as a long term cardiac/heart failure patient that the standard of care has certainly dropped during the last 2 or 3 years, it is not the nurses fault but the managers who treat patients as numbers and not as patients, these managers are not there for the benefit of the patients but the past and present governments in providing a cheap service like a fast food outlet so they can meet their targets.
Recently i had to suffer the agony of a gall stone moving in my gall bladder in November last year it was not picked up at that time it was not until this January that i decided that the pain was to unbearable to bear and asked to be admitted in to hospital, whilst in hospital it took approx 4 days for them to decide that my gall bladder was the problem, even though me the patient had told them on numerous occasions that the problem was with my gall bladder, it was a further 6 weeks before it was taken out by microsurgery but on the day following the removal i suffered a heart attack, a request was made 5 time for a cardiac doctor to come and see me but they did not come, i was eventually discharged on the saturday evening at 5pm, a week and a half later i suffered another heart attack and was admitted to the same hospital, 2 days later suffered another heart attack (this was my 8th one since July 2001) the doctors did not believe me when i told them i had a heart attack until the got the blood results back 12hrs later, it is now nearly 3 months since the last one and it will be another month before i find out what they are going to do to me.
I have to put up with this because unlike the southern half of this country of ours, my other cardiac hospitals are more than 60 miles away from where i live, i would rather they ensured the doctors went back to treating the patients rather than trying to reach so called target figures at the expense of the care for the patients.
Just so you know i have had a double heart bypass already, suffer from heart failure, an ectopic heart beat, a leaking heart valve and are a type 2 diabetic sufferer
More emphasis should be placed on the correct care and treatment of the NHS patients and employ only the necessary experienced managers to run the hospitals, at the moment there are too managers and not enough staff running the hospitals
If you ask the average person what they think the main problem is with the NHS, they will tell you that it is getting to see a doctor in the first place and the need to “book in advance” to be ill.
It’s amusing that the BMA are perfectly happy for individual hospitals to compete, but at the same time want GPs to form “consortia”, thus eliminating competition.
The first priority should be to give the patient real purchasing power in the form of a voucher good for his/her share of the practice overheads. This voucher can then be taken to any (yes any) GP’s surgery (as out of hours visits can now be provided by deputising services) thus making the payment follow the patient’s choice. Payment for treatment would be separate and continue as at present. One useful benefit of this would be that patients in employment would be able to be treated by a GP near their workplace, making the process more convenient.
It is notable that in places where GPs compete for patients, such as Spain and Australia, evening surgeries are not a distant memory as in the UK.
The question is misconcveived. It need first be shown that competition and patient choice will actually drive and not hinder NHS steady and continuous improvement.
Regards choice, I want to rely on the recommendation of my trusted G.P. – I am unable to choose between local consultants, whose ability and standing is not in the public view until there is a major scandal or s/he retires. In serious or complex matters convenience of access and quality of food are very secondary issues, which may give an impression of patient choice, as effective as moving the deckchairs on the Titanic !
Competition is appropriate for small shops in a High Street. Medical services need to be planned on the widest possible scale to meet a demand which is almost always caculable. To maximise use of scarce resources requires co-operation not competition.
There is no reason why the not-for- profit sector should not contribute – co-operation is basic to this sectors’ approach. Not so the commercial sector who needs always to take economies of scale into consideration; otherwise profits are too doubtful.
Minimal reading about the the provision of medical services and health insurance in the USA is persuasive in showing that a commercial approach to medical services spells the death of a compassionate, careing public service ethos. Furthermore the USA health services are known to be amongst the most expensive in the world, and among average and low wage earners adequate health insurance cover is considered unaffordable. US public health care is therefore internationally judged to be inadequate.
If, as is alleged, and seems likely, this is “creeping privatisation” we are overwhelmed with examples of this providing a poor service for the consumer. The great utilities are regional monopolists and their continuous price rises are barely held in control by a weak public interest controller and give rise to regular loud and ineffective public protests. Postal charges have ‘gone through the roof’ because of cherry picking by the private sector. I only need to mention rail – their failings are daily headline news.
We are assured that part of this is irrelevant because the NHS will remain free at point of use. The assurance is insufficient: the service may be free but access is charged for by punitive parking fees in England. Is it the hospital or a contractor who benefits from the very high charges for use of the hospital telephone service? or hospital TV cards? These might only be the first step: medical services remain free but “hotel charges” for in-patients are already occasionally mentioned.
A public service can only be a good service if it is publicly provided, transparently controlled and ultimately answerable to Parliament.
This consultation question assumes – without actually making the case – that choice and competition will drive improvement in the NHS.
If you are an ordinary person, diagnosed with a serious illness, you do not want to be offered ‘choices’ or to have to weigh up the pro’s and con’s of competing providers.
You want your well-qualified, local GP to refer you, promptly, to your local, well-staffed and properly equipped hospital, which will treat you quickly, with the most up to date techniques available.
If all NHS hospitals were properly staffed and funded and managed by medical experts, why would we need choice or competition?
If NHS services are put out to tender by any willing provider, then the competition will be to provide the service more cheaply than one’s rivals, in order to win the contract and to maximise profit for shareholders. This could be achieved by using less effective treatments, rationing healthcare, having longer waiting times and fewer staff.
It seems sensible not to take this risk.
Instead, let us look at improving the service provided by the NHS.
I have seen no argument to convince me that this is best achieved through complicating treatment with the need for competing healthcare providers to maximise their profits
Patient choice is irrelevant if it is a choice between 3 poor providers just interested in making a profit and not giving the patient the best treatment.
I am only concerned with having one excellent hospital run by the NHS in my area. I don’t need 2 or 4, I just want one that I can be sure of doing what is necessary for my family when we need it, free at the point of use.
David Cameron prior to being elected stated that evolution not revolution was needed in the NHS, having been elected, what is proposed is clearly revolution. The NHS in its current form is one of the countries most treasured institutions, it may not be perfect and there is room for improvement but the fundamental principles of the current format are entirely sound.
What the coalition government is trying to intoduce via the back door is a privatised American heath system. Whilst competition may be fine in the business world to reduce costs this concept does not tranfer to a healthcare system where the main goal should not be purely financial profit.
Patient care needs to be at the heart of the NHS not ruthless competition and profiteering by private company’s whoose main goal will be financial profit.
Many healthcare proffesionals have stated that the proposed reforms would be a monumental disaster for patient care, they would lead to enormous inequalities with private company’s cherry picking the lucrative areas and ignoring the non-profitable areas.
I am fundamentally opposed to changing the current structure of the NHS. Scotland is retaining the “old” system and data has clearly indicated that patient care has gradually improved at the same time that costs have been reduced. If this can be done in Scotland it can be done in England and Wales
This listening exercise has to be stopped and corrected.
I am deeply outraged that this listening exercise has been designed and implemented in the way it is.
- There is not enough publicity. No one I know (family or friends) know that there is a listening exercise, let alone how to get involved
- The interface has been just designed so that new participants cannot read what others have said. Am I supposed to make my point without reading the 529 other ideas that others are discussing below me?
- 4 different sections make the navigation more difficult, and sythetizing the information impossible. This is a good way of preventing anyone from being in the position of making their point
- There is no summary of what is being discussed which can be easily reached from this page. A document stating clearly what changes we are exactly discussing should be visible at all times.
- There is no information on how these random comments by users are going to be processed, valued or used. There is no statement on what guarantees that they are going to be even read by someone
- Any ethical and true listening exercise should start by listening to patients and citizens, who are the ones sustaining whatever system we come up with, and the ones suffering the consequences of any bad choice in this respect. The only section of society who seem to be giving their view here are mostly doctors, nurses and other institution workers who are aware of this sham.
Shame on this listening exercise, Shame on Mr Andrew Lansley. Shame on our government. Shame on this authoritarian and corporation-driven proposals.
We are citizens. We are patients. We are tax-payers. We are consumers. We have the right to be listened to, and above all, we have the right to be respected. Stop insulting us. Stop lying to us.
Choice, Choice, Choice is the mantra.
We do NOT want to choose a hospital. We want a good one nearby.
We do NOT want a choice of ambulance provider in an emergency. We want one there as fast as humanly possible.
We DO want some choice when we have elective surgery but we want it quickly.
Satisfaction with the NHS is at an all-time high. Why is there a proposal to break the coalition agreement which repeats what David Cameron said during the election campaign: “There will be no top-down reorganizations of the NHS”?
In my experience of working for the NHS for over 15 years I am hugely concerned that the proposed changes such as introducing competition and private providers will undermine the excellent, equitable and co-operative services which are currently provided.
At a time of austerity money will be spent on huge re-organisation and continued to be spent on administrative costs – including ‘branding’, marketing and advertising – how can this be cost effective or an improvement? I do not believe ‘competition’ will drive up standards nor is there an evidence base for this. Why are government advisers claiming huge profits are to be made by private health care companies and that we will be moving towards an insurance based system when this is not what the public wants.
I am also concerned about the meaningfulness of the targets services are being measured on and that at the same time as claiming to be putting patients and need at the centre of health care, the exact oppposite is happening.
Most people support the NHS as a publically funded and publically run organisation and I do not feel the government has a mandate to make the changes that are proposed. I fear that if these changes are pushed through, future generations will look back very negatively at the decisions made by today’s politicians. I only hope they truly listen to us.
In response to your question “How can we best ensure that competition and patient choice drives NHS improvement?” it is clear that you have made the decision that competition is the best driver of improvement.
I strongly contest this point.
Most patients want a strong local service. One usually has a single local NHS Trust to service the area, it is often not practical to shop around and travel outside of one’s area. Even if your GP is commissioning this care on patients behalf this is problematic. This is especially true when faced with chronic conditions requiring long-term treatment plans.
Does anyone honestly believe that the concept of competition can be applied universally to public services, I personally do not.
I work for the private sector and agree that in a commercial organisation competition drives improvement. However the NHS is not a commercial organisation, although I believe that at least partial privatization is the ultimate goal of these plans. It must be treated differently. With these ill thought-through plans the Government is putting the very future of the NHS at risk.
Mr Lansley are you really listening? I have just spent the best part of two hours reading ALL of the comments posted here. If you do the same you will be left in no doubt as to what the people of England want.
We want collaboration not competition. We want an equitable local service when we need it. We want it free at the point of delivery.
We do NOT want to be told we have to travel a couple of hundred miles to access treatment or that there is no money left in the budget. We do NOT want the NHS left with the most acute cases because the private sector has cherry-picked the ‘soft’ ones. We do NOT want EU competition law applied to NHS services. We do NOT want the private providers or insurance companies making a profit out of our ill health. This last point is morally indefensible!
Whilst other posters have expressed their detailed opinions from a basis of knowledge & experience & far more eloquently than I can, I have no less passion & belief in the NHS. These changes were not proposed in either manifestos and therefore you have absolutely NO MANDATE to implement these changes.
You ask ‘How can we ensure that competition & patient choice drives NHS improvement?’ This is such a loaded question & so obviously aimed at getting the answer you want. You are presenting a fait accompli & the NHS is being set up to ‘fail’. You will then say it’s not working so we’ll have to get rid of it entirely.
So Mr Lansley are you really listening or has the decision already been made? Just remember you are a servant of the people of this country & as another poster has already said, ‘ignore the will of the people at your peril’. You must publish the findings of your consultations if you want to retain any credibility.
Listen to what we are saying and SCRAP THE PLANS NOW!
Choice for patients with mental health problems is a real must! Patients can choose their GP, the sex, the nationality etc. and which doctor they wish to to see within their practice. In mental health is nearly always a foreign doctor who has poor English language skills, they repeatedly asks the same questions and the cultural background of some of them makes it difficult for patients to engage.
Female patients are expected to talk to a foreign male doctor about issues like child abuse, often the doctor coming from a country that practices child abuse e.g. FGM.
Mental health patients need a wider choice that enables them to open up and recover more quickly.
Appointments should not be rigid, e.g. 20 minutes and out the door, and psychiatrist have to available in the same way that GP’s are, when a patient is unwell the can ring for an appointment and be seen, not have to wait fro their next fixed appointment that may be months away.
Mental health patients ALWAYS get poor choice, if indeed any re who they see. Psychiatrists always think they know best when often the patient knows what works best for them
Unfortunately the NHS treats mental health patients like brainless people and it is about time they realised they are just like everyone else and need help!
By forcing choice on patients, you discriminate against those people least able to make those choices. People who are ill are often – precisely _because_ they are ill – not in any fit state to spend time, effort and money informing themselves before making a choice. Choice is meaningless unless it is informed.
The way this question is framed is shockingly leading. Choice may not improve quality at all. This consultation is shambolic
Choice is only choice when there are real options. I want Quality of care close to home that is able to meet my and my families needs. If you have a very complex condition, there is unlikely to be choice, the private providers will not want to provide for us, we are not profit making.
I have had many dealings with the NHS over many years and want to say it is not Broken, it needs tweaking not destroying. Leave it alone and let those who know devise this not inexperienced politicians trying to make a name for themselves.
Why do you say you need choice? When there is a limited amount of funding available, this makes no sense – also it suggests that some organisations may be better than others. Standards need to be developed around clinical best practice and quality assessments to ensure ALL providers are equal in their delivery of care – then anyone can go to their local hospital to be treated well… which is what the vast majority would do given the choice anyway!
Competition is the biggest threat in the reforms, not because of the way in which the private sector will move in, but because it will stop NHS providers talking to each other – I remember fundholding where GP’s and Hospitals truly hated each other. What the NHS needs is integration of services, and clinicians can do this best in collaboration. When there are competeting pressures, this won’t happen so you will need a layer of commissioning managers who would have to struggle to force each change through.
Patients don’t care about competition.
They just want to know that they can access good quality healthcare locally.
There are plenty of high quality health care staff in this country and it doesn’t make sense to organise them in a way that introduces competition between them. Systems that emphasise cooperation between health care staff and are are based on a focus of patient care are likely to be more effective. Competitive systems change the emphasis to marketing and accountancy because of the need to take business from each other in order to be profitable.
The Heath and Social Care Bill 2011 has called forth a magnificent range of thought on NHS improvement. A holding operation, for patient-care and staff-training, is now needed to allow reformulation. Much good may yet come from the turmoil in progress.
As the Bill stands, institutional chaos would endanger both care and training, the latter casting a long shadow on future care.
I have posted a comment in Section 4 (training), but in case the review is ‘run in lanes’ I hope that mention of democracy (given evident democratic deficit) will be seen to justify copying here:
So much good sense from so many respondents. The objective is widely shared of ‘a good hospital, reasonably close, in a national service sharing best practice’. Even to think of ‘the service we all wish’ is to think of democratic expression. We may thank the Coalition proposal for raising the fundamental choice to be made between democracy and variants of ‘human husbandry’.
As a retired doctor, also a patient and a relative, I welcomed the promise of the Health and Social Care Bill 2011, at first sight the ‘liberation’ of all to ensure ‘equity’ and ‘excellence’, within a reformed system of Health and Social Care, preserving the 1948 NHS principle of ‘treatment free at the point of need’.
Unfortunately, definition was lacking as to the meaning of principal terms:
1. The ‘liberation’ intended is for competition, in pursuit of profit, leaving quality to be defended by ‘regulation’ rather than advanced by secure conscience and free communication.
2. The promised ‘equity’ in care will continue to be ‘as far as might be deserved’, inequality of access left to be dictated by inequality of political power or insurance cover, poverty left as deserved and to be only palliated by state or private charity.
3. The hoped-for ‘excellence’, serving the top end of a market with unequal access, might easily be both exclusive and precarious in its isolation, and its impact on national statistics might be overwhelmed by a long tail of poorer performance, emulating the United States in value-for-money failure.
Many have drawn attention to the downstream semantic deficiencies of the Bill and of the Listening exercise. We are invited to comment on four groups of questions, in areas sensibly to be addressed only alongside each other:
1. With respect to the leading question, ‘how can we best ensure that competition and patient choice drives NHS improvement’, we should rather be asking ‘what steps must be taken to liberate inventiveness and care and funding as appropriate to democratic ambition?’
At present we can only guess at the dimensions of ‘patient choice’ that in a democratic society might be thought ‘worth the bureaucracy’: given equality ‘in the market’ we might wish to choose our surgeon, priority in non-urgent procedures, the latest of room facilities, etc.
In a democracy the essentials of health care would not be delivered in ‘a levelled playing field’ for the material elevation of doctors or managers or share-holders.
Even if, in a democratic society, global and sectional healthcare budgets were adequate, competition would play a part in the allocation of funds for individual training, for particular research projects, for service developments, for new sites, etc.
Healthy competition would be on merit, for society, not tainted by fear or greed possessing concerned individuals.
We do not have to choose between systems half-understood in America or Europe, or in recent party propositions: we can choose democratic liberation.
2. With respect to the vital question ‘how can we make the NHS properly accountable to the public, and make sure that patient involvement is at the heart of its decision making’, we might trust to luck (!), to political salesmanship (and luck!), to simple humanity (our care for the unfortunate, and luck!), to humanity expressed through inherited belief systems (injunctions to care, and luck!), or to the social contract offered by democracy.
A democratic society might make mistakes, but it will tend to make its own ‘luck’, to afford what is wanted and what is deserved, by the agreement and contribution of all.
If we give up income inequality (to give and not to count the cost), and set a savings maximum at a reasonable level (my cup runneth over), we will free ourselves from fear and greed, enabling trust and liberating conscience.
We need openness rather than ‘transparency’ (having to watch out and ‘seeing through’ each other’s dastardly schemes), and rational trust rather than ‘accountability’ (having to defend or hide the hardly defensible).
GP-led Commissioning, set-up out-with democracy, cannot emulate democracy: no more than could PCTs working to ‘equality agendas’ in recent years.
Including the voices of other health professionals, patient representatives and politicians, and replicating much of past structural complexity, will quite soon be found essential in preserving or in re-creating the creaky NHS of today.
The current proposal appears set up to allow a shake-down to a system of local private NHS-franchise-holders, sized for viability (comparable to PCTs), and like PCTs offering competition or co-operation according to population geography.
Adopted as proposed, much bathwater and a few babies will no doubt be thrown out, much more of financial bureaucracy will no doubt be added, and the transition costs (financial and human) might alongside other looming problems within months or a very few years precipitate final demand for democracy.
3. With respect to the linked questions, ‘ how can we ensure that advice and leadership from NHS staff themselves on improving services and tackling patient needs are at the heart of the health service’, and ‘what more could we do to ensure that commissioners collaborate to fit around the lives of patients and carers, and the particular circumstances of certain conditions’, let there be freedom of movement of people towards worthwhile work, and freedom of voice to attract funding towards worthwhile work, no personal financial advantages and fears to corrupt, just the joy of the worthwhile and the ever better.
In all of the scandals that over decades have continued to emerge, in ‘our NHS’ as elsewhere, ‘someone knew’ or had concerns.
Our great need is for the liberation of all, making all representative of all. Only income equality can deliver the security required for universal freedom of conscience.
The logic has to be faced – every labourer treated as worthy of hire – if we are to enjoy the fruits of democracy, an end to the rush to use up the Earth, a future of not hundreds but millions or billions of years.
4. With respect to the question ‘how can we make sure that NHS staff in the future have the right skills to meet changing patient needs’, the need is to respond to demand, and if possible anticipate both increase and decrease in demand, erring on the side of over-provision, trusting in the good sense of trainers and trainees, all aiming for ‘careers of service’ rather than ‘careers of shelter or financial advantage’.
There is scope for far more cross-fertilisation of ideas and practices, with earlier recognition of need to adapt, or focus more narrowly, or move on, unimpeded by personal and family financial considerations.
Strategic planning will always be difficult, more so with commercial secrecy. Past arrangements were poor, the current I am not involved with, the proposed will have to be proved in a context of chaos, I would guess leading to greater variation in quality, increased emigration, and even greater reliance on imported labour with attendant difficulties of integration here and of loss from countries of origin.
Until we have genuine democratic government – all free to represent all – we can only guess what systems of care and investment a democratic society would choose. Until we have such a democratic context, it must be the responsibility of pro-democratic governments both to lead towards democracy and to frame legislation as far as possible as if for a democratic society.
We live in a society that has worked and fought for democracy. If a democratic future is wished, then each generation must educate the next to that end. In the spirit of Benjamin Disraeli, truly to ‘educate our masters’ we must show willingness to educate ourselves. As a start we need to have a shared language, recognising ambiguities and clarifying central intents in the use of words, aiming for sharable understanding based on a logical sequence of value choices. I would commend the prime choices of faith in the worth of caring, and trust in the wisdom of genuine democracy, not to ‘officiously strive’ but to ‘give care to others’ as we would wish for ourselves.
The Coalition has to deal with the world of today, but we all today could affirm our choice for a democratic future, taking account of life’s trials and seeking to reform the NHS as if for all, for patients and relatives and staff and society as a whole.
Which are the types of services where choice of provider is most likely to improve the quality?
In my experience of working 23 yrs in the health service competition is only useful when like for like services are provided. e.g. the episode of care should contain all the follow-up services that historically would have been provided e.g out-patient therapy. It is no good a GP purchasing a THR from a private provider if the F/U O.T and Physio is not provided.
What is the best way to ensure a level playing field between the different kinds of provider involved?
Contracts and Service Level agreements provide for this as the NHS will be able to bid for services along side other providers, however the contract manager must ensure that the successful provider can deliver on the quality target’s within the contract to ensure patient safety and that satisfactory outcomes are achieved.
What else can be done to make patient choice a reality?
Listen to the Users views, we currently already allow patients to choose thier hospital provider of thier choice. This can be extended to include more providers as long as they met the quality standards already set by the exisiting providers.
If we are “all in this together” could we hear a lot more about cooperation and stop thinking all can be cured by competition.
The production of baked beans can be left to the market, healthcare cannot.
A successful organisation requires people to work together, not be at each others throats.
I want good care provded close to me, monitor,advise and if necessary compel but avoid naked competition at all costs.
I believe the ‘competition and choice’ proposals are something of a mirage and will only lead to the carving up of profitable elements within the NHS.
I recall Thatcher’s argument of private provision of utilities, trains, etc. leading to improved service and more value for money. Can anyone seriously look at the disastrous outcome of the privatization of trains as offering cheaper, more efficient, spacious trains. No, it is simply about profit and squeezing as much from the minimum amount of carriages, leaving crowded environment. Additionally, they seem to remain open to taxpayer subsidies.
As for the utilities, we have more expensive, less accountable ‘choice’, where they operate in a manner akin to a cartel.
The NHS cannot be allowed to be cherry picked by private companies, UK or Worldwide established. I have no trust in anyone, politician or other, to provide control or safeguards for patients.
Patients merely want effective, expert healthcare provision offered promptly as near to home as possible. All hospitals should acquire the standards suitable for all patients wherever they live. It is the duty of Government and health providers to ensure that.
In my experience, the last people to offer adequate knowledge and accessibility to Consultants, etc. are GP’s. I have no faith that the proposals involving them having budget and control of access, will work. I feel it will lead to inefficiency, self interest for the GP practice,and in many cases patients being denied access to treatment on budgetary grounds.
The NHS requires more investment in training and staffing of nursing care at practice and hospital levels.
I do not trust this coalition to do right for the NHS. They are solely obsessed with profit and ideology.
I completely agree John I have already tried to post a comment but it would appear I have been unsucsessful or it has been censored, PRIVATIZING the NHS in any way would be a disaster.
I too am very concerned that cherry picking will have an adverse knock-on effect on those NHS hospitals who lose out because of it. The NHS generally functions very well and we do not want it damaged for ideological reasons.
But I want to use this opportunity to advocate what I consider to be one of the major overhauls needed in primary care, which is that GP practices should be open 7 days a week and 365/366 days a year. Opening hours should be as a minimum 07.30-19.30 M-F, and 9-1 at weekends and public holidays. Illness and the need to consult a doctor or a practice nurse is not confined to 9-6, Monday to Friday.
I also do not want the reforms to be another opportunity for the earnings of GPs, senior hospital doctors and NHS administrators/managers to be uplifted by more than inflation. Indeed, these groups did so well out of the changes brought in by the previous government, and this was a sigbnificant factor in NHS budget increases not being as effective as they could have been. Indeedd, there is a strong case for a 5 year incomes freeze, thus enabling significant savings that can be used to improve services such as by increasing clinical staffing levels, purchasing of the latest equipment and making new and effective drugs available.
Health is not a commodity that can be bought and sold in the market place. What has someone’s health got to do with shareholders making profits. I find it immoral for this to be even considered. Benchmarking and raising standards are surely the best way of improving services. American and foreign health companies are chafing at the bit to get their hands on NHS money and this must be resisted at all costs. If this reform goes ahead the NHS will be diminished, and the public may have to travel miles to get treatment as their local hospital will no longer be able to offer the services required. The cost of the reforms is exorbitant and in these cash-strapped times why is the Gov’t even considering it.
I believe that the Conservative manifesto and coalition commitments should be stuck to: no top down reorganisation and not privatisation.
I believe a massive expansion in private providers will be highly detrimental and the removal of the requirement on the secretary of state to ensure universal health care provision is extremely damaging. The universality of the NHS is a fundamental principle.
Stop these reforms before you kill the patient! And stop your MPs sending out misleading letters claiming that doctors and nurses are in support of the changes. We’re not stupid!
The question presupposes an answer, yet it is by no means clear that ‘competition and patient choice’ are the best way (or even a way) to drive improvement in the NHS. I am not convinced that introducing the possibility of private healthcare providers making a profit for shareholders will drive improvement (rather the opposite) and patient choice is very often irrelevant, especially for those who live in remote rural areas where distance forces the choice.
I don’t want choice of provider within the NHS. I’m not in the place to make choices about how healthcare is provided. The government and the NHS is. If multiple companies are used to supply various parts of the system, I certainly do not want to have to make a choice about which one to use.
If sticking with the idea of multiple providers the level playing field must be controlled by the government. The idea of the government is to regulate business and ensure private companies don’t leave the NHS in a mess.
Finally, I don’t want patient choice. I am not a doctor. I do not have the time or capacity to research my own treatment. Leave it to the NHS.
PCT’s are non profit making organisations, put in place to oversee commissioning and ensure there is standardisation of procedures and equipment across the service. Open this to the free market and the whole structure will break down at the cost of tax payers lining the pockets of private enterprise. I cannot think of any of the privatised utilities that have benefited the consumer.
Also GP’s should have enough work on board without distractions from commissioning matters.
I am already seeing the problems of outsourcing where support previously done by the PCT has gone to an external supplier. Their software is incompatible and adversely affected a practice managers PC. This will be the tip of the iceberg.
Competition for healthcare improvement was today discussed on BBC R-4′s World At One, a health economist dismissing as suspect the fears of a Trade Union. Given that we all have ‘collective affiliations’, and blind-spots, it may be worth exploring the issues raised as to motivation and ‘evidence’ in system-design.
At the level of individual medicine, ‘a doctor is a doctor’, someone doing his or her best to diagnose, to treat, or to refer patients, the latter being people to whom in the eyes of society the doctor has a formal or moral duty of care. Where the patient cannot pay, the doctor may find a way to help, whether from human conscience or merely from concern for reputation amongst the tender-hearted.
At the level of public health, an employed system-designer – doctor, politician or health economist – may be driven by many things, as well as by human conscience and concern for reputation, in large part by the belief system of his or her employer(s) and potential future employer(s). So much will be obvious; but beneath lies the need of the elector, the tax-payer, the democratic representative, to know whether the designer’s aim is for democratic access to health (as near as reasonably possible, ‘health for all’) or some other concept of equity (such as ‘strongest to the fore’, or ‘first come first served’, or ‘what’s in it for me’, or ‘where are you from’, or ‘who is your father’).
With a little faith in Providence, it might be agreed that given genuine democracy, with universal freedom of conscience, the need would not arise to even think of setting up ‘private competitors’ for a National Health Service. As now, there would be enough ‘competition’ between the many headings of preventive, clinical and educational need, and the many individuals seeking qualifications and experience to make their best life-time contribution. Promising new treatments and new sub-systems can be ‘trialled’ rather than rolled-out blind or everywhere in duplicate. No wholesale change would be introduced except after careful examination of logic and / or evidence.
Being invited before all else to consider ‘how to ensure competition’, as implicitly the only or vital substrate of ‘patient choice’ (ahead of prevention, diagnostic access, treatment access, political expression and representation), tells us that we are headed away from democratic access. Beware the designer who will not share your fate, the would-be trader of ‘a mess of pottage’: rather than be competed for, by might or by trickery, the ‘birthright’ of the world can be shared – if we so choose.
If, having disrupted the NHS, it becomes difficult here, as in the USA, to think other than within a system of institutionalised competition, then even as non-partisans in party politics we might be reduced to asking questions such as: ‘what minimum of care should we guarantee’; and ‘exactly when will the guarantees start’. For every individual the lurking thought of every day will be ‘how much insurance can I afford, for myself, my family, our neighbours, the unlucky wherever they are’. It will always be possible by super-injection of money and enthusiasm to ‘make things better’, in particular respects and in particular places: the Hawthorne effect should remind us of the naivety of ascribing any such improvements to any particular aspect of a trial, e.g. to ‘competition’.
This might not by most be accepted the place to describe fully the nature and fruits of genuine democracy: suffice to say that equality of political power requires the establishment, based on general understanding and agreement as to the necessity as well as the moral justice, of secure equality of income share in our shared world (to give and not to count the cost), with a reasonable maximum to personal savings (my cup runneth over), and perhaps a reasonable equal ring-fenced budget for individual charitable/political/cause donation (a tithe, perhaps). Even in a world of such equality and security, there would be causes enough, personal charity, scientific curiosity, sense of sport, adventure, discovery, justice, efficiency, etc.
In today’s world we can at best hope to design AS IF for a democracy. I say ‘we’, I mean those with power and still-stirred conscience. We are all learning in this debate.
Choice can be a delightful thing when buying a new bicycle, but is the last thing I want to be bothered with when my appendix needs whipping out. Give every hospital the resources it needs, from general taxation, and trust professionals to do the job. And keep the profit motive right out of it; it’s incompatible with a genuine welfare state, which puts people first, not money.
I’m in favour of informed choice that does not undermine the NHS as a whole. It is not unreasonable to expect your GP to guide you to the best service that is available. Everyone should have access to the best. So, if there are wide variances in the standard of service this should be addressed as a seperate issue. Let’s bring every service up to the same level.
I’m not against public private partnerships. NHS lift is a good example of how this can work well. However we should understand that the NHS is a service not a commercial enterprise. The profit motive will not add value to care – think of the story of the good samaritan (Doctor Luke’s gospel chapter 10 verses 25-37).
Privatising the NHS (and let’s not kid ourselves, that’s the long-term plan) would be a recipe for disaster. When has privatisation ever worked? Let’s see; Railways? Energy Companies? The NHS is bigger than any of them, the damage will be proportionally greater.
Every Conservative government since 1951 has tinkered with the NHS and none of the reforms has been an improvement. We don’t need “choice” or “competition”; we need a properly funded health service with more “front-line” staff, fewer managers and much less government interference.
I am very upset : reforming the NHS is actually privitisation. Is competition good? Not when it is not needed. Competition in this case means for-profit care, and the percentage taken from our healthcare for the profit is an automatic addition to our healthcare costs. Any competition would come after this – all competitors would require they profit. The NHS as it is is a beautiful thing. Ask any British citizen like myself who has lived overseas. We don’t complain about an occasional minor problem, no way, no how. We recognise the NHS for what it really is, the world’s best overall FREE care system. Privitisation is so AMERICAN!
The NHS reforms are opposed by Sir Norman Tebbit, Tory GP and MP Dr Sarah Wollaston, and even David Cameron’s brother-in-law, consultant cardiologist Dr Carl Brookes.
If the government want to listen to people’s views regarding NHS reform, they should LISTEN to the BMA’s objections to their plans, LISTEN to the 99% of nurses who voted NO CONFIDENCE in the NHS reforms, and LISTEN to the well-over 400,000 people (and counting) who signed the petition against the Coalition plans.
The plans described in Andrew Lansley’s White Paper were not described in either the Tory or Lib Dem manifestos, so to use back-room brokerage to sneak through policies that not one single British person actually voted for is a total abuse of the democratic system!
Competition only works to drive quality when there is a level playing field i.e. when it is not possible for providers to only provide certain parts of the care or certain types of care. Patients should not have to be shunted from one provider to another just because their needs change. If someone be it a private company or an NHS trust is taking the money to provide the care then they should provide all and any aspects of care that patient needs.
All providers should be able to demonstrate they have the resources to do this and no provider should be able to cherry pick they types of care they will provide failure to provide every aspect of care should incurr financial penalties
PROPOSED NHS REFORMS –
A PATIENT PERSPECTIVE
Perceived Inequities of the NHS ‘Internal Market’
1 How can NHS patients benefit from a Public Health Service that is forced to buy services from its self? This is surely an unnecessary burden of bureaucracy especially as the Bill promotes competition for health care services to be based upon ‘Patient Choice’ and ‘Quality of Care’ rather than cost.
Every transaction presents an opportunity to the unscrupulous for the misappropriation of public funds and poses a particular temptation for NHS purchasers whose operational budgets are in overdraft or under threat of being cut.
2 The Bill provides for Monitor to be given legislative powers to enforce ‘good procurement practice’.
Under the proposed organising structure, such enforcement would be retrospective, responding to a particular complaint.
This is surely ‘too little too late’. As should have been learnt from the banking crisis, for fiscal regulation to have any chance of success, it must have a remit to provide a ‘pro-active’ rather than a ‘re-active’ response.
If Clinical Consortia are forced to provide a purchasing roll, each and every transaction will require constant independent scrutiny at local, grass roots level.
The current proposals fail to provide for any legislative mechanism or funding to facilitate public and patient involvement in this respect.
3 It comes as no surprise that services for mental health and the elderly are among those hardest hit by an increasingly ‘market based’ health service that has lead to cuts in funding and facility closures. These cuts and closures are inevitably blamed on ‘market forces’ but these forces have been deliberately unleashed upon the NHS by successive governments beginning with the 1990 ‘Community Care Act’. This introduced the ‘internal market’ concept creating the ‘Purchaser-Provider split’ within the health service.
This ‘market lead’ framework has lead to purchasers being incentivised to ‘trade off’ services between NHS and private service providers. This poses a real risk of the proceeds being siphoned off to ‘line the pockets’ of the purchaser and private provider shareholders.
More importantly, from a patient perspective, the focus of General Practice is being increasingly diverted away from the core principal of delivering a personal, family orientated quality service in favour of a systemic cash orientated business operation.
Patients demand a National Health Service not a National Health Business!
Proposed Solution – A Patient Lead Reform
4 It is clear that, to abolish the NHS ‘Internal Market’, would involve radical reorganisation but surely the future of our NHS is far too important to be consigned to the ‘too difficult to’ action tray.
The current demise of our national finances demands more than ever a radical and entrepreneurial approach to achieving optimum value for money from all of our public sector services.
This solution is, perhaps less risky than the current proposals in that it would, in many respects, require the NHS to revert to the pre.1990 operational model.
However, it must be acknowledged that there is an increasing demand upon what has, and always will be, a finite resource. For this reason, it is clear that any solution will require the continued involvement of ‘private sector providers’ to have any chance of success.
The key is to establish a procurement method that can be centrally managed and easily monitored by a relatively small group of administrators, the only involvement required by clinicians being with the selection process.
The introduction of ‘Contract Retainers’ could be the most effective solution.
5 The establishment of an annual ‘contract retainer’ for existing private providers could be based upon an historic value of service over the past 5 years, for example, including allowances for inflation and any perceived increase in service.
In the event that a ‘retainer’ is in danger of being exceeded at year end, the provider could be empowered to apply for a ‘top-up’ which would be subject to validation and negotiation with the administering body.
An assessment of service volume together with a defined set of resources and quality assessment could determine the value of an ‘initial contract retainer’ for new providers.
Any surplus to the retainer fund for both new and existing providers would be deducted from the retainer fund allocation for the following year.
6 The abolishment of the NHS ‘internal market’ would negate the need for the SHA and PCT’s together with Hospital Trusts and other ‘for-profit’ providers currently operating within the NHS.
Each independent NHS hospital/service provider could be allocated an annual operational fund valued and administered directly by the DoH.
Fund values for established hospitals could be based upon the average bed allocation for the previous five years together with the number and type of clinical procedures undertaken and general overhead and running costs. Plans for additional resources and services could also be factored in subject to negotiation with the DoH.
Operational fund values for new hospital facilities could be based upon the building overhead, number of beds and estimated allocation, employed personnel and an estimation of the number and type of clinical procedures to be delivered. The estimation could be based upon audits from established hospitals that are comparable in size and breadth of service.
7 Each service provider could be independent and autocratic. They could have their own ‘in-house’ management team made up from senior clinicians and administrators working on an equal footing and responsible for the procurement of all medical equipment, building maintenance, cleaning and catering contracts and all associated operational facilities as required to meet NHS quality standards within their allocated fund.
Hospital matrons could be re-established in every hospital and be equal in status to that of the appointed Chief Administrator. They, along with other principal clinicians, could share the burden of all key decision making where this has a bearing upon the standard and quality for the delivery of care.
8 Similarly individual GP’s and partnerships could receive an annual ‘operational fund’ direct from the DoH. The fund value could be based upon the surgery building overhead and running costs, contracted GP and other appointed clinician salaries, the number of registered patients, taking age and medical profiles into account and established local needs etc.
The GP(s) and practice manager would be responsible for procuring all associated clinical and administrative personnel and equipment within their allocated fund as required to accord with the NHS quality standard for the delivery of primary health care.
Patients should have the right to be assigned to an individual family GP of their choice and to receive a continuity of care. Individual GP’s or Partnerships serving an urban district or rural village should be required to co-ordinate their ‘on-call’ availability to provide 24/7 care to their community.
9 The NHS and Local Government are both publicly funded.
The abolishment of the ‘internal market’ would negate the need for charges.
GP’s and Hospitals could refer patients to their relevant local authority for the clinical services they provide.
Those services delivered by Local Authorities could receive annual funding direct from the DoH as previously described for the NHS (Item 5 refers).
10 Where are the incentives?
In an ideal world all clinicians should be motivated by an overwhelming desire to make a difference to the quality of life for the patients placed under their care. Achieving a successful clinical outcome should be incentive enough.
The generous contract remuneration awarded to Hospital Consultant’s and GP’s, whose working hours have also been considerably reduced should negate the necessity to provide additional ‘incentive payments’ for services that are considered by the current administration to be beyond the remit of their contracts.
As is the case with most private sector service industries, success or failure is dependant upon ‘customer’ satisfaction leading to repeat business. If, as suggested previously, the value of a retained fund allocation is ‘patient lead’ by the numbers of patients registered to a GP practice or Hospital bed allocation, then this, coupled with the vocational nature of the profession, should be incentive enough to motivate clinicians to ‘go that extra mile’.
11 The NHS is, of course, a finite resource and can never meet the financial and operational demands driven by the combination of an ageing population and relentless medical advancement. It can never be ‘all things to all people’.
However, it is incumbent upon government to provide a framework under which the NHS can deliver an optimum value and quality of service which is patient driven to improve the standard of care that is paramount to achieving successful outcomes.
—– END —–
I work in adult social care. My experience is that competition can be damaging i.e agencies in social work paying social workers £500 to work for them and then selling them back to desperate council’s for more than they were originally paying them. At worst I’ve seen poor services for vulnerable children and adults, while somebody still makes a good profit and drives a very posh car to meet you. If you put in a lot of effort, it is possible to provide good services for less money, but this often takes a concerted monitoring effort on behalf of the commissioner and the fear of losing your contract. The private sector will negotiate long term contracts in health care services and so much investment that it will take a long time to get out of it. The private sector will then say ‘how do I make this bit of the process cheaper’, then ‘how do I get this bit of the process cheaper’. Our local hospitals will have wings chopped off, until running the building becomes unfeasable. When we go to hospital, we’ll only be able to get our blood pressure done here, but you’ll need to go over the hill for your blood test. Older people and vulnerable people with few transport options will stop getting their health care because it will be too many visits, too far away. Good health care comes from good people with good training and good management. Privatisation does not necessarily get you that.Some things in the NHS are not good enough.We should fix them, but don’t expect privatisation to fix things. It is entirely possible that the private sector can put in a cheap price for something that works very well in the NHS. It could be damaging and my experience is it often is.
I don’t care about choice in provider – all services should be striving for the same high quality. I want to be able to access this quality close to where I live.
Where I want to see real choice is in the terms of treatments available – good information about options available for treatment – for example what benefits and risks are of medication and alternatives eg “would seeing a chiropractor actually be cheaper and more beneficial to my health than many years on painkillers?”
My recent experience of having a good level of choice was giving birth in Bradford. I had a choice of whether to have a home or hospital birth, with good information and support for either option. This level of choice would be made even better by the planned birth centre.
People don’t always know that there is a choice in the types of treatment available (not based on cost or distance) and it is here that the choice and information about these choices is vital.
The majority of patients I deal with every day want quality, not choice.
If my house is burning down, I do not want a choice of fire brigade, I want the nearest one to come & help me quickly;I trust them to do the job, because they are professionals, and they know what they are doing.
The British tax-payer is by inclination stoic and traditionally slow to anger. As a person who wishes to reflect on life and conclude that his life and work contributed to society, one reason for this stoicism is because the tax-payer placed his faith in institutions of long-standing, which he could proudly say his years of hard work helped pay for; institutions which would, in exchange, protect him and his loved-ones.
The NHS brought us into this world, and it is the NHS we rely on when we call “999″. While we have the right to enjoy the luxury of private medicine if and when personal circumstances permit, the government must respect the historic sacrifices of British tax-payers.
As an older person in an aging population, the legacy we (as parents and grandparents) leave to the young is life itself; but the young (especially in times of hardship) won’t cherish this land enough to care, or even be physically well enough to help overcome this nation’s problems, unless their health is protected. The NHS was created at a time of great financial hardship, and was not created despite that hardship, but because of it. The NHS was created in a spirit of co-operation, not competition. It is not the case that we must reform health services to reduce the deficit our children will inherit. It is the case that we must defend health services to protect the legacy our children are entitled to inherit.
This is a simple plea to the government for common-sense, decency and understanding. We trust you. We pay for you. Please don’t betray us.
Well said!
I am deeply concerned and oppose these reforms most strongly. for the following reasons and based on analysis by others;
‘Monitor determines whether a trust may become an FT and sets conditions that include balancing the books, meeting healthcare targets, and meeting financial targets like caps on private healthcare income and on borrowing. If an FT breaks these conditions Monitor can replace the management.
The health bill will abolish NHS Trusts on 1 April 2014. A trust that has not achieved FT status by that date will no longer be an NHS provider. A month ago, Health Service Journal reported that the Department of Health had brought in management consultants to advise on 22 trusts thought unlikely to achieve FT status before the deadline. The government has not ruled out privatisation, as happened in Hinchingbrooke.’
What is also deeply concerning is the removal of the asset lock:
‘ The Bill will also abolish the current caps on private income and borrowing. With severe cuts coming to the NHS (hospitals will see a 1.5% cut in their income this year), FTs are expected to make up the shortfalls by expanding their private work, which will inevitably lead to a two-tier system. In July last year Lansley announced that FTs would no longer have access to the £5bn NHS capital budget, instead, they would have to borrow from a bank for capital projects like new buildings. The Bill will remove the “asset lock” on FTs meaning that if a trust defaults on its debt repayment a bank could sell off part of the trust.’
If part of a trust is forced to sell off its assets this could have a massive impact on patient care, resulting in reduced services, longer waiting times and so on.
source: http://falseeconomy.org.uk/blog/what-the-health-bill-means-for-hospital-trusts-and-why-it-matters
If you are giving patients a choice the choice has to be like for like. It is no good having a private provider who does a specific type of surgery very well but provides no physiotherapy or follow up clinics.
I beleive from a professional and personal/ patient point of veiw that when accessing healthcare choice isn’t as high on the agenda as politicians and media think.
Patients want to know that they are safe, being offered a good standard of care, being kept informed and that the treatment they are offered is the best for their situation. Patients do not want to be confronted with a huge array of choices of places and people who they have no knowledge of, and therefore offten do not make an informed decision.
There may be a place for some private an voluntary involvment in healthcare as there has always been. This should not be at the expense of accountability. Is a private provider going to be accountable to the Doh and CQC as we are in the NHS at present. Are they going to be mionitored by the HPA and bodies such as the NPSA? As a patient I want to know that standards are high, not that I will get a nice carpeted room and a huge food and beverage menu.
I am deeply concerned that the changes that Andrew Lansley wants to make will end up damaging our health service.
For example, I am concerned that new commissioning bodies will not be properly accountable and will not operate in a transparent way. GPs should not be able to take decisions behind closed doors, and other stakeholders including patient groups and other health professionals should also be involved.
It is my personal opinion that if leading health experts such as the British Medical Association give advice about the NHS then this advice should be followed. Any changes planned should be trialled in small areas for several years in order to assess impact, and for the results to be assessed by the BMA.
The Government (and, it must be said, Labour before them under Blair) seem deternined to destroy our NHS. I heard on the radio this morning a Tory MP saying there should be a ‘red line’ beyond which the Conservatives should not compromise on the Health and Social Care Bill – the red line being ‘opening up the NHS to competition’. These politicians just don’t get it. How do you compete for people’s health for heaven’s sake? Health is not a supermarket commodity. It stands to reason that if you make a business out of healthcare, the businessmen and shareholders want only one thing – profit. Since the NHS is a public service it does not generate a profit, but its funding comes from us, the taxpayers. Why should businessmen and shareholders get even richer by taking a slice of our money? Our money should be put directly into what we pay our taxes for – providing a good free health service – and none of it used to enrich greedy private individuals and companies. If the NHS is ‘opened up to competiton’ will these greedy companies pay money towards the training of NHS doctors and nurses? I bet not. They will cream off staff trained at NHS (taxpayers’) expense and say ‘thank you very much’.
I am certain that Tory MP on the radio knows nothing about the NHS (I bet he is rich and has private health care insurance) – and Mr Lansley himself has no experience whatsoever of working in the NHS – as an ex-nurse of 20 years of being trained and working in the NHS I find that appalling. How can any politician know the real problems without having worked in the NHS? This is a bad Bill which will undermine and ultimately destroy the NHS. It should not be merely amended – it should be scrapped forthwith.
I agree, as a health service user, I want whatever clinical care I need, provided as close to home as possible, in the best way possible. This is more important than having a choice.
I think the money that goes into the health service should be for paying healthcare professionals for their work and towards infrastructure maintentance, not for creating profit.
Choice has been massively overplayed as an issue for patients, as many have already observed. One aspect which has not featured much is the huge inefficiency introduced when “choice” leads to one patient attending many different providers which results in multiple case records which do not communicate which, in turn, results in wasteful duplication of assessment, investigation, etc, etc. Thus far better for patients, whenever possible, to attend their local hospital for all their problems – which is also what the overwhelming number of them actually want to do!
Competition which is enforced will fragment the service for patients leading to frustration and inefficiencies for all. Every one at least seems to agree that we want “joined up” services but this will only be achieved with co-operation, and NOT competition! It is particularly worrying that Monitor is to get involved, bearing in mind the disastrous role that it played in the sorry tale of Mid-Staffordshire.
Choice is not an option for most admissions to hospital because:-
1 Heart attack, stroke, accident etc
2 Close to home so that patient can have visitors.
People also want to go to local hospital for outpatient appointments for reasons of convenience.
Choice should be applicable for:-
Childbirth, hospital, small units and home delivery.
End of life, home, hospice (not just for cancer but any cause), small local “cottage” hospital.
Choice of GP
When people are ill what they want is good care not the research skills to find a hypothetical “best provider.”
The questions posed here presuppose that the public wants choice and competition. I want a local excellent service, hospitals working together to share best practice, not fighting over patients. Choice and competition best serve those people who are educated to a level to engage in the options presented to them and have the financial resources to pursue their choices; unfortunately, this is not the majority of the country. Any reform of the NHS needs to come from thorough and in-depth consultation with the NHS; it is unreasonable to expect patients to fully understand the complexities of such an important institution and the suitability of any change in mode or method of the provision of services.
The NHS is our most precious national asset; it cannot be improved by change for change’s sake. This listening exercise needs to be conducted over a much longer period, with greater access and information for all on how to contribute.
The following views were submitted to NHS Stockport’s own listening exercise by staff and members of the local community:
It was felt that the Healthcare bill makes strong assumptions that competition is always a good thing. In many sectors competition has been a driving force behind major advances and savings. However, a note of caution was raised around the application of market forces to the health economy.
One of the clear ways of reducing overheads in the NHS has been the pooling of resources and merging of teams to operate under a single set of overheads. Inviting tenders from any willing provider may be a way of increasing competition and reducing costs, however competition between potential providers would make services less likely to cooperate. This could have a damaging impact on patients, if the range of services they require will not work together with their competitors.
The majority of Stockport people responding to our consultation felt that a wider choice of service providers would not improve service quality and that the NHS provides better services than private clinics.
Another caution around the competition element of the bill was the fact that the driving force behind companies is the need to succeed or go out of business. It was strongly felt that the NHS cannot be allowed to fail. This radically alters the dynamics of competition within this sector.
A clear view was given that competition must be fair and conducted on a level playing field. ‘Any willing provider’ must be tempered by the need for all willing providers to comply with the same standards,CQC registration and rigorous monitoring. Otherwise, competition could actually reduce quality to the lowest common denominator in an attempt to compete financially.
In addition, safeguards must be in place to ensure that patient choice does not make vital rural hospitals, in particular, unviable. It was noted that choice is not always an option for the more vulnerable or deprived in our society. Elderly people or those without a car, for example, may be limited in how far they can travel for care. There is a real risk that if certain services are outsourced to more competitive providers, local hospitals may no longer be able to offer vital services to protect these people and reduce health inequalities.
The Bill should also be clear about who is liable if something goes wrong and standards are not met.
GPCommissioning Consortia will need to have strong contract monitoring in place to allow them to measure outcomes in a fragmented provider market and ensure high standards of patient outcomes are maintained.
To allow patients real choice, they will need to have “standard, accessible information on each of the providers.”
“How can we ensure providers collaborate in a free market? They won’t!”
“Who will measure outcomes from a fragmented provider market?”
“How do existing NHS services drive out inefficiencies? Commissioners unable to pay for uplifted activity. Efficiencies mean less staff, clinical redundancies, and associated costs. Who picks up the bill for these?”
“The most vulnerable in our society – especially young and old – want access to local services. Choice may fragment this as private providers won’t want to go where there is little demand. Who picks this up?”
“Standard, accessible information on each of the providers.”
“Lead to a postcode lottery”.
“What about the multi-disciplinary pathways? Can’t bid for just one part of it.”
“Limited amount of NHS funds means there is a limited number of providers that can be viable.”
“Is there any evidence that choice and competition has improved the NHS?”
“What evidence is there that choice will drive NHS improvement?”
“Wider choice only benefits affluent communities”.
“The public want good local services.”
“All service providers must be registered and meet CQC standards”.
“Private investors should be encouraged to build hospitals like BUPA for better competition. More private hospitals will give patients better choice”
“Private health insurance should be encouraged more.”
“Vastly improved and consistent information on service quality would improve choice and service.”
“The market only works if failure is allowed. Can failure be accepted for individual or organisations?”
“Competition and collaboration don’ sit well together. Collaboration is more powerful in improving quality than competition.”
“What will be done to ensure quality is maintained in a competitive market?”
“”The employers should be encouraged to contribute to the health insurance of the employee”.
“Many patient groups find it very difficult to engage due to transport or comprehension.”
“How can commissioners monitor quality of service when there are hundreds of potential providers?”
“Full range of services to be available from providers, not just cherry picking.”
“What will happen to ICU, A&E costs when private providers have taken the other ‘cheaper’ services, leaving just very costly services. Everyone who remains in the NHS will have even higher overheads added to their benchmark price.”
“Any qualified provider: real concern there is no level playing field. Single handed clinicians have very low overheads, so lower costs and being an ‘Any Qualified Provider’ exempts them from being registered with the CQC. Lower costs and lower standards. No way back in to see NHS staff – they will have gone.”
“Health service is not comparable to gas / electricity.”
“Rigorous process and structure for accreditation and monitoring quality.”
“Choice is important, but is not the only thing that matters: also local services; quality of services”.
“Danger that we lose focus on prevention / public health”.
“Patient choice is important. But needs assurance that there is sufficient choice available.”
“Choice does maybe not work for all patient groups”.
“Private providers will cherry pick and are motivated by profit, not the best holistic care for the patient.”
“Local provisions must be maintained for more vulnerable groups.”
“To ensure level playing field, providers have meet the same quality and safety standards.”
“Applying the principles of competition in the arena of complex care is fundamentally inappropriate.”
“Focus on patient choice is less important than patient satisfaction and the provision of good quality care on people’s doorsteps.”
“Risk of fragmentation of services.”
Feedback from survey of local people
1. Do you think a wider choice of service providers would improve service quality?
Yes No Don’t Know
32.9% 52.9% 14.3%
2. Would you be willing to wait longer to go to a clinic/hospital of your choice?
Yes No Don’t Know
46.4% 40.6% 13%
3. Do you think private health companies provide a better service than NHS clinics and hospitals?
Yes No Don’t Know
22.9% 62.9% 14.3%
4. If you answered yes to the previous question, please explain why you think private healthcare companies provide a better service than the NHS?
17 responses:
• Waiting times (x6)
• More personal service & choice (x5)
• Better, more modern facilities (x3)
• Private rooms & less patients (x2)
• Flexible appointment times so don’t need time of work (x2)
• Higher standard of customer care and respect (x2)
• More time spent with the healthcare professional (x2)
• Private companies would go bust if they didn’t have high standards – incentive not just to meet the minimum standards but to excel (x2)
• Cleaner
• Clearer feedback
• Not a like-for-like comparison as private companies can pick the most lucrative treatments
The biggest problem that has ever faced, or will ever face, is the never-ending attacks of the capitalist minority who would have a health service run for profit. Their profit!
NHS stands for National Health Service “service” is defined in the dictionary as “The condition of being a servant; the fact of serving a master.” The “servant” is the healthcare system established to be free at the point of service, non-profit making and paid for from National Insurance contributions, (not Taxpayers).
In the UK’s case the “master” is us, the population, not the government, not investors, not profit-mad speculators, THE PEOPLE OF THE UNITED KINGDOM are the masters!
The word National means “Of, or relating to, a nation or country, esp. as a whole; affecting or shared by a whole nation.” Whole Nation – everyone – not just those who can afford it – everyone.
Not only should we be keeping the health service run on the same lines as at present, we should be renationalising the private healthcare sector. I won’t hold my breath!
I don’t want choice – I want a local, quality service, with short waiting times. I have an appointment for tests at the end of next month, while my condition is deteriorating daily – then I have to wait to see the consultant again & then wait for whatever treatment is prescribed.
I don’t want a provider whose main motif is their profit (and all private companies are going to be in it for the money (not for the love of the patients).
Maybe these proposals are good but we have no way of knowing as there have been no trials to test them out. Why further screw up the NHS – let’s get it right this time. Test the proposals in several areas – if it works good – roll it out – if not back to the drawing board. Andrew Lansley is proposing taking a huge risk with the NHS future. Does he have health insurance? He might need it if he ruins the NHS.
I am concerned that the plans outlined in the Bill, will lead to increased privatisation to the detriment of patient care. I am also seriously concerned that the proposals outlined in the Bill will undermine the core principles of the NHS, which are a comprehensive service available to all and in particular that all care should be free at the point of use and based on clinical need rather than the ability to pay.
In the run up to the election last year the Conservative party in particular made claims that it was the party of the NHS, that it was against costly and unnecessary re-organisation of the NHS, but at the same time outlined plans in the Conservative Party Manifesto 2010 to do the opposite by changing the whole structure of the NHS.
In a recent article in the Lancet (16th April 2011 -NHS reforms: Stop. Look. Listen), the extent of the proposed changes are outlined.
–”The reforms—which would radically tear up the structure of the NHS, hand over 60% of the NHS budget to consortia of general practitioners to commission health services, and extend market forces across the system—have been widely criticised. The Lancet, doctors’ leaders, and health-care experts have all called for more time to consider the bill.”–
I was particularly concerned, when I ran across an article in the Guardian (David Cameron’s adviser says health reform is a chance to make big profits) which details some unguarded comments made by Mark Britnell one of David Cameron’s “kitchen cabinet” advisors and head of health at KPMG.
–”In unguarded comments at a conference in New York organised by the private equity company Apax, Britnell claimed that the next two years in the UK would provide a “big opportunity” for the for-profit sector, and that the NHS would ultimately end up as a financier of care similar to an insurance company rather than a provider of hospitals and staff.
According to a glossy brochure summarising the conference held last October, Britnell told his audience: “GPs will have to aggregate purchasing power and there will be a big opportunity for those companies that can facilitate this process … In future, the NHS will be a state insurance provider, not a state deliverer.” He added: “The NHS will be shown no mercy and the best time to take advantage of this will be in the next couple of years.” Writing in the Health Studies Journal, Britnell also suggested that the NHS would be better served by breaking with the mantra that all services should be free at the point of delivery by allowing co-payment, where patients share the costs of care and drugs.”–
This latter article would seem to lay out what is really on the cards if you read between the lines of the proposals outlined in the Health and Social Care Bill 2010 – 2011.
When you look at the recent report by The Royal College of General Practioners (RCGP), where they detail the changes they believe are required to Health and Social Care Bill 2010 – 2011, the concern that the NHS is being reformed for purely ideological reasons, rather than for the benefit of patients is re-enforced. Several points made in the report are particularly relevant when looked at in light of the reports in the Guardian.
I particular the RCGP detail serious concerns that the Bill:
• Will remove the duty of the Government and Secretary of State to provide a comprehensive health care service.
• Risks allocating resources as a result of GP lists rather on geographical populations.
• Risks competing for patients.
• Will result in an inability to adequately plan local services.
• Risks worsening health inequalities.
• Lead to fragmentation of services and a further post code lottery.
• Will result in Consortia being able to determine which services form part of the health service and result in the need for patients having to pay for those services that the Consortia do not wish to provide.
• Refutes the idea that increased market forces lead to better patient outcomes and highlight the lack of evidence to support the idea that market forces have any effect on the quality, effectiveness, or efficiency of health care.
• Provides a comparison with the privately funded US Health Care system which costs nearly double what the UK system costs and leads to significantly lower life expectancy than in the UK. They also make the point that “For Profit” hospitals have worse results than “Not for Profit” and also that most market driven activity incentivises the drive for profits not patient care. They also note that the US system has failed to contain costs or match NHS outcomes.
• Note the situation in the Netherlands where competition law has de-incentivised health care providers from collaborating and providing coherent and effective health provision.
• They also raise serious concerns about the transparency and accountability of the systems being proposed to determine service provision and raise concerns about these systems being outsourced.
In light of the media reports, and serious concerns expressed with the Health and Social Care Bill 2010 – 2011 by professional bodies such as the RCGP, the only conclusion that I can come to is that the agenda being undertaken by the Government for the NHS is one which is ideologically driven for the benefit of management consultancies and private business and not one that is being driven by a desire to help the most needy in society. I find what I see of the plans for the NHS utterly disgusting and a frankly criminal threat to an intuition that is superb.
The NHS is so mcuh better than health services in other countries. Yes, in America you can get very good private care, but it is cherry picked and for those without insurance there are problems. Competition may make some services more efficientt but there are the added costs of monitoring, which in the long run are likely to outweigh the savings. I am also concerned that we will lose efficiencies of scale if services are split into smaller parcels and that GP s will only commission what they know, not what might be the best possible treatment. Wholesale competition is an ideological whim, not necessarily the most rational choice for the future.
Whenever I’ve been unfortunate enough to need hospital treatment my ‘choice of provider’ was based on distance from my current location and that alone. I am sure this will be the same the next time.
This is just a transparent attempt at spinning cost-cutting privatisation into something that apparently benefits the consumer.
Whereas this type of action caused merely frustration and inconvenience when taken in regards to the rail service or BT, here the lack of provision for inclusive quality service will have far more serious repercussions.
The NHS should focus on providing quality healthcare, not on competition. The role of the regulator, “Monitor”, should reflect this and promote collaboration.
The government’s “duty to provide” a comprehensive health service must be kept. Dropping this duty would erode the foundations of the NHS.
“Cherry picking” by private companies must be fully ruled out, and the mechanism for preventing it must be clearly established.
Any changes to the NHS of the scale currently proposed should be trialled in small areas for several years first
Any new commissioning bodies should be transparent and accountable. They mustn’t be allowed to meet behind closed doors. Patients and other health professionals must be represented as well as GPs.
I believe that competition has no place in the National Health Service. It will end up being “cheapest is best” regardless of quality. What patients need is expert guidance from their GP as to the BEST treatment, not that which coss the government least.
I am unconvinved by Andrew Lansley’s claims to be listening to vociferous complaints about his plans for the NHS. It is not only that he is trying to change too much, too quickly. All the signs are that he is undermining the “welfare state” version of the NHS in favour of more privatisation.
It is utterly ridiculous to expect busy health care specialists, especially GPs, to devote time to competing (as they will have to) for resources and access. Patients do not need to be forced to chose (as they are already now) but directed to excellent local, regional or national services. Choice for the sake of choice is not progress. That is, we want more than the right and ability to chose choice. We want to be offered an improved, less bureaucratic, and less privatised NHS. Cut out the nonsensical competition. Centralise the delivery of resources to local, regional and national providers.
Where the NHS has been damaged it had been by a crazy mix of Thatcherite obsession with “choice and competition” (if sometimes in its Blairite forms) and over bureaucractisation. The rhetoric of “patient choice” flies in the face of medical expertses. Even where people object to the nonsense of medics being disinterested in patients’ opinions about their conditions, we’d rather medics got on with telling us what the best solutions are are than faffing about offering choice among competitors. Let them do the job we expect them to’ve been trained to do.
I am writing to register my deep concerns about Andrew Lansley’s NHS proposals.
For example, I am very concerned that the legislation proposes to remove the Secretary of State’s duty to provide a comprehensive health service. I think the duty to provide a comprehensive health service is crucial and should be retained.
Any new commissioning bodies should be transparent and accountable. They mustn’t be allowed to meet behind closed doors. Patients and other health professionals must be represented as well as GPs.
The government’s “duty to provide” a comprehensive health service must be kept. Dropping this duty would erode the foundations of the NHS.
Choice is something that works for people with the time, energy and capacity to weigh up options. For the rest of us we want confidence in a good standard of healthcare when we are unfortunate enough to need it. As for competition, I don’t understand the assumption that competition automatically leads to genuine improvement, rather than a load of different providers chasing the same set of targets. So I’d just rather we invest in what we’ve already got.
The problem with competition is that it favours big, non-specialist companies. This has happened with the NorthWest Hub, where big companies have come in to offer one-stop contracts at ridiculous prices. So small specialist, skilled companies, who know their communities well, are priced out of the field. This has already caused problems with poor provision of interpreters to police services.
I work as a freelance sign language interpreter and am aware that big spoken language interpreting companies (some with not very good reputations in how they treat and pay their staff) are getting the interpreting contracts to provide interpreters to hospitals and police. But the contracts do not provide for adequate pay to interpreters, and their targets for fulfilling a certain percentage of bookings are overall rather than per language group. So if one particular minority language group receive NO interpreter provision whatsoever, the company can still meet their target.
In Nottingham City and Nottinghamshire, the NHS now have an interpreting contract with Pearl Linguistics. The sign language interpreter provision used to be via Nottinghamshire Deaf Society’s Nottinghamshire Sign Language Interpreting Service, a specialist service that knew its community well and knew the kinds of questions to ask. It is staffed by qualified sign language interpreters and was also able to provide deaf awareness training if NHS staff required. Pearl Linguistics do not have this expertise and now that they have the monopoly in this area, they are driving prices down. There are also concerns that some spoken language interpreting agencies are employing staff with NVQ Level 2 or 3 in British Sign Language – these are staff who have the equivalent of a GCSE in BSL and NO interpreting training, so no awareness of boundaries, professional issues, medical jargon, safeguarding issues etc.
So essentially the ‘competition’ is aimed at making it easier for the purchasers in creating a one-stop shop; choosing the cheapest option possible irrespective of quality; eradicating the small-medium sized service providers who have specialist expertise and strong community connections.
Added to that, the consumers who benefit from the interpreting services lack the knowledge and assertiveness to make complaints about the quality of service. I fear that the situation will only be redressed when safeguarding issues arise.
I am a taxpayer.
My family and I have used NHS services, private medical services supplied thru the NHS but paid for by BUPA and private medical services we have paid for by ourselves.
Unfortunately, we have good and bad care from all the providers! Money does not buy the best!!!
I think it is very easy to asume that private care is best from a patients point of view because it affords a higher degree of comfort and there are shorter waiting times. But these are not measures of medical quality! Similarly, a slower NHS where patients are in large, impersonal wards does not imply that medical care is bad.
So how can we, as patients, make a choice? Doctors and surgeons do not undergo annual tests so we can’t compare league tables of results as we can for schools (and don’t get me started on the choice we have as parents in that sector!!!)
As many have already said … we would like to go to a healthcare provider that is nearby, where the medical care is the best the science world can offer, where we feel comfortable, can eat at least as well as we can at home, where it is clean and safe and where we don’t have to pay!
Why don’t we review the care that we as patients actually receive and match the procedures that the NHS can and should provide against what is needed. Why not ask us the patients!!!
As has been said we have been asked about AV and have had a national census. Surely we can do the same kind of research into our needs!!!
I think competition is a wholly inappropriate way to run the NHS. As some commenters have said already, quality of life is also to do with the services which are close to hand. Recently I have had to choose a clinic for a procedure, and despite great results in Brigthon, I decided to go to Bath, because it was the closest to my house and would disrupt my and others lives least. Choice is an illusion and a tyrrany. Time is the most precious resource the average householders in the UK has – and time spent with family and friends does a great deal of good for our health and general resilience.
Handing different disciplines to different companies will lead to drawn-out commissioning procedures and constant fear of the incumbant that they will not get the same contract the next year – in my experience of large government contracts, a lot of money is wasted on BD or business development of those companeis who are not paying attention to the contract they already have. These companies will also need to make a profit for others. With NHS services already at breaking point where is this money going to come from?
My father was in intensive care recently and the nurses were very unhappy and spent so much time looking after themselves, each other and the ailing equipment that they simply didn’t realise my father couldn’t reach is water and food.
This privatisation breaks my heart and I know its the wrong thing to do.
The patient doesn’t need competition, they only need good healthcare, the
one right choice. Forcing the NHS to focus on competing rather then
patient care will be to the detriment of the service and patient care.
Obviously there needs to be a way in which services are accountable but I do not really understand why there is so much onus on patient choice being the driving force. I do not know anything about medicine. If I have a medical problem I want to be in a position whereby an expert, employed by the NHS, decides for me what is the best course of action. How would I know which would be best one when I am not trained?
I am concerned that bringing in competition will mean that services are less likely to work together and also that key resources for frontline services will be siphoned off for the expensive business of commissioning whereby those responsible will need to take time considering all bids and NHS services will take up time writing those bids.
It is far better that an independent body, with the knowledge and expertise necessary, NICE, for example, oversees the work of NHS services and ensures they are accountable.
Most people dont have time or expertise to pour over websites comparing services.
The original concept of the welfare state was much like a club. You pay when you can via National Insurance so that in times of illness or unemployment you are able to maintain your standard of living, Get the country back into full employment and get rid of freeloaders flooding our country from EU states and much beyond. They have no intentions whatever of contributing but claim their “human rights” for care and attention.
Competition for care providers will make for a third world standard of health care and private company shareholders rich at the expense of the patients they are supposed to be careing for.
I think this bill should be scrapped, we did not vote for a total reorganisation of the NHS, no political party had this in their manifesto. Satisfaction in the NHS is at a record high. The NHS, as a publicly owned resource which offers equal access to local facilities and values public health as being too important to place in the hand of the market, is one of the few things this country is rightly proud of. We do not want competition in health, we want quality at a local level and equal, local access to publicly owned facilities. We want politicians who are accountable to us about the funding and prioirities of our NHS. Competition will exacerbate existing public concerns about a postcode lottery. Putting GPs in charge of commissioning is a terrible idea. When GP funding holding was previously introduced, the amount of administration which had to be done by each surgery or group of surgeries was enormous, it did nothing to improve the quality of services. Services have improved over the past decade because funding of the NHS improved. The private sector are already over involved, ripping us off with PFI payments to cover the costs of not investing upfront in new hospitals with public money. This privatisation of our NHS has got to stop. In Scotalnd the private sector are being squeezed out of the NHS because there is the political commitment to the values of publicly owned and publicly accountable public services.
As many other posts have said, competition is not what we want in health, the NHS is not yours to sell.
The concept of ‘choice’ here is either facetious, deceitful or deluded. If I want to catch a train from Chepstow to Gloucester I have the choice of catching a train from the company that operates this route or walking. Most NHS patients will be in this position. There is no parallel service for the end-user to select, no two trains running side by side, one obviously faster and less likely to derail than the other. The denationalisation of the railways was not a success for anyone other than companies that made big profits out of it. The same will apply with regard to ‘choice’ and ‘competition’ in health service provision.
I wonder which health service provision company Lansley will be directing if these plans go through?
I hope this really is a genuine listening exercise, because if the comments above are anything to go by then the vast majority of people agree that we do not want the proposed changes.
Most of us seem to agree that allowing private companies to cherry pick parts of the health service will weaken the NHS and will lead to patient care coming second to profit making.
We don’t seem to want choice – we would prefer a good local hospital. And when it comes to our health, we want co-operation not competition.
So I hope Mr Lansley really is listening, because if he is there is no way this bill can go ahead as it is.
The beauty of the NHS is that it is owned by it’s users, the British public. With private healthcare companies it will be owned by it’s shareholders. Some of whom may not even be in this country and so will have no concern over quality of care.
If the NHS is publicly owned we can vote out those who ultimately manage the NHS.
Competition is not a panacea for the NHS and would most likely bring many more problems than it would solve. Competition in the rail network has given us the lowest safety standards and highest ticket prices in Western Europe and the cost of negotiating contracts runs into hundreds of millions of pounds every year – money which should be being spent on the core service.
The Government clearly wishes to privatise the NHS and take billions out of the service in profits for large private companies – again, money which should be being spent on the core service. This is ideologically driven and wrong.
Hiding behind the concepts of choice and competition to further privatisation plans is misleading and disgraceful.
There are very few areas in healthcare where choice of provider will improve quality, We just have to look at the privatisation of railways and part-privatisation of London tube to see the get a glimpse of how ‘choice’ does not equate with quality. The issue is not patient choice, but quality of care and practice, and only public investment can provide secure that. GPs in particular need more time freed-up to attend to their patients, not on commissioning services.
Any idea of “competition” as an improving factor in the NHS is not going
to benefit those in need, or anyone, except that of capital. Everywhere where market priniciples are brought into the functioning of institutions (like Health) it concentrates capital in the hands of ever-fewer groups and individuals in the who possess the most capital–It’s basic free-market economics, according to which these proposals are obviously changing the NHS.
“Choice” of healthcare provision will replace “right” to healthcare.
These proposals are disingenuous, wrong, and contra to the notions of welfare that many in this country have worked long, hard, little and briefly, their whole lives or a few minutes to preserve.
Mr. Lansley should resign and take these proposals out of government with him.
Kindly requested, of course.
I don’t think choice is necessarily a good thing. I just want a good local service from my GP and hospital I don’t want to choose between providers or travel too far. I want to get to know my health providers and build a realtionship of trust.
The current patient choice agenda has not driven up quality because very few people are able to accurately research hospital providers and do not want to travel large distances. Therefore, the emphasis should be on achieving high quality care locally and ensuring that where a person lives does not dictate the quality of care they receive.
If this is not achieved that the result is likely to be an increase in health inequalities because those that are able and can afford to travel will do and those that are unable to travel such as the less well off and older or disabled or those with childcare committments will have no choice but to be treated locally.
I have fundamental concerns about these proposed changes to the NHS and I think Andrew Lansley needs to go back to the drawing board.
For example, I am concerned that proposals to make competition the priority within the NHS would undermine our health service.
There are only 3 points I would like to make:
1. Doctors should not be responsible for managing accounts withsuppliers, dealing with contracts, or any other essentially business management and admin tasks. Doctors are highly trained specialists in health care – this single skill and duty should retain unique value unsullied by having to spend time managing the local healthcare network.
Doctors should work in conjunction with specialist managers – as they do now, I believe.
2. I object entirely to the mantra ‘introducing competition into the NHS will raise standards’. For me, this is entirely ideological. Competition is not the only way to drive standards, and tends to produce a culture of cutting costs and undermining opponents etc.
Competition skews the priority of the providers, engaging them in a market battle with competitor agencies, as opposed to focusing on the quality of the service ie providing healthcare to the best of their abilities without feeling threatened and stressed out by being in some kind of health care gold rush/rat race.
Collaboration is the key. And the ‘state’or government is the facilitator of this collaboration. Healthcare should really have nothing to do with competing interests. It is in all our interests that it is good, and the governement should retain their duty and responsibility to provide this.
It is Conservative mantra that the state is negative and should be reduced, but in fact the state can be positive if it is given such regard. If it is given value, if it takes on its duty to care for the citizens.
I will only ever vote for a government which says ‘healthcare is essential and too important to open to market forces, profit motives or unnecessary competition.’
3. Choice – the goverment talks of choice as a positive in healthcare,as if what any patient lacks and really desires is a choice of healthcare providers.
Well, I totally disagree. All anyone wants is a trusted healthcare provider, not to be forced to evaluate different brands and select the best based on a series of reviews online! If you are seriously ill, all you want to know is that you will be taken care of, not to fear that by making the wrong choice of provider you could end up writing your bad review of them from beyond the grave!
If construed effectively, if ‘spun’ appropriately, the NHS could be a highly valued, governement run trusted British institution which is admired throughout the world and marvelled at for its ability to retain central human values unsullied by the market place.
Please do not introduce any more competition into the NHS. I cannot vote for it.
I strongly oppose Andrew Lansley’s plans for wrecking our NHS.
We need to keep private vulture ‘healthcare’ companies out of our NHS.
There is hardly any public support for these proposals – 99 per cent of
nurses are opposed, as is the BMA and the Royal College of Paediatrics and Child Health, and virtually every other body representing those who actually work in the NHS.
Children’s health services in Britain are in danger, says the Royal College of Paediatrics and Child Health. They point to the financial crisis, large-scale workforce pressures in many inpatient paediatric units, poor health outcomes for the childhood population, and inadequate provision in many aspects of children and young people’s healthcare. (See Wellbeing and Child Poverty: Where the UK stands in the European Table? (Child Poverty Action Group, spring 2009) available at: cpag.org.uk.
See also Professor Sir Ian Kennedy, Getting it right for children and young people: Overcoming cultural barriers in the NHS so as to meet their needs (Department of Health, September 2010) available at dh.gov.uk).
In UNICEF’s recent study of children’s well-being, Britain came 21st out of 21.
In his report, Sir Ian Kennedy called children and young people’s healthcare a ‘Cinderella’ service. It is the College’s view that unless this crisis in paediatric services is addressed the health of Britain’s children and young people will continue to suffer and it will not stand by
and let that happen.
In its response to the Health and Social Care Bill, the College’s President Professor Terence Stephenson said, “we have real concerns about the rationale for the reforms, in that they risk undermining partnership working across children’s services and may fracture continuity of care, particularly for children with long term conditions or specialist or complex healthcare needs. … Market-based competition in health without expert collaborative commissioning will undermine links between professionals, leach expertise, reduce service availability and increase waits. There must be safeguards in the Bill to ensure that services for children, which may not be lucrative enough for competitive market improvement, do not suffer.”
The move to clinical outcomes rather than process outcomes is welcome but probably aspirational. Clinical outcomes are much more difficult to measure and collect which is why process outcomes have been used as proxys for these. We may end up with much more beaurocracy than at the moment. Besides who wants to wait on a trolley for more than 4 hours in A&E? Surely that is an indicator that slick processes are in place. We probably need a combination of both process and clinical outcome data to really improve services. I just don’t see how that can all be collected and how GP commissioners will have the time and inclination to interegate the data and ensure providers are delivering on all accounts.
The idea of introducing competition in the NHS will make it fundamentally unfair. A good uniform service would be ideal, at the moment we do have something rather close to this. My fundamental objection is that when you introduce competition on the provider’s side then there will be competition on the consumer side to get the best service. Who will get the best service? It will be those with connections and money, people who can exploit the loopholes and afford to travel for care. This is privatization and it will favour the rich and privileged, a typical right wing policy.
The idea that the private sector has all the answers is flawed, best we not forget which sector caused the recent recession.
Dear NHS listening exercise,
I am writing to register my deep concerns about Andrew Lansley’s NHS proposals.
For example, I am very concerned that the legislation proposes to remove the Secretary of State’s duty to provide a comprehensive health service. I think the duty to provide a comprehensive health service is crucial and should be retained.
The NHS should focus on providing quality healthcare, not, under any circumstances, on competition. The role of the regulator, “Monitor”,
should reflect this and promote collaboration.
The government’s “duty to provide” a comprehensive health service MUST be kept. Dropping this duty would erode the very foundations of the NHS that have served this country so well since 1946.
“Cherry picking” by private companies MUST be ruled out, and the mechanism for preventing it must be clearly established.
Any changes of this scale to the way in which the NHS operates should be trialled in small areas for several years before being rolled out
nationwide.
Any new commissioning bodies should be transparent and accountable. They mustn’t be allowed to meet behind closed doors. Patients and other health professionals must be represented as well.
The proposition of private enterprise and “competition” within healthcare is completely inappropriate without heavy and intense regulation which this current government would be ideologically opposed to.
Healthcare is not like purchasing homewares and there are severe limits to how “choice” can, realistically, be realised for patients (for example, emergency care). The previous, Labour government’s opening up of choice in terms of where patients can seek treatment (within the bounds of the NHS system) was an excellent idea but represents the extent, to my mind, of what is feasible, desirable and beneficial to the public with regards to competition. Beyond that, competition creates a commodified field which ignores the actual needs of patients and instead becomes a money-printing factory for private health providers akin to the situation in America which costs more in GDP to that country, than on a comparative basis with the UK in real terms (20% vs 7% respectively).
Ultimately, patient choice should be about the best healthcare within the NHS, not about “how can we sell this to lowest private bidder?” (as seems to be the loaded question here). I feel as it not been posed to NHS-users or staff as a question if they do or do not want private sector involvment, a far more fundamental conversation needs to take place in which the government is a little more honest about its’ ideological reasons for wanting to involve private capital rather than spinning it as a “necessary” change. No alternatives have been posed aside from private sector involvement and the public/stakeholders are left with a Hobson’s choice that will affect many generations to come.
Competition being introduced into the NHs is in effect privatisation. It will in signal the end of the NHS, which is what the Tories have been trying for decades to achieve. I for one do not wish to see this happen. Others have already commented on the disasterous effects of privatision for the general public, in energy, water and railways. We have seen multinational corporations asset strip our once thriving public utitities and the net result has been for a worsening of services for the public whilst the business leaders have grown fat our expense.
Like education there ought to be a way of chopping off the hands of those potliticians and senior civil servants (surely a contridiction in terms!) who wish to dabble with our public services.
The NHS suffers from many faults, most of which should be laid at the door of thatcher but which have been perpetuated by both sides of our political arena, including the establishment of too many managers posts and posts where the incumbent has created a career out of attending meetings for meetings sake. Those faults need to be sorted out by streamlining out the costly chief executives of PCTs and the like.
PPI was supposed to allow local people to have a voice in the NHS, but that never worked and the fragemented way of splitting the NHS did no favours either. What is being proposed in the new consortia organisations seems to me to be like turning the clock back to the locality PCT’s.
CAMERON, TANSLEY and your acolytes – the message is clear – keep your interfering hands off the NHS and just ensure that sufficient funding is provided to provide ALL of the population who have been contributing to the NHS over the past 40 years or more, with the health services that they have been led to expect. Divert some of the funds away from foriegn wars and foriegn aid and back into the instituions of this country for a change.
The private healthcare sector should not be able to cherry pick the
‘standard’ proceedures, leaving the NHS to clear up the rest. The NHS is the jewel in this country’s crown. Yes, it needs to be improved, but
Lansley’s plans are defined by the strength of the private healthcare lobby firms (from swish offices with purses wide open), not by the wish to improve what is an equitable system of healthcare which the majority of people are happy with.
Improve the NHS – yes. Ditch the privitasation agenda – yes. Go back to the founding principles of Bevan and think again.
I think that the NHS works well on the whole as it is – I agree with many others who said the private sector would cherry pick the more lucrative and short term patients to the detriment of the NHS who would be left with the more difficult and long term patients. I agree that managers should be paid less than they receive currently and this is probably where major savings could be made. I feel safe with the NHS and I’ve had three major surgeries and after care of broken foot and broken ankle in the last 4 years with no complaints about the medical treatment of my conditions. Long live the NHS as it is.
The economics :-
With just the NHS and public funding
Cost of care=cost of buildings+cost of materials+cost of ‘coal face’ staff+cost of providing materials+cost of administration
With competition to provide services …
Cost of care=all the above plus profit margins for the providers, plus cost of tendering etc, plus cost of keeping ‘failing’ hospitals running until the point they close, and the cost of closing.
The areas where private tendering have come in, such as cleaning, have resulted in dirty loos, and wash areas, and the appalling lack of care in the area of feeding etc There is no control by the hospital on the quality of staff used to do these tasks.
Surely it is better if the actual problems in the NHS are addressed specifically, and that the things which are wrong are put right by people within the system, for example central purchasing, buying drugs in minimal packaging etc with one person responsible for over-seeing all procurement who can listen to both the doctors and the nurses and the people doing the ordering.
My grandfather was a GP and he opposed the foundation of the National Health Service, but once it was in place, he totally changed his mind and strongly believed it was so much better for everyone. There are few people alive now who were old enough to remember the time before the NHS who can tell us what it was like to not have care available when they were ill, and to watch their families struggle on in pain, or die; but we only have to look at the poor areas of the US and Africa and India and we see the consequences.
I would urge the Government not to throw away something which the general population are very satisfied with.
Beeching thought he was doing a good thing when he got on his hobby-horse and shut so many railway lines and stations, don’t let the same thing happen to the NHS under this government or I am sure that our children will have real reason to regret it and to blame us for not stopping it from happening.
It is imperative that there is choice but it needs keeping in the nhs NOT private.
What I want from the NHS is not an over complicated system of service providers, but the healthcare system which we have all paid for over the last 63 years. Please stop playing economics and politics with our NHS and just fund it properly through our NI contributions, it is that simple and easy.
I want my GP to choose the best healthcare available – I do not want to choose as a patient. I want the GP’s choice to be guided by medical not accountancy reasons.
Healthcare is NOT a suitable area for market-led economics, particularly where private profit from the public purse is the inevitable outcome. It will not lead to patient health benefits but rather to the benefit of individuals speculating their wealth in the private sector. The drainage of any funds from the public healthcare sector to fund alternative private or Social Enterprise sector treatment will hit the NHS in overall financial performance where positive cashflow is the key to a continually improving developing national service. More attention to the financial management of the NHS is clearly necessary, but to scuttle the process by diverting public funds away from it in the short timescale proposed, would not help in the strengthening of the management of this vital national service. Keep the NHS as a social asset, and do not destroy it in the name of individual choice where wealth still counts more than need.
I don’t want choice. I want my local hospital to be good.
Having lived in the USA I can say my experience of the healthcare there is that it is just as good as our excellent NHS, but substantially more expensive. I had health insurance provided through my work, but many graduate students I worked with could not afford to buy health insurance because they were considered high risk (young, healthy – but the right demographic to ski and mountain bike). We are spoilt in this country to have such a wonderful service free at the point of use. I cannot see how competition would improve this service. I just want my local hospital/GP etc to be the best they can be.
Zoe, I am beyond just agreeing with you.
Elswhere in this discussion I’ve just commented on how a friend of mine had keyhole surgery on her knee in Hawaii, was billed $17,000 for it, and her insurer declined to pay out, just before Conservative MEP Daniel Hannan went public in America and rubbished the British NHS on Fox News.
As an ex Local Authority Procurement Manager of 25 years and now working as a consultant with Small & Medium size companies in the private sector on their PQQ & Tender submissions I am concerned that the proposed set up will not understand what it is like to be the other side of the fence – I have been in consultancy since for about 7 months and have personally seen 23 sets of Tender documents from Public Bodies all over the South East and Midlands and these are the kind of things I am finding:
1. Adverts left still in specialist journals after the closing date
2. Some PQQ & Tender documents for large contracts (in excess of £2.5M) so sloppy in their presentation (tracked changes left in, cut and pasted information from old websites, no proper criteria setting etc) I am amazed they were actually sent out,
3. The overall requirements of the contract are not clear and the contractor is being asked to give information that appears to have no relevance to the contract,
4. PQQ’s withdrawn (after contractors have been advised that they were successful), and then re advertised in a different portal,
5. Tender documentation that is not complete,
6. Requests for huge insurance cover for very small contracts,
7. Pricing schedules that are not consistent with the requirements of the contract
8. Q&A’s not being responded to on time, and sent out without anonymising the details.
All of this type of behaviour costs the potential contractors a lot of time and money, and I know it costs the various Public Bodies a lot in time and money too. It has the potential to cost the various Public Bodies money in legal fees if a contractor wants to follow up on EU and UK contracting rules. Mostly it does not give contractors any faith in the Public Bodies ability to understand what they want to achieve and how the contractor can meet the requirements of the contract.
I have recently had excellent service from Moorefields and would recommend that their system is excellent and should be used as best practice.
Also recently my son was admitted to Queens Hospital in Romford, and my daughter in law was admitted to the same for the birth of her third child, the service in both instances was appalling. Admission and release taking up to 12 hours, dirty floors and facilities, elderly people being left food they were unable to eat (despite the large notice on each bed saying to feed the patient), notes with private information left open at the nurses station, large numbers of staff on the ward but no one to answer the phone or the ward doors (which were locked). The general attitude of the staff from Doctors down was that they were doing you a favour, lets get the attitude and the basics right before we start throwing the baby out with the bathwater.
Dear NHS listening exercise,
I’m making this submission to the NHS listening exercise because I have
huge concerns about the proposed changes. I think it’s time to drop them
and start again.
The NHS should focus on providing quality healthcare, not on competition.
The role of the regulator, “Monitor”, should reflect this and promote
collaboration. Competition is anathema to care.
The government’s “duty to provide” a comprehensive health service must be
kept. Dropping this duty would erode the foundations of the NHS.
“Cherry picking” by private companies must be fully ruled out, and the
mechanism for preventing it must be clearly established.
Any changes to the NHS of the scale currently proposed should be trialled
in small areas for several years first
Any new commissioning bodies should be transparent and accountable. They
mustn’t be allowed to meet behind closed doors. Patients and other health
professionals must be represented as well as GPs.
The Government is not listening to experts and patients as the vast
majority express their horror at this implementation of a policy which lays the NHS wide open to predaTory private companies.
The idiotic waving of the ‘ choice ‘ banner must stop.
Quality and availability are required, not choice.
True care and the pursuit of profits first are incompatible.
Please take your appalling American led ideas away.
They make me ill.
Mr. Lansley
Where will the profits that these companies make come from?
If there is too little now, how can they take their profits unless the
services suffer?
Why are you creating yet another means of funnelling the people’s money
into the pockets of these companies who have NO public service ethos and
are driven to produce only wealth for their shareholders?
Need reminding already ?
” “PM aide: health reform is chance to make big profits”
“Mark Britnell, who was appointed to a “kitchen cabinet” advising the prime
minister on reforming the NHS, told a conference of executives from the
private sector that future reforms would show “no mercy” to the NHS and
offer a “big opportunity” to the for-profit sector.”
Lovely.
Pause, listen and reflect………….and then show “no mercy” and “make
big profits.”
Please stop these unwanted and damaging ‘ reforms ‘.
I have several fundamental concerns about proposed changes to the NHS. I
think it is time to go back to the drawing board.
For example, I have not so far been reassured by what I have heard from the
government on the issue of “cherry picking” of NHS services by private
companies. “Cherry picking” could be extremely destabilising to our health
service, and there must be a clear plan and legal mechanism to rule it out
Competition means cherry picking what services to provide, and disregarding the unprofitable ones. We’ll end up with more cosmetic surgery and less care for the long term sick or elderly. People are not a production line.
Choice? Who gives a damn about choice? All I want to know is that when something is wrong with me, I can get treated locally and efficiently and properly. Few sane people like hospitals anyhow.
Many of the companies earmarked to provide “competition” have appalling records in the USA. America is the last place we should be emulating for healthcare. Or anything else, for that matter.
I am very concerned about the “choice and competition” agenda. These concepts have often had negative effects on public services and there appear to be no effective safeguards in place to ensure the NHS doesn’t suffer further.
The Care Quality Commission report publicised yesterday, raising concerns about the standard of care in some Trusts, demonstrates some of the problems with private sector involvement. For example, in many hospitals meals are provided by a contracted private sector partner: the individual workers distributing food and drink don’t have the investment in patients to ensure their needs are properly met, so patients lose out.
Most people I speak to do not want “choice” and “competition” in hospitals, schools, colleges, the fire service, the police… There is no evidence that competition would improve the NHS and plenty of examples from other public sector organisations where is has been very damaging.
My family and I want our local service to be as good as it can be. Private sector organisations exist to make money for their shareholders. They don’t have to care about people, pupils, patients, parents, carers, or anyone else unless it is in their interest. Please do not allow private companies more involvement in the NHS.
In my view, any reforms of the NHS should focus on ensuring that any targets are properly thought through to benefit patients; to ensure that local trusts can commission effectively and can expect high standards of any external providers and proper measures if their contractors aren’t up to standard; to ensure that proper training and management structures are in place to ensure all NHS staff are performing to their best ability and getting the opportunities they deserve; to ensure that healthcare professionals can do what they do best, supported by professional managers who understand the needs of the service and care about patient outcomes; and ensuring that improvements can be implemented across the whole NHS, based on the best up to date research.
Given past efforts to introduce ‘competition’ into areas of public services and life and their abject failure to deliver on their promises I have no confidence of a better outcome for the NHS. These proposals really seem like more of the same. They are both hasty and ill conceived and I believe will cause irreparable damage to the service we all rely on.
These proposals are opposed by the vast majority of both the professionals within the NHS and the general public, surely this factor alone should be more than ‘pause for thought’ by the government?
GP’s do indeed have insight into their patients needs but this does not make them the right people to ‘do’ the commissioning. I have many years professional experience in procurement both in the public and private sectors and personally do not believe that GP’s either have the necessary experience to achieve the best results or, where the skills do exist in their consortia their time spent in these activities would be an unwelcome burden, distracting them from what we pay GP’s to do. They are extensively trained in medical practice not procurement.
The likely outcome of this is not GP’s commissioning at all, but a giant, fragmented new low level of bureaucracy being created in the NHS unable to drive value by leveraging the marketplace through aggregation.
I am also concerned that new commissioning bodies will not be properly accountable and will not operate in a transparent way. GPs should not be able to take decisions behind closed doors, and other stakeholders including patient groups and other health professionals should also be involved.
Why do successive governments obsess about giving us ‘choice’? I don’t want choice. I just want a clean, free at the point of use, reliable, compassionate NHS which has no interest whatsoever in making any kind of profit.
Why is that so difficult for politicians to understand?
If democracy still means anything stop this idiotic revamp of the NHS .Why not look at ways to reduce the unending levels beauacracy which have invaded the system. The number of press officers alone indicate a need to cover something up
We don’t need ‘choice’ – when someone is ill they need to know that local services are up to the job, and the only way we can achieve this is by having centralised, streamlined governance, not a fragmented system where different GP consortia can choose to provide services… or not.
I have seen the results of competition and the profit motive in the United States: profit takes priority over care; health is a byproduct. Decisions are made by managers, not clinicians; hospitals are understaffed, and clinicians are demoralised. This is not a system to envy and it should not be recreated here.
When you are ill you want the best service without having to worry about whether you have made the right ‘choice’.
Yes, keep on trying to make the NHS efficient, flexible and sensitive to people’s needs, but a market model will always only follow the profit motive in the end.
We need to cooperate not compete
“Which are the types of services where choice of provider is most likely to improve quality?”
There is no evidence that choice of provider improves efficiency or quality in health care. What is the evidence-base for your proposed changes?
“What is the best way to ensure a level playing field between the different kinds of provider who could be involved?”
Irrelevant. Services should be provided by the NHS as part of a coherent, unified and integrated health service, which is a far more efficient model. Management and administration costs in the NHS rose dramatically with the introduction of the internal market, and will rise further with the fragmented and uncoordinated free-for-all planned in the Bill.
Question: would Tesco be more or less efficient if they were broken up into hundreds of smaller organisations forced to compete and/or buy services from each other? Would their management/admin costs rise or fall. What would happen to the quality of the service?
“What else can be done to make patient choice a reality?”
Patients do not want choice of provider. They just want good local services. The choices which are most important to patients involve what their treatment should be rather than where they have it, and these decisions should be arrived at through sensitive discussion with trusted health care professionals who have the patient’s best interests at heart rather than their profit margins.
I have not seen any evidence that competition either reduces costs or improves patient care. The example of the US health care shows the harmful consequences of “competition”, allowing any willing provider to sell their health services to docters and treating health as a marketable product rather than as a public good.
We are right to be proud of our National Health Service. Satisfaction levels are at an all time high. By all means improve its management through incremental changes but lets not have any more radical top-down revolutions. They don’t work.
Personally, I don’t want choice and I don’t expect a perfect service. I want an excelent quality of treatment as and when I need it. I don’t want people making profits out of my taxes and I don’t cherry picking and a reduction in quality in pursuit of profit.
The difficulty with competition is to do with differing overheads and costs. NHS providers who cover elective and emergency patients have to be in a position to respond to varying levels of need. If a private organisation is only filling an elective need, then the overheads in terms of staffing, equipment, and many other costs will be much easier to regulate. this makes a mockery of saying that any ‘other sector’ provider will not be allowed to ‘undercut’ NHS prices.
I am particularly concerned that the proposal puts so much power in the hands of GPs. GPs are generalists and do not have the expertise of consultants. Where I live it is almost impossible to obtain an early appointment with a GP and patients are too often fobbed off with a nurse who cannot diagnose. Given the attitude of the local GPs my concern in giving them more input into the NHS is increased. GPs do not have managerial experience or experience in the tendering process so they would need to buy in the services of external providers. Is this change? Too much money and responsibility in one group is dangerous.
We are seeing some disgraceful audits of hospitals concerning the elderly – we have also had the saga of dirty hospitals and the dangers that has posed for patients. Patients want clean hospitals, qualified and considerate staff who behave in a professional manner. They also want their treatment/operation within a reasonable time. The government proposals do nothing to address patients concerns. A monstrous proposal has been dreamed up by people who have no idea about management or health care. It does not need a rethink but cancellation of the proposals and for government to address the real issues of providing professional care and the emplolyment of responsible, professional people who really do care about patients. The current situation in some areas of the NHS is a disgrace and the government proposals will make matters worse.
not happy with competition-has never worked yet. causes fragmentation & confusion. choice is fine within nhs resource. what about eu competition law?
worried is privatistaion by back door & this is totally against my principles.
my patients are happy with the choice of local hospitals. any private provision has vetos on obese pts & mental health patients- so if you are at all difficult the good old NHS has to deal with you-cherry picking as always by private sector. destabilises the whole health care sytem. private companies are alltruistic & not thinking about profit for share holders??- i think not
As a patient, I would like to add my voice to those seeking a strong emphasis on cooperation and integration of services rather than competition and fragmentation. As with the police and armed services, the prime competition is with the enemy, with health the enemy is illness and disease. When the enemy is complex and unpredictable, the top brass should pull together to focus their efforts on improving technology, skills and strategies to fight it, not being distracted by or divided by commercial rivalries.
Any new policy towards the NHS should have started with a strategic review of the current purposes and requirements, followed by wide discussion with the public and medical professionals and only then concluding with proposals for change. This Bill seems to be one person’s top-down plan to play around with structures rather than to focus on needs and outcomes of the service. A bottom-up procedure would start with patients and their ailments and work up to what service is needed to treat them. Now that the consultation has taken place, is not too later to re-write the Bill based on the ideas and information supplied rather.
The Bill does not seem to address the one of the most important issues facing the NHS today which is the public’s confidence in the quality standards in hospitals. With responsibilities being devolved and localised, the need for a strong oversight of quality is vital. I think the Bill should give the Care Quality Commission the teeth to deal quickly and firmly with any failures of quality. This is best done by allowing rewards to success and sanctions or replacement of failed leadership at the top of a trust or consortium, rather than financially penalising the organisation and their patients.
Some existing problems seem to be due to too little management rather than too much. Managers’ prime task must be to ensure patients receive the most effective treatment, which includes hygiene, nutrition and psychological care. However when managers have their time and energy taken up with re-structuring and financial targets (as in Staffordshire Hospital) they take their eyes off the ball and standards fall. What measures are being put in place to ensure that management and clinical time and focus are not reduced during such an unprecedented re-organisation?
I cannot talk with big words, medi-babble, politico-babble, economics-babble etc. I am simply a patient who thinks care has deteriorated through transfer of responsibility of my condition to GPs.
Let me tell you what happens to care, when GPs who do not have the qualifications or experience take over patients they are ill qualified to care for.
Under the Labour Government, Diabetes care was farmed out to GPs. I believe GPs were paid extra to do it, after all they are private providers not NHS staff. I was told off by my GP practice for refusing to see them, it was clearly stated that the practice would lose money if I did not attend clinic there. That does not give you confidence, if you believe you are just a money earner for the practice.
The care of my Type 1 diabetes was “transferred” to my GP practice, after over 50 years of living with my condition under consultants I trusted completely. I was not asked if I agreed to the transfer or informed by hospital or GP, just my appointments with the consultant I trusted suddenly stopped. Patient choice was totally absent, who really thinks patient choice is paramount when money moves with the patient. If my GP really cared, they would have wanted to see me re my diabetes before the transfer of funds occurred, but never a beep from a GP before this happened.
Since then I have only had routine tests that are given to all diabetics. These tests have to be done for the GP to earn their money from my care, they tick boxes when each test is done in order to get the cash. I see numerous people, no joined up care with one person supervising it. The diabetic nurse “specialist” says that she is not experienced in insulin therapy, if I ask the GP anything he has to ring up the consultant for advice. I left one practice after they introduced the policy that any nurse could deal with diabetics, I was sent to a respiratory nurse for one appointment – she didn’t have a clue, but they will have earned their cash as boxes were ticked.
I know this has happened to others throughout the country, and not just with diabetes.. Why couldn’t either Labour or Conservative governments made sure GPs were first educated to a suitable standard to look after these conditions, thats what I want from a GP if I am forced to see them..
Taking over commisioning will not make any GP a specialist, if they do not understand a condition how can they ensure optimum care. I believe cost cutting and political dogma will endanger the health and well being of patients with chronic conditions, as specialist care falls away in favour of cheaper, form ticking options.
Keep the whole of the NHS in the public sector
My “choice” would be to keep the NHS in the public sector. If I am the victim of a crime, I don’t want the choice of police officer to help me, if my house is on fire, I don’t need a choice of fireman. Similarly, if I am ill, I just want to go to my local doctor and would rather have no choice, but good service from my local doctor.
When I buy something like a car, food or a holiday, I want lots of choice and a free market. Some services are just better in the public sector and health is one of them.
I agree with this, bring back in house things like cleaning, maintenance and cooking aswell. Has there been any improvement in service or cost, with these being farmed out? Just short termism and reducing numbers of public sector workers is at the heart of this philosophy, not results.
It is really important that GPs effectively shopping on behalf of their patients remains at the heart of the reforms.
When my father was very ill 18 months ago approaching the end of his life, it was our GP who understood how difficult it would be for me to cope at home and understood how bad an experience my father had recently had at the acute hospital and how much he dreaded going back there. Our GP chose a local community hospital for us which exactly suited our needs.
Please don’t lose the original purpose of having GP consortia – I want my GP to have the power to choose – that is a more practical solution than ‘patient choice’.
It is the focus on patients within their communities and locally commissioning a mix of services around them that has the potential to transform the NHS. All professions must be involved in designing patient pathways but do not need to sit at the commissioning table – get the system right to ensure everyone is included but let GPs do the commissioning.
I do not want choice. Its nonsense and it will inevitably exclude the most needy and advance the ‘well heeled middle classes’.
I want the NHS to be the best it can be for all regardless.
Competition is privatisation by any other name. It hasn’t worked in any other public institutions that have been privatised because ultimatly private companies loyalties lie with their share holders and not patients.
Don’t mess with the NHS!
Any privatisation of the NHS would be disastrous. Please do not open up provision to “any willing provider”. The experience of other countries shows how bad this would be. Any attempt by private companies or other profit making organisations to participate in public health provision should be disallowed under the new Bill.
I DO NOT want choice or competition. I want my local health service to continue as a *** NHS. My experience of private medicine is disastrous. They are incompetent and leave the NHS to pick up the mess and put it right.
absolutely…please, do we seriously think they will take their share of the complicated non profitable patient cases, they will just cream off the easy ones and bankrupt the NHS.
My experience of private medicine was dsastrous too. I would NEVER go to a private hospital again. The NHS had to spend a great deal of its resources to put me right again.
Competition will not drive NHS Improvement. Investment in the NHS and full confidence in it’s staff will
i agree
My choice would be an NHS which is not driven by profit but by the care of people in need. If anything needs to be changed it is the pricing policies of the drug companies and the NHS suppliers who have been using the NHS as a cash cow for decades. If real supply and demand was introduced then savings on a massive scale could be realised.
I think private competition will be a good thing – look how well its worked in the private utilities – my neighbour had to wait weeks for a simple job from the water company to stop raw sewage running over the pavement – a representative from the company who came out to look at it said “good luck getting that sorted” as it was common knowledge that the company would avoid doing anything if it could. Anecdotal irrelevance I hear you cry – the point is its a fact, that demonstrates the inability to create an effective regulatory regime for Corporate entities staffed by people with no morals, under pressure to fulfill the companies LEGAL duty to put its shareholders before its customers (patients)!
Still why would we want to recycle £100000000 each year in the UK economy when we could haemorrhage it abroad though foreign corporations – Greek economy here we come. Answer I gues a few juicy directorships for guess who!
Patient choice will probably be a successful as parental choice of school –
over-subscribed schools, children force into their 5th choice miles away, covert selection – wonderful and apparently no going back!
The NHS is currently better than it has ever been – obviously time for a radical shakeup!
this is an exercise in involvement that smells of – nobody can say we didn’t listen – but oddly enough there will be so many voices and views the outcome will be what the government feels it can get away with.
the NHS as all public sector services will struggle because selfish people think individual rather than societally and competition is driven by profit before anything else.
How would competition have helped my mother secure better care?
She is currently in a ward in her local hospital. Clearly there is not going to be another one built, so the universe of choices will remain the same (unless she is to be admitted even further from home). This simple example demonstrates that choice is a cod word for privatisation – any willing privateer in fact.
What my mum needs is good quality local care. The evidence from research into the market in health care indicates that competition between providers may reduce costs but it has little impact on quality – and that is largely negative.
The NHS is not perfect – it requires an overhaul, but an overhaul to put back the care, to reduce fragmentation (my mum is still treated s a collection of bit, not as a person – how is choice and privatisation going to improve that – it won’t), to build in the generation of evidence and then use it to improve care.
It’s cooperation I want, not competition. Sharing best practice to reduce costs while improving quality is the way forward within a motivated, focused and realistic NHS. The organisation is the envy of the world, much improved from earlier times and a fantastic aspect of British life that we must preserve. We should fund it properly and demand that its management ensure efficient delivery.
These ideas put forward on choice and competition are completely ideologically driven, with no regard for the founding principles of the NHS. Its a mistaken belief that private enterprise and free markets reduce costs and improve services. Profits are the be all and end all to business and this will not change in the healthcare sector. Therefore this leads to corners being cut or prices going up as profits need to maintained.
What happens if a private provider goes bust or decides it does not want to fulfil its contract?
Skills and infrastructure will be lost and when they go, taxpayers will be at the mercy of the market. It will be the beginning of the end of the NHS.
Did the Conservatives mentioned these proposals before the election, No. Was it in the coalition agreement, No. If the Tories want this for the NHS they should stand an election on it not try and sneak it through.
Private medicine in the UK has so far survived thanks to the so called “fixed price system”. Private patients are charged a (reasonable) fixed priced for a procedure by the provider, in the knowledge that, when things become messy (and expensive) the local NHS Trust will pick up the pieces, providing expertise and facilities that the private providers do not have. For free….
Competition would therefore be fair only if NHS Trusts were allowed to charge the private providers for their assistance in difficult cases (which in turn would, I can assure you, wipe the competitors off the market).
Couldn’t agree more
Choice and competition are not needed. What is needed is a National Health Service that delivers a first class service nationwide. It is the NATIONAL Health Service, which implies an equal service everywhere, not competition, and if it is a first class service everywhere, there is no need for choice, because it means anyone can get the service at their nearest hospital, surgery or medical centre. All of Lansleys reforms are just schemes to allow the Tory party’s big business supporters to get even richer at taxpayers expense. If Lansley and the Tories truly believed in they would make sure it was a service of equal high quality everywhere
The NHS does need to be reformed but privatisation – aka patient choice is not the way. We could do with fewer managers and more practicioners.
The NHS should not be based on competition but on cooperation between the different agencies involved in healthcare. Competition encourages hospitals to concentrate on cases that are more likely to have a positive outcome, so that targets can be met and results boasted about. Cases that may require long-term care and are likely to be expensive tend to be put on hold. Everyone knows that private companies’ primary motivation is profit, and the health service should be just that, a service, not a money-spinner.
I don’t believe competition will in anyway improve NHS efficiency or patient care. For myself like for education I just want good quality health care locally.
How can I make the judgement without the training about what is the best care for my needs? I need the health care professionals to provide that information without feeling that they need to dress it up in some kind of fancy terminology to make me think that will be the best thing so that there service gets the contract. I just need my GP to be able to provide that information in the most unbaised way as possible.
Compared to other health systems around the World the NHS is very efficient at providing an effective health service. It’s only problem is that it is starved of resources, compared to what other developed countries invest in their health care.
Thanks for listening.
When surgical operations go wrong in the private sector, where do private hospitals send the poor patient? To an NHS hospital, of course!
I am writing to register my deep concerns and anger about Andrew Lansley’s NHS proposals.
The clue is in the name: NHS. It’s ours: by the people, for the people.
Whatever the inefficiencies and problems it faces, it must remain the Secretary of State’s duty to provide a comprehensive health service. The idea of dumping responsibilty for commissioning onto busy GPs who may be untrained and unmotivated or morally, poltically, philosophically opposed or even just plain incompetent is just blind dogma.
We all know there is money to be saved, but people are wary of companies making money out of their loved ones ill-health for the very good reason that the consequences of chasing profit may be much more than financial for vulnerable patients. Imagine the scandal if businesses get it wrong and people die for the want of robust, patient centred care.
Most people are also frightened by the scale and pace of this change, because it is completely untested, with dubious reasoning and scant evidence that it will deliver anything more than chaos. That spells death in a Healthcare environment.
I have grave concerns with regards to Mr Lansley’s proposals:
- Commissioning bodies should not be meeting in private and should be working with health professionals
- Duty to provide a comprehensive health service must be safeguarded
- Anything as drastic as this should be trialled first otherwise how can the government monitor its effects and effectiveness?
- There should be tight controls in place with regards to private companies
I am therefore strongly against any further action being taken at this time on this important issue.
I have rheumatoid arthritis and as I have had it from age 13 I have relied on the nhs to provide treatment for it.
The choice of private health care is not available to me due to cost and no health insurance covering pre existing conditions.
What do I need from the NHS?
I do not need my GP to commission my healthcare, he has shown little interest in my RA, prescribes antibiotics contraindicated due to meds I take, and wouldn’t have a clue how my RA affects my daily life.
Why would I want him to control funding for all my health needs?
Will that really be so much better for my rheumatologist? After all don’t rheumatologists have a problem already with GPs referring RA patients early enough?
What is my choice? Well let’s see, maybe give adeqate funding in the first place.
I have Rheumatoid arthritis…….I remember when the NHS wasn’t funded well (more than a decade ago)….friends waited 2 years for knee replacements…2 years of pain and incapacity.
In the last 18months I have had 3 foot operations, scheduled to take into account of recovery times…..will that happen with all these cuts and changes in the future?
My local hospital had waiting times of 12 weeks, and this has already increased to at least 16-18weeks.
let’s remember the election promise to ringfence funding to the NHS and that the NHS was not to changed dramatically!
Echoing comments pertaining to the grave risk of ‘competition’, I want an NHS acting in /my/ best interest not that of private practice.
I do not want “choice” in the NHS. How would I know how best to exercise it, without the government wasting further millions on unnecessary marketing communications? I want a quality medical service from skilled practicioners. From previous experience with private-sector health I believe that only NHS staff can deliver this kind of quality – if they are allowed to do so. “Choice” was a red herring introduced by T Blair. We were and still seem to be given no choice as to whether we want choice or not.
This seems to be the wrong question. I want improvements prompted by co-operation and dissemination of best practice, not competition.
There is enough choice already. It is much more important to keep services local, integrated and accessible. Competition leads to fragmentation and may destroy some local services.
It is difficult to see how administrative costs can be reduced if everything has to be tendered for or how quality can be maintained, let alone compared, without massive inspection costs.
The government are clearly centred on privitisation and fragmentation of the NHS.I am an nurse currently working in primary care and remain concerned with the ‘hurried approach’ the coalition seem to taking.
The NHS does have areas which do need improvement but that does not mean it should be dismantled.
The blurb says this is a listening exercise, lets see if they listen to the patients & professionals, and reflect on why the NHS was set up initially.I would encourage them to talk to the generation who experienced life without it.
I do not want a financial orientated system which will mean no choice for most of the population and more inequalities for the vunerable.The system I want is the one that is present yes improvements can be made but with the real involvement of patients, a wider variety of health care professional, and voluntary services
I have several questions ..what is this whole process costing in terms of professional time & money ,why are the coalition trying to reinvent the wheel ,what is the advantage of so called ‘choice commisioning’ is it really really SMART.
After working in the health care system for 27 years and experiencing far too many changes in the NHS to mention …I feel there is a hidden agenda and patient care is certainly not the central focus.
The problem with ‘choice’ is that people who are better educated and more concerned about their health will tend to make better choices. This means wealthier people. We already have a situation where ‘pushy’ patients, for example doctors themselves, see specialists earlier and thus get better care. Increasing choice risks improving care for the better educated and wealthy, whilst leaving the poor ever further behind.
The level of health inequality based on social class in this country is scandalous. We should be working to reduce, not increase it.
The majority of NHS users are happy with the service they receive. US style competition of the kind proposed is neither effective nor required. Like the sell off of public utilities under Margaret Thatcher the objective here is to give a massive bonanza to global corporations whose only interest is in profit. The principal of a health service free at the point of delivery and fair to all will disappear with this government’s policies.
The premise of the question is false. It assumes that competition between providers will lead to improvement. (Private sector competition in the financial sector has plunged the global economy into the current mess.) Private sector providers are answerable to shareholders and must deliver profits. Profitable care will not be derived from offering long-term care (patients ‘cluttering up beds’) or from complex and risky but necessary treatments. Private providers will bid for – and will accept – only those cases which will allow them to advertise their ‘success’ rates. They will operate like selective educational practices. We will have league tables. There is a very serious risk if competition is to drive a ‘market’ that NHS hospitals will lose ‘customers’ and that means income, and – since the NHS will have neither the power nor the desire to turn away patients in need – they will become increasingly responsible for the ‘hard cases’. They will appear to be, quite wrongly, ‘inefficient’, and this will accelerate a drift to private care. Moreover, to step up their profits, it will not be long before private providers will be offering basic treatment for some and privileged care with ‘add-ons’ for others – at a price. We will end up with a two-tier system, from which the NHS has rescued us since 1948. Pre-war voluntary hospitals off-loaded ‘chronic’ cases to municipal and poor law hospitals. If the private sector is allowed to receive more NHS patients than it does already, co-operation not competition must be strictly enforced and ‘cherry-picking’ must not be allowed.
It is also a nonsense to suggest that patients are clamouring for choice. They want proper care and swift treatment, and that is largely what the NHS delivers, as public opinion polls overwhelmingly indicate.
The NHS is not the government’s to sell. A sell-off should be decided by the owners, ie the voters, ie, only a referendum would justify a sell-off.
I am concerend that the NHS should focus on providing quality healthcare, not on competition. The role of the reugulator, “Monitor”, should reflect this and promote collaboration.
This question is put the wrong way round. A lot of effort has been put into creating limited competition between hospitals and between GPs. The Secretary of State should be spending more time thinking about how to promote the best care in the areas where competition is not a suitable model. These include care for disabled people, care for long-term complex conditions, community-based care linked with social care, care for children provided in partnership with schools, care provided in regional clinical networks, care for people with long-term mental health problems, care for people who are socially disadvantaged or vulnerable. These and similar areas account for a great deal of NHS activity, though they may account for less of what the NHS spends. They have to be provided through long-term partnerships, not through the short-termism of the market-place.
There is not a place to drop my comment in, so I have included it in the Choice and Competition section.
Why I am really concerned about the increased privatisation of the NHS is because of what it can easily lead to. The American situation, where with the exception of their Medicare style program, medical care and choice is determined by insurers and payroll. There are too many Conservative or Euro MPs such as Daniel Hannan who have very publicly sided with the American approach. If we have the private sector competing to provide GPs with services, it is only a short step before Free at the point of delivery becomes Fee at the point of delivery.
An example of the danger to be stopped. Around 2007, my friend went into hospital in Hawaii to have keyhole surgery on a knee cartilage. The operation was swift, she was home the next day. She then found out the bill for the operation was suddenly $17,000, and in the same post, that her medical insurer had declined the claim after previously accepting it. I helped her negotiate it down uncovering a whole empire of crooks on the way, from how the insurer used anything it could find from previous medical history to disavow the claim, to how simple operations wind up with unjustifiably inflated bills. And I learned how to challenge them. By the time we’d finished the bill she had to pay was $2,800.
Shortly afterwards, Daniel Hannan very publicly rubbished the NHS on Fox News at the behest of the American legal insures seeking to overturn US health changes modelled partly on the British NHS.
I run my own business, and I exist to provide worthwhile services my clients value that earns a profit for me. But I see too many people who do not see the world this way.
In private medical practice, as with the British Banks my concern is the profit motive will simply overtake the people motive, and Free will go to Fee – there is too much American evidence to support this, and too many people like Hannan in the Conservative party to trust the Conservatives on this.
I don’t think people really care about having choice per se. What matters more than anything is knowing we have one good service that is nearby, completely reliable and readily accessible at the point and time of need. You simply do not need competition to provide this.
There is too much obsession over choice – look at the nonsense ‘NHS Choose and Book’ is. It pretends to give me a choice, here in Cornwall, about which hospital I can have an operation at. I’m subsequently informed I must go to the one furthest away, which I explicity said I did not want to go to. Every time, and at great cost in terms of travel and time. Moreover, if there is a cancellation of the operation this leads to even more costs in terms of wasted travel and even overnight accommodation that must be taken in order to be at the hospital early in the morning, my home being so very far from it.
Privatising the ‘best’ bits of the NHS in the name of choice is just the thin end of the wedge towards a creeping, chronic, and ultimately total privatisation of our precious NHS. We don’t want a US or Australian style of insurance based health service. Many people will recieve a second class or worse of healthcare because they cannot afford better. But is anyone in the Tory party really listening?
Patient choice within the NHS is a good idea. It allows regional centres of excellence which may improve quality of care.
I am completely against privatisation by the back door done in the name of patient choice. This will weaken the NHS and the services it can ultimately provide. It will also prove to be more expensive, and any extra cash will end up in shareholder’s pockets rather than paying staff or providing increased services.
We need to keep private companies out of the NHS full stop.
Competition by private companies, particularly if the market is completely open such that EU competition law applies, will kill the NHS. Simple as that. I fear it would also kill a lot of people in the process.
I think this would also put a lot of UK jobs at risk.
Safeguarding quality of practice and care would also be a regulatory nightmare and would require such policing so as to render it untenable.
I do not want choice, I want a good local hospital.
I had a choice 41 years ago when I changed my GP from the one my mother chose for me in 1948 at the start of the NHS to the one my wife used. Although none of the doctors in the practice now were there when I joined I have found no reason to change. If I need care that they cannot provide I accept their recommendation as to where that care should come from. Usually from a hospital in the Leeds Teaching Hospitals NHS Trust. I see no benefit in widening my choice this bill should be scrapped and the views of all should then be considered. The present plans will ruin the NHS.
Price driven competition undermines quality of care and if choice is taken away from us thats limits patient options. Think again, Andrew Lansley.
Choice is not required as all services should be up to standard.
Competition does not belong in Healthcare.
There is no doubt that the NHS needs ‘tweeking’, especially when there appear to be multitude of high paid managers at the expense of those staff – nurses, auxilaries, etc who actually deal with the patients, leading to lack of time, lack of care.
Privatisation would be disastrous. We have only to look at the result of privatisation of other services to prove that. Rather than better and more efficient services, privatisation has usually resulted in services being provided at the lowest price with a lack of resources, equipment, consumables, etc and overloading of staff so they have far too much to do so can’t complete all their tasks properly. A good example is my Mother in Law’s care where many of the tasks are either not done or only partially done simply because the carer isn’t given enough time.
I dont want choice and competition. The assumption that this is somehow desiable and will lead to better outcomes is driven by misplaced ideology. I want an NHS that is free to all and provides good quality care free for all.
Therefore in answer to your question “How can we best ensure that competition and patient choice drives NHS improvement?” my answer is “please don’t”.
To: Sir Stephen Bubb, NHS Future Forum lead on Choice and Competition.
28th May 2011
Dear Sir Stephen,
I doubt that anyone in the country would begrudge a starving private provider the odd ‘cherry’ from the NHS (‘self-interestedly defensive culture’) cake. High-quality Locum Services spring to mind (including some level of teaching responsibility).
Private providers would however seem less than duly grateful (to their customers), were they to echo your denial (web-chat 12th May) as to the very existence of cherries.
The NHS Bill threatens ‘relief’ from the NHS of more routine work, airily leaving responsibility for all else (challenging care, long-term care, teaching, universal equality of access, etc. etc.) with hapless GPs and with multiplying ‘oversight’ of oversight’ bodies.
Envisaged or not, the outcome will be ‘relief’ from the (impoverished) State of any real-time responsibility (beyond paying whatever is demanded for services that cannot attract private fees from customers or their insurance companies).
For integrated care and financial efficiency, ‘someone’ has to ‘manage the whole cake’, the crusts as well as the cherries. You appear to have chosen either chaos or monopoly-capital over genuine national public provision. You justify this to yourself and others as being ‘for choice’, as if the NHS is somehow inherently incapable of offering valued ‘choices’, and as if a private free-for-all or monopoly would afford ‘choice’ in ‘everything’.
I ask you to consider, might not you be selling Snake Oil?
Yours sincerely,
Robert Reynolds.
Since the NHS is a unified service, accessible to all, choices should be made by the medical professionals so that medical services are shared fairly.
The service should be organised centrally to enable everyone in the country to share the scarce resources at our disposal. Co-operation, not competition will enable us to do this. We should trust our highly trained professionals to act in our best interests.
I went to THE hospital, was investigated by THE team in that clinic, was assessed by a consultant, was in the hands of THE theatre team and recover in the hands of THE nursing staff.
I dont want a choice; I want to stay alive! I want that high standard of care in all provision. I do not want a lower standard that I can chose not to have!
To make choice a reality you must train all users with sufficient medical knowledge that they are equiped to make those choices. (Oh, and duplicate provision so there is something to chose between.)
Choice, and its consequent financial burden, is tolerable for fashion items but unsustainable for critical services.
I would also like to add that I object to the partial way the above questions are framed.
I say no to the greed and self interest that is (privatisation) competition. Local personal services that meets the needs of the public, not a consumer driven approach, why is the government so keen to turn this public service into another ruthless money driven business.
I contribute as a patient representative to the work of task groups and committees at my local hospital, mostly, but not exclusively with non-clinical staff. They are already being driven by strong competition, being constantly compared with other hospitals against a wide variety of performance indicators, mainly in the form of measurement of health outcomes and patient feedback. Some of these indicators seem to me to reflect the real quality of the services offered, and some are poorly formulated box-ticking exercises. The hospital staff set up action plans and make great efforts to improve in areas in which their performance has been relatively poor. They are motivated both by the need to safeguard or enhance the hospital’s funding and by a genuine desire to provide a better service for patients. This kind of outcome-driven incentivisation may help to safeguard and improve the health service. Economic profit-driven competition cannot by relied on to provide the kind of health service we need.
Hi Andrew & team,
A choice of provider is not likely to improve quality, gaining instant access to medical care and diagnosis is not going to improve quality. More trained hospital staff, less stressed hospital staff, an increase in QUALIFIED DOCTORS would improve quality. Less first-year Doctors in control at 3am would improve quality. Reforming the structure of the NHS this radically is probably not going to improve quality. Not for at least 5 years…
There is never a level playing field between competitors. I do not imagine that the person who came up with this statement has ever worked for themselves. Or been a little bit poorer than the other person in competition with them…
Complete Patient choice can never be a reality in a competitive market where there are budgets per capita and some districts can afford drugs that others can’t. They would like easy access to specialists who can diagnose disorders quickly.
Please do not encourage competition within the NHS, there will be no one to price check and monitor and the contracts will be open to ANYONE with a company. There will be security breaches and protocols missed as you attempt to wedge the private sector into the very public serving NHS.
If I become ill, the last thing I want is to have to choose between alternatives I may not know much about. I will have other things on my mind and will not want hassle. What I do want is to be sure that my GP can refer me to somewhere I can get the care I need at a decent standard. We should be looking at current problem areas and dealing with them individually rather than throwing everything up in the air and hoping it comes down without having created new unforeseen problems (a pious hope). And I want to be sure that my local skill centre hasn’t been lost because it was out-competed by someone out to make a profit.
Surely choice is not what is important? It is about being provided with the best service that is needed by the patient.
Competition is also all well and good but for those who either cannot afford to go private, the priority is for a good local NHS service which is held up to account to make sure that the decisions made reflect what is actually needed.
I don’t want choice and competition I want everyone to receive a good level of service wherever they live and however much they complain or keep quiet.
I believe the so called carrot of choice being offered is a deception, my local Conservative MP, has indeed confirmed this sometime ago, the only choices made will be by Doctors who hold the purse strings, and who know who the providers are.
We want our local provider to be the best for our vaired needs, If the conditions are rare and call for expertise then specialist centres should be available for all, for example in Neurology etc.
It must be admited that once a so called level playing field is allowed it will be the death of the NHS as we know it, under EU competition law it will have to be opened up completely to private companies, who will be able to bid to do everything. It does not seem to be understood that in competitions there are winners and there are losers, simply we will end up with a fractured service. Doctors should not be commissioning services it was a failed excercise when tried in the past, my doctor has five minutes to see me, how on earth are they to find the time doing more. The NHS is people by excellent people, on the whole it is working, it can be fine tuned in places, but to destroy it as will happen is just unbearable.
I work in the NHS in an emergency department(A&E). I started there in 1997 just as there was a change from Conservative to Labour government. At that time in common with all emergency departments we were pitifully understaffed and quite incapable of dealing with the workload and the weight of public expectations. Waiting times of 6-8 hours were not uncommon and we were always in the local paper with lots of bad news stories. With investment we have now got a new department with far more staff , far less long waits and more importantly quality of care is hugely improved. Health economists would probably say we are now less efficient as the number of patients seen per doctor has gone right down. I can assure you though you would far rather be treated in the department today than in 1997. So all the investment has had many hugely beneficial effects. Healthcare we can all be proud of will ALWAYS be very expensive and labour intensive.
Having said that there will need to be changes made but I cannot see that what is currently proposed will have any beneficial effects whatsoever. Our workload is rising inexorably. Why is this? Increasing elderly population and new techniques have made a big impact. For example stroke care is now far more labour intensive and time critical and this is a very good development. Even more importantly for emergency departments is the huge change in the ways GP’s work. Out of hours care is patchy and often overwhelmed. Management of risk in primary care just seems to be disappearing and a new generation of GP’s refer in masses of cases on a “just in case” basis. I could give you loads of examples of really bizarre referrals from primary care. I honestly believe that most GP’s in our area are excellent and provide good service. There are however many poorly performing practices. How will commissioning by GP’s improve this performance? In acute trusts we have been and continue to be closely performance managed. How do we do this for primary care? One of the targets that use to apply (appointments within 48 hours) was quietly dropped and we already see the results. A large increase in attendances at A&E and an endless number of patients complaining they could not get a GP appointment so they come to A&E. GP access is a huge issue and is not just down to numbers of GP’s but much more about how GP’s run their practices.
This really has to change. I strongly feel that GP’s must move back to 7 day working (not 24hours – maybe 8am – 10pm) and need to be set some sort of performance targets for referral rates to acute care. Practices should also be tied to residential and nursing homes and set targets for how many residents end up in A&E such that they lose money if more referrals occur.
There are several practices in our area who already perform brilliantly in these areas. If all practices came up to their level we would see huge benefits across the board and huge savings for the NHS. This sort of primary care performance management may be buried somewhere in the white paper (which is absolute torture to read incidentally – I gave up). I do believe however that putting commissioning solely into GP hands is a mistake. Strangely our local PCT’s after a rocky start were just really getting to grips with all this and now that has been undone at a stroke as PCT’s shed staff. GP’s are providers of care as are trusts. So really a “detached” organisation such as a PCT are best at commissioning. I am sure their staffing could be slimmed down a bit and then they need to be given real teeth to manage the local health economy in the best interests of patients. In particular they need statutory powers to bring under performing GP practices up to speed as up till now they have been untouchable.
Apologies if rambling but in a nutshell – the NHS is so much better than it was in 1997. Rather than giving huge power to one group of providers let’s beef up the powers of streamlined PCT’s and see performance management across the whole NHS system. This would cost virtually nothing and could yield huge benefits.
The best way for you to answer your own stupid question is to ignore what everyone is telling you – which you will no doubt do. But just to make it clear: co-operation NOT competition, GPs as Doctors NOT managers, Public Hospitals NOT profit making businesses. The NHS is unprivatisable if you want to keep the ethos of it. Perhaps you need a hearing aid?
i SHOULD HAVE ADDED, i DO NOT WANT COMPETITION, i WANT THERE TO BE excellent health provision for all, throughout the country, if there is competition the service will be fractured, I cannot stand the thought of being one fo the luckier ones, and others receiving a lesser service. Our Governement, who represent us the people, who are paid for by our taxes should wish for a Health service that provides all of us, an excellent service, an equally good service regardless of our indivdual wealth, or status, in short it should remain the NHS with the purpose and structure that it has now.
Please consider social enterprise as an alternative to competition. It offers a new approach to commissioning as well as to provision of services.
We do NOT need choice and competition. These features simply ensure that the intelligent and articulate (and usually rich and mobile) get a better service than others.
What we DO need is good local services available to all.
With respect to different sorts of providers.
We do NOT need private profit motivated providers at all. They will simply cherry pick problems that it is easy and profitable to service leaving the public provider to struggle with all the intractible and unexpected health problems. The public provider (what’s left of the NHS) will then be unjustifiably criticised for its inefficiency.
What we need is what we still have mostly an integrated health service where all problems are treated within a single service.
The profit motive is not a recipe for care.
I am a GP currently working in the NHS. I do not feel that GPs have the skills or indeed the desire to undertake the commisioning role on the scale proposed. Most GPs want to look after patients and can see that managers in the PCT are better equipped to undertake the commissioning. Many of the best PCT staff are likely to move on amidst the chaos of the overhaul and will not be available when the consortia come to employ staff.
I believe that introducing competition into the NHS is fundamentally wrong. Efficiencies can be made but I believe strongly that the best way to do this is by improving cooperation between hospitals and between primary and secondary care. I firmly believe that competition with reduce quality and will open the door to the private sector who will be motivated by profit.
I have not yet been in a forum of doctors where I have heard positive talk about the proposals. Consortia are getting on with the changes because they have been told they have to. This does not reflect support for them. The changes should at the very least be piloted initially.
There are currently record satisfaction rates with the NHS. Another overhaul of the NHS will lead to demoralisation in the workforce. The NHS depends on a great deal of goodwill from its staff and this will erode this.
These destructive plans were not in the Conservative or Liberal manifestos and hence there is no mandate for them.
I am not interested in having to make a choice between a private and NHS provider. What I want is the public NHS to provide high quality care at a hospital near my home. If the NHS is properly funded and managed, yes giving GPs and hospital staff a say in the provision of services locally would be a good idea.
The profit motive does not have a place inn the provision of public services.
1. Which are the types of services where choice of provider is most likely to improve quality? The fact that this exercise opens with this question suggests that there is a fundamental ideological drive to these reforms and a complete disregard for the views of the vast majority of professionals. The firmly held but delusional belief that a commercial system introducing open competition will improve quality and produce value for money is not supported by the evidence, the Office of Fair Trading, the government’s own impact assessment, or the experience of treatment centres and private finance initiatives (BMJ 2011;342:d1695). In our own area, Tower Hamlets put out to tender a local GP surgery. This was won by Atos Healthcare a few years ago. It has since been one of the poorest performing surgeries in the borough and Atos have pulled out citing it as being an uncommercial venture. Is this the legacy the governement wishes to leave the NHS, a series of failed ventures blowing in the wind? We do not believe that choice of provider is likely to improve quality. In fact the necessary regulation of a plurality of providers through commercial contracts will increase the non-clinical burden of the NHS, transaction costs and take away precious financial and non-financial (clinical professionals) from the provision of actual clinical care.
2. What is the best way to ensure a level playing field between the different kinds of provider who could be involved? The best way to ensure a level playing field is to remove the threat of a competitive element and to acknowledge the fact that the provision of health care is not the same as the provison of discreet commodities.
3. What else can be done to make patient choice a reality? Patient choice is constantly used by all the political parties to provide cover for their latest ideological wheeze; a cheap political stunt. In fact the most recent British Social Attitudes survey reports that 64% of the public are satisfied with NHS, the highest level since the survey began. Perhaps this uncomfortable report for the government is why Mr Lansley is withdrawing funding for the BSA. In the one area of the NHS that has been commercialised, the dentists, satisfaction has fallen again to 48%, the lowest level for any section of the NHS surveyed. Whilst this use of “choice” can be annoying; it is potentially a dangerous concept to introduce so forcefully into a health care system based on need and equity as important founding principles of the NHS. Choice is an indulgent luxury that comes at a high cost. It fosters a culture that suggests it is possible to have whatever you want whenever you want it, a premise that is patently absurd. We risk moving from a more realistic needs based society to a constantly disappointed and insecure (maybe there was better choice out their that I was not aware of or I didn’t get) wants based society. The Prime Minister enthuses about happiness but as we see vast numbers streaming through the lower levels of the IAPT psychological therapies service a society where you are encouraged to try to have whatever you want leads to disappointment and unhappiness.
If choice means competition, then it surely means privatisation. Privatisation means that someone or some organisation needs to make a profit. Please explain how diverting resouces from patient care to shareholders, or their equivalent, will improve patient care. I am at a loss to understand. Go back to first principles.
I find the question ideological in that it assumes competition. I and members of my family have had operations and care from the NHS in the last 3 years and not once did any of us think “What we need is more competition”.
I find it appalling that these major and potentially disastrous changes appeared from nowhere after the last election. The NHS does not need competition. It needs efficiencies, investment and a recognition of how good its services and and its staff are despite the occasional problems.
To me, the overall message from the NHS proposals is contained in the fact that the Minister for Health is not to be required to “provide”, but to “promote” NHS services.
I am concerned that the proposals are too competition-based, and will allow private companies to cream off the profitable areas and leave the NHS suppliers to do the rest. Already, when major complications occur in private hospitals they are not equipped to cope (ie they will not spend the money on the necessary complex training and facilities) and the patients have to be passed to the NHS if they are to have any chance of recovery. Private suppliers are answerable to shareholders, and their motivation is share-holder profit involving as little risk as possible.
Patients don’t want competition, just a service that works for them, in their local area. Why do governments keep imagining that people want choice in everything? This may apply to commodities like washing powder, but not to complex specialist services such as the NHS provides.
I am reminded of what happened to the Post Office,also a much-loved and respected organisation, when it was not allowed to invest in modernisation, and its services were opened up to competition – standards of both service-levels to the customer and staff conditions deteriorated beyond repair, and it is likely it will be sold off completely.
I don’t think everything in the NHS is perfect, but any changes to improve the quality of care should be properly trialled and evaluated in pilot areas before introduction nationally is even considered. The trials should be monitored and judged by independent bodies, and the results published to public and medical professionals in the pilot areas.
A time of huge cuts in public spending is not the time at which to start
imposing changes of the scale proposed.
Patients are by and large not interested in making choices about provider. We want the NHS to provide and we want it to remain free to us, paid for by taxation, and no-one to make a profit out of it.
Could the listening exercise consider:
1. how does the not-for-profit NHS’, world class record of cost-efficient, high quality patient care (e.g. in cancer) compare against models of the proposal’s cost-efficiency and outcomes?
2. can mission creep, under the influence of private healthcare corporations, be avoided?
3. in what way is competition preferable to collaboration between providers with different strengths?
4. that per capita costs for health care in the United States are twice those in other developed countries due to:
a. increasing salaries across the entire health care sector under the guiding influence of free market health insurance;
b. emergence of competitive health plans in a free market culture, competing amongst employers and providers to make profits.
5. piloting proposed changes, using metrics to assess outcomes before wider roll-out.
I agree with other comments about choice; I think we patients have common sense and can consult our own GP whom we presumably trust, since they are caring for our health anyway. We can get more info from the internet and from the Media and from friends and relations. I say a loud ‘NO’ to these proposed changes. As for competition again ‘No’. This is about medicine , not about business and profit.
I too am not interested in having a choice of provider. What we need is an NHS that provides high qualtiy care at hospitals near where we live. Quality of care should not depend on where you live or how well off you are. Everyone should have access to high quality services.
I think the whole idea of choice and competition is a nonsense. What most people want is one, decent, local hospital, which is reasonably easy to reach by people in the area, using public transport, if necessary, whether as patients or visitors. The idea of going to a hospital a couple of hundred miles away for its perceived higher standards is completely impractical, especially for the poorer members of society. For more specialized treatment, patients will, inevitably, have to go further afield, but not beyond the county boundaries. For the most specialized treatment of all, patients may well have to travel far beyond county boundaries, because there are unlikely to be more than a handful of treatment centres. This will be balanced by the fact that there will be only a small percentage of the patient population so affected.
The NHS is supposed to be, primarily, a service, and it’s not much of a service if it’s not convenient for patients or their families. If it costs a bit more to run that way, so be it. Very few of us always choose the cheapest option. We weigh up the pros and cons and make our choice accordingly. Convenience is one factor that always scores heavily.
When the NHS was created in 1948, every single Conservative MP voted against it. There doesn’t seem to have been much of change in attitude since. The NHS may not be perfect, but I’d rather leave it pretty much as it is, than risk it in the unsafe hands of Conservative MPs.
I agree with many previous posts. It is OUR NHS Mr Cameron, and not yours. It is not for you to privatise and offer up to cherry-picking private health companies. I am totally unconvinced that the only way to improve NHS efficiency is to hand it to profit making private companies.
Far better to save money by removing administrators. Do you really expect anyone to believe that handing NHS money to shareholders is a step forward?
I echo previous comments. Give us a referendum on your proposed reforms.
The question assumes that locality and access to all services (or at least a choice of two services) is equal. This is not so. NHS services are therefore not like two brands of cola on a supermarket shelves.
So let me rephrase the question: in order to run a trial, to see if competition and patient choice can drive significant change, which group of patients/services would seem to offer the best chance of success?
That is: which services would patients put up with travelling 2 hours each way, involving two bus changes, rather than have a worse service only half an hour, and one bus away?
I think that people with chronic conditions, where the quality and quantity of support can make life-changing differences are probably the best example of a service where people would invest the time and effort to get to a halfway-decent service / to avoid a poor service.
Services which could use e-delivery, including video appointments, email consultation, and so on (typical of chronic conditions such as type 1 diabetes) to minimise the need for clinic visits would be particularly useful to see if this would drive change.
The study would have to be long term. Improvements in care of people with chronic illnesses tend to have long payback periods: it may cost more to provide a better service, for example, but if it cuts down the death rate, or onset of dibilitating symptoms that prevent people from earning/paying taxes, it can cost less overall…
Since patients do not have a choice (because two services are not competing head-to-head), competition and choice is going to be so limited in effectiveness. NHS improvement would be better driven by facilitating patients and NHS employees and other stakeholders to make improvements.
As a health service user and long-time qualified Nurse I would agree with the many issues highlighted relating to choice. What I and the majority of other patients want is high quality healthcare delivered in my local area by competent trained staff in fit for purpose accommodation.
These services need to be integrated into Primary and Secondary Care with a national overview and outcome framework to be measured by. How will local Commissioning provide this?
How will the Commissioned services be accountable to the Public?
What choice will there be for the vulnerable groups, who will there be act as their advocate during the Commissioning of services?
We are hearing about the financial issues with Care Services for the elderly provided by Southern Cross Healthcare. What will happen when the local hospital services are no longer viable due to the same financial issues?
The changes that are already happening within other areas such as Special Needs Education will also contribute to the longer term concerns raised by Dr Dikon Bevington, some of our most vulnerable children and young people are already being impacted upon by our Governments agendas.
The Health and Social Care Bill needs to be considered within the context of the society that we now live, not as a paper exercise of six years consideration. Our NHS is not for sale to General Healthcare Group.
I don’t want “choice” and “competition”: I want excellent NHS services available throughout the country. I’ve recently been staying in a rural area (I’ve always lived in big cities) and realise that “choice” here is between driving 20 miles one way or the other to get to a hospital: I don’t want people here to have to drive even further to get quality treatment.
Please keep private competition out of our precious NHS, and fund the NHS adequately to provide for all of our health needs, without feeding the dividends of shareholders.
Why should competition and patient choice drive NHS improvement? What is the evidence that competition and patient choice are actually going to improve the NHS? What is the evidence that any of the governments proposals are actually going to improve patient care?
Considering the NHS is required to make considerable efficiency savings over the coming years, I would question the cost effectiveness of such an extreme reorganisation of the NHS.
I don’t want a choice. I want to get a decent service from my local provider. I choose my supermarket mainly because it is the nearest, but I know that if it closed down, another is nearby and the gap would soon be filled. If my local hospital closes, the nearest alternative is over 20 miles away. The alternative doctor is another 5 miles. Not much good in an emergency. My choice is the current provision. Can you promise not to reduce this choice?
Your question ‘How best can we ensure that competition and patient chice drives NHS improvements?” is based on false assumptions. Provision of choice costs money. Providing more choice will cost the public more as it requires provision of underused capacity and duplication of services. If the underused capacity ceases to be funded, possibly following competition between providers, the choice will no longer be available.
Unless a great deal of underused capacity is funded, patients who can wait for treatment may get some choice of where and how they are treated while patients who need urgent attention will have to accept treatment where there remains capacity to treat. This is not a good time to begin a major change to health services given the present national economic situation. Any reorganization will, in itself, cost money. As a patient I would think it a poor outcome if, because of a limited budget, the NHS gives greater choice but in a narrow range of available treatments.
Whatever the healthcare system, choice for most patients will always be very limited and can never be comparable to the choice possibilities available to say the prospective buyer of a washing machine. While people may choose to buy a washing machine from a range of alternatives manufactured all over the world, few patients can normally travel great distances for treatment and, unless there is gross overprovision, no health system can provide any great range of choice within reasonable travel distance for most patients. Patients, because they are in pain or their condition is deteriorating, have little time in which to make choices and, commonly, have limited knowledge and no prior experience of their current compliant. Therefore they will continue to be largely dependent on the advice of the expert at hand (often their GP) and, in the great majority of cases, will accept the choice their medical expert advises them to take: i.e. in most cases the choice is made by a medical expert. As a patient, I am more concerned to receive good and timely treatment than to enjoy choosing between small differences between alternative potential providers.
Health services are improved largely because those who get involved get great personal satisfaction, and public recognition, for doing a good job. Teamwork, openess, co-operation and spreading of good practise also play a part – none of these are particularly improved by competition.
Having worked in Health care in Europe, there were areas where the business ethos just did not allow any choice. many of the hospitals were run by insurance companies and the bottom line was money.
It took a very strong director to enable patients to have any say in their care. The worst example of business over choice was where maternity services were withdrawn from a hospital with 4 weeks notice – the hospital provided choices that the insurance company did not agree with so they just refused to pay for any maternity services the hospital provided.
We run the risk of offering a two tier system with people who do not have the means to investigate services or travel further afield having their choices reduced to what the local hospital /clinic can afford to provide, not what is suitable for them.
This can then lead to a skill drain, with staff migrating to areas where they have the means to improve their practice and patient care.
How does can this system save money or improve care?
The reality of profit over service should be acknowledged as the outcome of any measure to ‘outsource’ or ‘privatise’ – we need only look at dimishing services within and beyond city boundaries, Post Offices, bus services, railway maintenance, and the extortionate if not illegal private clamping companies, added to the already observed results of privatisation of ‘care homes’.
Any changes on this scale should be trialled in a few areas for several years first.
This ‘listening excercise’ is another example of the subversion this government is so fond of. These are leading questions with no real choice.
“How can we best ensure that competition and patient choice drives NHS improvement?”
We’re not being asked if we want competition (privatisation by any other name) to be the future of the NHS, or even if we think it will improve it for staff and patients, just ‘how can we make it work?’. The NHS greatly improved under Labour after years of neglect from the Conservative party, and patient choice is an area I didn’t witness until Labour came to power. There is no proof the Conservative party has ever or will ever consider the NHS, or the public’s ‘lot’, worthy of ‘improving’, and every proof the public are just the ‘cash cow’ to be milked till dry then ignored.
I think there is a significant danger in assuming that added competition, whatever form it takes, must be better than what currently exists.
There are two very different cultures A) NHS culture based upon providing a good quality healthcare B) private healthcare providers with shareholders where profit is a more significant driver.
Healthcare should not be delivered by providers who are making a profit from doing so, as that in itself reduces the value for money being obtained. Providing a cheaper service to a lower quality standard is what privatised providers seem best at.
Forcing services to be passed to the private sector has demonstrated millions of pounds being spent for work that was never done, because contracts were guaranteed regardless of whether the work was available for them. This is how applying industrial principles to healthcare can harm it – assuming more competition must be better than less and then allowing private operators preferential terms to encourage them to get involved.
Some work in the NHS is relatively simple, whilst other elements are extremely complex. If all the easy stuff is farmed out to private factory style providers with production line processes designed to be as cheap as possible (attractive to them as more profit can be made), then the NHS will be left with all the complex and expensive work and will be in an even more dangerous position.
Please do not apply law on monopolies to the NHS as it will irreparably damage it and lead to services being delivered by providers with more concern about their profit than about quality of care. Encouraging the NHS to provide better care does not need the threat of work being sent to the private sector, instead acknowledgement of the excellence already within the NHS and its promotion throughout the country would make a lot more sense.
I believe that to increase the amount of choice for patients from that available now will cost more for the NHS. It should not be altered from the amount of choice there is now.
Just because a place is private and not NHS does not mean it is better or provides better quality treatment, and I have worked in both sectors in health care.
Patients are not machines and do not recover in the same way and therefore business models of competition do not wholly work in healthcare.
It would be a mistake to alter this.
Bit of a Hobson’s choice in the question – why do we want to ensure competition and who says it produces better healthcare outcomes? I want to see collaboration between doctors, sharing best practice and learning from each other, then reinvesting profits in the NHS instead of some American corporation somewhere.
I am a GP in Tower Hamlets; my wife and I took over a singlehanded practice as a jobshare 20 years ago. We now have 2 part-time GP colleagues, and a list size of 3,520. I am sceptical about this exercise as I do not believe the people in power will use this feedback in any significant way. I say this because I believe they have their minds made up and will do what they can to proceed with their plans unchanged. This ‘pause to listen’ is largely a PR exercise. Also: the previous government established a ‘consultation’ about the ‘Choose Your GP Practice’; the conclusion after the consultation, issued a few months after the present coalition government took over, changed absolutely nothing. They used what they wished to back their plan, and ingored the rest.
But it is important to speak out, so here goes. Competition: for several years the Department of Health (DH) has trumpeted competition as a way of improving primary care (=general practice). I must say that in 10 years I have never felt in competition with my GP colleagues in Tower Hamlets. Not even for 5 minutes. If we do a good job, if we aim for good quality, it is because we want to provide a good service, we want to be up-to-date with our practice, it is because we take pride in our work. A few days ago Stephen Dorrell was quoted as saying “The idea there is no competition in the NHS is just bonkers. There are few more competitive groups of people than good doctors. They compete and that improves the care of patients.” I don’t know what he means by this; it does not ring true for me. I would recommend the writings of the American surgeon Atul Gawande; these are thoughtful accounts of the complexity of providing good quality humane care to sick people. What makes doctors better, is not ‘competition’ with each other (in fact, collaboration between professionals is a very important ingredient).
A few years ago a practice in Tower Hamlets became vacant through the retirement of the incumbent GPs. The practice was put out to tender under the present rules; two local Tower Hamlets practices put in bids, as did Atos Healthcare, a private multinational. Atos won the bid as they had underbid the local bids. At the time I wondered if they would be able to provide good quality general practice. From the stories I have heard, they were not. They scored at the bottom end on a number of measures when compared to other Tower Hamlets practices. Did the people who champion competition come to Tower Hamlets and observe this, have they learned a lesson from this? The local planners have learned something, but the Andrew Lansleys and DH people have not. You can read about this story at this link: http://bit.ly/mOMyeI
One particular issue that has vexed me is that of GP practice boundaries. When my wife and I were interviewed in 1991 (please note that it was the GPs who were interviewed in 1991, not some men in suits from Atos who were not doctors as was the case outlined above; when Atos were awarded the contract they still did not have the doctors who would actually deliver the service identified; I know because they later tried to recruit GPs and sent me a job application), we were asked what we were going to do about the ‘outliers’ (the patients who lived outside the practice area). This because in 1991 it was thought to be bad practice to have patients living at a distance from the practice. So we have been quite firm about our practice area; when people move outside the area, we ask them to register with a local GP. They are often reluctant to do so but, with an explanation, they understand the rationale. We have in essence carried out a pilot study of this issue over 20 years and our experience has been that the further away a patient lives, the worse the care they receive, and the more complex it is for the practice to deliver that care. In some cases it is unsafe. So when Andy Burnham proposed in 2009 (after being chided by Andrew Lansley who was then in opposition) that New Labour would abolish practice boundaries within a year, I was horrified. It seemed a parody; if there was a measure that would undermine care, stretch resources, and be unworkable, this was it. And the government was behind it, and the DH.
And this raises the issue of choice. Choice is the (stated) rationale behind this proposal. Choice seems to have a hypnotic quality: you say ‘choice’ and people seem to go into trance, and switch off their critical faculties. With reference to the abolishing of GP boundaries, when you will (theoretically) be able to register with the practice of your choice anywhere in England, think about this for a moment. Let’s say you know of a good practice 5 miles down the road from you (or even 20 miles or 100 miles); you must understand that this practice is currently working at full capacity or close to it. They do not have significant space for more patients; sure, they might be able to expand a bit, take on a few more doctors, build an extension, but they will have a limit. And besides, if they grow significantly, they will not longer be the practice they were before. And if you were hoping to see Dr Special, well Dr Special is already fully booked as it is today. How is she or he to have the time to make their skills available to you (and all the others like you who wish to ‘choose’ this doctor)? It is a mirage, a con, a scam. There are some who say that in fact the (unstated) aim of this policy is to open the door to providers on the model of American HMOs (health maintenance organisations; for further information see Wikipedia).
There is a very major problem in this whole debate, with all these issues (and they are multiple, and complex). And that is ‘methodology’. The method that seems to prevail at the moment is to take an ‘idea’, and then try to implement it without actually taking into account the most basic practical issues. So when Andrew Lansley tells you that there will be no decisions made without you, ask yourself just what does this actually mean and then try to model it, think of how it is going to work (along with all the other processes that have to work alongside it).
So what do we need instead? A brief sketch of my thoughts. We need to ask the question: what is needed? what do I want? what is essential? in the health service of this country. Then we have to ask: ok, what is needed in order to provide this? What are the structures, processes needed? What are the different possible ways of doing this, how would they work? What would they cost? What would be the unintended consequences? How would we know if it was working? How would we know if it was not working? We really need to move from the level of the abstract (choice, modernisation, reform…), to the concrete. And honesty, transparency, and an evidence-based approach are necessary. That’s it from me.
If you want further details, see http://www.onegpprotest.org
The NHS is surely a wonderful resource, one that sets us above other countries where health care is solely available from the private sector. I do not believe that anyone truely wants to rid themselves of public sector health care. Certainly not when they see the bills that they would be left with the next time they fell ill.
The NHS should be better funded, yes, but this does not mean transfering it to the private sector. I am sure that the majority of people would rather pay a little extra on their taxes for proper funding for the NHS than to see it go completely.
Patient choice needs to be ‘informed’ choice. There are some specialties/ treatments unheard of by many of the public and dare I say some GPs, who have somehow to be up to date with all the vast range of services currently accessed by Hospitals and other clinicians.
I am an Orthoptist. How many times am I asked – ‘what is that?’! We provide diagnostic and therapeutic expertise alongside Ophthalmologists and our knowledge is not available in its depth and breadth via other practitioners in ocular-motor anomalies. If you have never had double vision, a lazy eye or an eye muscle imbalance you may never have come across an Orthoptist.
Patients do not want to guess at where to seek the most appropriate help for their condition. GPs do not want to have to fret about time wasted by inadvertently referring to an inappropriate provider.
Maybe the system is cracked but we don’t want it broken. We don’t want competition from services which have a louder voice based on numbers but which would smother what is the best source of management for the patient and ulitimately therefore the most cost effective. In Ophthalmology a team approach is often the most efficient.
Yes, I have to admit that I do like to be able to choose whether to have my tests in one hospital/clinic or another, usually because I can then be assured that I/my relatives will have easy access to the chosen hospital should be end up as an inpatient. But that is as far as it goes. As for competition, absolutely not – I am not a professional in these matters, but commonsense tells me that there will be profits on offer, and that these will not be ploughed back into the NHS but will line the pockets of the rich. I am totally against competition in the NHS, and I must point out that whoever voted in this government did not vote for “choice and competition” in the NHS – indeed, David Cameron specifically stated that there would be no top down changes to the service. There is no mandate for these proposed changes.
Choice and competition are notions that belong to the market and healthcare is not and never should be a market-driven service. Superficially it might sound attractive to have different providers competing to provide healthcare services to you and to choose who you ‘purchase’ from but the reality is that the shareholders are the first consideration and the profit motive means that available resources are split between serving the ‘customer’ and serving the shareholder instead of all resources being used to serve the patient.
The question “How can we best ensure that competition and patient choice drives NHS improvement?” assumes that competition is the best way to drive NHS improvement. Where is the evidence that backs up this assumption.
Clearly in a democratic society, it is only fair that individuals should have choice in healthcare matters which will affect their quality of life. HOWEVER, choice does cost money- especially where services are needlessly duplicated. Furthermore, it is a foolish waste to give the pretence of choice through asking for headline-grabbing knee-jerk responses from the general public.
By way of example: in the Trust I work for, the local population were asked whether they wanted some services closer to them- such as X-ray facilities. Of course, they said yes (as any sane person would). However, if you actually needed treatment as a result of the x-ray results, you have to then be referred to the local hospital and await an appointment to see the Consultant, and then be referred for Plaster/Splint/Rehabilitation etc. Surely, it would have been more efficient not to offer this “choice” and duplicate the x-ray services only a few miles down the road. None of the patients I have spoken to would have said it was a good idea after having to go to three different appointments on different dates/locations when the could have just gone to the old X-ray/A&E/Minor Injuries unit and have been sorted out in one go. (Similar applies to non-acute injuries too).
Resources must be spent in maintaining the excellent services which our large, acute hospitals provide, as well as to provide efficient Primary and Community services. We should avoid duplication and a competitive business model- which is not appropriate in a publicly funded organisation which should be striving for excellence as a whole. Patients should of course be allowed to choose where to give birth, whether to have cancer treatment nearer to relatives, or to have an appointment somewhere nearer to where they work. However, I would strongly oppose encouraging duplication or internal competition.
This is, and always has been, an issue of ideology. The NHS is a cornerstone of our culture, founded on humanitarian ideals. Previous conservative governments have already imposed an internal free-market economy, now the conservatives aim to continue with their mantra that everything is better under competition, but I say it again, the NHS must not be tampered with by a government that has no mandate! ‘Choice’ is a by-word for priviledge. ‘Choice’ is something you can have if you can afford it. Conservative ideology accepts that their is inherent unfairness in a free market economy, this is totally against the principals of the NHS – back off Lansley and leave our NHS alone!
Choice is simply not needed in the NHS.
If I were suffering from cancer, I would not wish to have to look up the best survival rates of different hospitals, my chances of dying at my local hospital or the success rates of different surgeons. I would want an NHS where every hospital has the funding, the staff and the equipment it needs to make me better.
Allowing choice will create ghost hospitals, where survival rates aren’t as high as others, where people cannot afford to get to the best hospitals are forced to go and die. The better hospitals will be inundated by patients from all over the UK.
Choice is not needed or wanted.
On the other point of allowing the private sector into the NHS, one needs only to watch Michael Moore’s documentary, “Sicko” to see the effect of allowing competition and privatisation. The NHS is featured as a gem in the developed world and allowing competition in will destroy this and create a heartless, profit hungry, cherry-picking conglomerate of healthcare companies after one thing… money.
There are such asymmetries of information in healthcare (in other words doctors know more about the patients condition than the patient does) that it is impossible to have a classical free market.
That is why doctors and nurses and AHPs must be professionals. We have to trust them act in their patients best interests, not in a narrow self interested manner.
Therefore neoclassical economics does not apply to the market in healthcare.
Note also that the proposed “free market” will involve large complex tenders from a small number of providers. The high barriers of entry necessarily created will create an oligopoly of large corporations (like most mature customer facing markets – think of supermarkets, petrol service stations, electricity, mobile phones). This is not a classical free market with perfect competition and does not create efficient outcomes even in neoclassical economic theory.
(Even on neoclassical assumptions it is better for society to have one state monopoly provider ordered to find the output maximising equilibrium than a small number of corporate mini-monopoly providers who will find the price maximising equilibrium.)
Therefore the idea that competition between providers and patient choice will necessarily lead to greater efficiency and social utility is fundamentally flawed.
You might more profitably look at patient outcomes, patient (reported) satisfaction, and overall population health outcomes and use let this affect the remuneration of key staff (senior managers and senior professionals). The metrics chosen would ideally be secret. As this is not realistic, using very broad unfixable metrics such as health outcomes in a region would be the next best thing.
As a GP currently working in the NHS I feel my grave concerns have been comprehensively represented in the RCGP’s document ‘An Analysis of the Need for Clarification and Change’ and in their formal response to the listening exercise.
On a personal note I have NEVER been asked by a patient to make a referral other than to local services or to our local hospitals. Some patients may lack the transport, health literacy and the internet access/skills to negotiate ‘choice’. Often we may both be uncertain about an exact diagnosis. Excellent comprehensive local community and hospital provision therefore becomes paramount and anything other than this worsens health inequalities.
Every time we have elections in this country, manifestos fly all over the place about the 4 major services that any state in the world should provide, protect and secure: Education, Health, Policing and Defence. These are the areas that any state in the would must not compromise on. I am not sure how competition is going to improve the NHS and patient choice. Labour started the disasters of Foundation trusts with all the drums of independence. Comes with it the right to be independent of the “Terms and Conditions of Service” and the right to have own constitution and TCS. Foundation status is the corner stone for privatisation of the health care system. This bill would ensure that there it will go ahead. “One less battle for political parties to fight on elections”. We are already hiring the French Fleet for defence, and will hopefully find one of the supermarket chains to govern our Policing organisations on the streets!
I can’t see how competition is going to work. This bill is going to ruin the most civilised and humane thing we have in this country. We are envied by so many nations in the world for what we have!
Thatcher did not intend it but, dentistry went into the Market with consequences are well known to us. Give the nation to have a say on what you are proposing!
1. Which are the types of services where choice of provider is most likely to improve quality?
Simple one stop procedures in otherwise healthy patients where complications are unlikely, eg repair of small hernias. But outcomes for these procedures and patients are already very good, so major improvements in quality are unlikey.
2. What is the best way to ensure a level playing field between the different kinds of provider who could be involved?
Oblige all providers to provide a comprehensive package of services
to prevent cherry picking. eg a provider wishes to provide outpatient elective endoscopy services in competition with the local NHS hospital. This provider should be obliged a. to take all patients including high risk patients, b. to provide an emergency out of hours service for acute GI bleeding just as the NHS hospital is. Along with supporting services such as emergency surgery and intensive care.
Or a provider wishes to perform elective hip or knee replacement. Again the provider should be obliged to take all-comers including patients who have heart failure or lung disease or dementia or poor grasp of English. In addition the provider should be obliged to assess and treat their patients in the event of complications post discharge eg if the patient develops a deep vein thrombosis or a wound infection. These patients should not become a cost to the local NHS hospital.
All providers should be obliged to contribute to training of the future workforce. Either directly by having student nurses / junior physios / trainee doctors etc working in them or by paying a training levy to support those hospitals that do employ the trainees.
3. What else can be done to make patient choice a reality?
Patient choice is already a reality – for those with insurance or sufficient funds, there is private health care. For most elective hospital care there is the Choose and Book system. (Most patients ‘Choose’ their local hospital.) For those who don’t mind travelling and part funding treatment, there is the option of going to another EU country and getting the NHS to reimburse money equal to the NHS cost.
To make choice more available, the NHS could fund the travel costs and accommodation costs of people travelling around the country to go to a provider with better quality services. Under EU law, the NHS would then have to fund the same costs if someone chose to go to another EU country.
4. a. As a general comment, choice and competition can improve quality. But they do not have to occur only in a commercial context. If robust quality measures can be devised which fairly compare different providers, and these measures are widely published in an easily understandable format, and then patients were supported to go to the best providers, then choice and competition could work within the exisitng NHS structure.
b. However competition and choice imply that there must be excess capacity – if the most popular provider cannot accommodate you, then you don’t have the choice to go there.
c. In addition, failure of providers is an inevitable part of competition. So there must be clear mechanisms to ensure care continues when a provider closes. The National Health Service and Community Care Act 1990 allowed councils to outsource care to any willing provider. Private providers took over council homes, new providers moved in, these merged or were taken over, the private equity firms followed and now local councils are faced with possibly having to rehouse residents or take over the running of 750 care homes owned by Southern Cross Healthcare.
With the abolition of primary care trusts and strategic health authorities, who will take over when a Commissioning Consortium or a Foundation Trust goes bankrupt? This is not a possibility, but an inevitability in a free market.
The NHS is already a competitive way of providing a national health service, in comparison with the bloated system in the US which costs much more (twice as much?) and doesn’t even serve everyone in the country.
On indicators such as hospital cleanliness, public sector hospitals outperform private sector hospitals. There is a danger that the government’s proposals will introduce a “race to the bottom” in some key areas.
The core purpose of the NHS is to provide the best possible care for its patients, and this should be enshrined in law. Whilst there may be alternative proposals for how this may be achieved, like any new proposal, they should be tested out in pilot areas first, independently and thoroughly evaluated, before rolling out nationally.
The core purpose of GPs should be to provide the best possible patient care for their patients. Introducing a financial/profit motive in the role of the GP is a serious conflict of interest, and the government risks widespread discontent if there is a postcode lottery in the provision of some services. This must be a huge legal minefield, and there would be a lot of litigation caused by the proposals.
Patient choice is an empirical question – so if the public (the patients) are telling you that they choose a properly funded NHS, without any expansion of private provision or competition, this is the patient choice, and you must respect this. Why you are talking about increased patient choice when the range and depth of services is already being cut is beyond me.
Please can you represent these serious points as a point of view in your response on the consultation (because if you are consulting then you need to fairly summarise what people have told you). Please can you also provide me with a written response of what you will be proposing in relation to each of the points made above?
Many thanks – kind regards,
David M
I don’t want the NHS to have to use competition based on price. Competition should only be employed as a principle to affect the provision of basic disposable items to hospitals, such as surgical gloves or stationery, and should be on the basis of cost effectiveness: i.e. price for quality. Hospitals should be incentivised for collaborating for maximum cost effectiveness, i.e. coordinating on bulk purchase of surgical supplies to get the best detail. But competition should end there – between suppliers of basic items. Healthcare providers of all types should be incentivised to collaborate for improved patient outcomes. The evidence points to this being a far more effective approach than instilling or increasing competition as a principle between healthcare providers. Healthcare providers should not be able to undercut each other on cost of treatments received by patients.
The UK spends less of its GDP on healthcare than many other European nations. What we need is more investment in quality care for patients. Public funding of the NHS should bePatients like me don’t want choice – we just want the quickest and easiest possible route to the best experts and treatments available. We don’t want our GPs to be making decisions about cost, or managing our healthcare budgets; GPs should be there to refer on to the best available sources of expertise without having to worry about budget issues. Separating healthcare expertise from budget control functions is important for ensuring that the two key priorities of quality services to patients and cost effective management are fairly balanced. It is too much of a conflict of interest to combine these functions in a GP role.
I don’t want an increased role for private providers in the NHS, other than more efficient provision of basic supplies, equipment etc. I particularly don’t want private providers to be able to ‘cherry pick’ by offering the cheapest and easiest services at rock bottom price and not getting involved in more complex treatment and care.
Accountability to patients would be better served by reinforcing the goverment’s role to be directly responsible for a high standard of healthcare through the NHS, and by protecting and publishing a strong budget for the NHS. Don’t cut public funding to the NHS, cut Trident instead.
I am not comfortable with the proposal to turn our National Health Service into a National Health Market, with profits for private providers funded through taxpayesrs money. It will cost billions to implement and be unequal ins provision of services compared to the current system. It will save little money as existing public sector managers will be replaced by costly private sector consultancies. NHS professionals (including NHS chief executive and the majority of UK General Practitioners), the health unions, the Royal College of GP’s and the BMA have warned against these proposals. THe only people who welcome them are the private sector proiders who can see profits for themselves while the rest of us could see the fragmentation of our most popular public service.
I agree wholeheartedly with Jenny. Private sector providers are fundamentally motivated by making a profit for shareholders – not by what is in the best interests of patients. Those of us who have worked in the pharmaceutcial industry see this clearly. If private providers are set up as Community Interest Companies or social enterprises, that MAY be more in patient interests. However, the NHS will still be providing all the training, the emergency servcies and the centres of excellence that are vital. Other organisations will be using this expertise without contributing towards it. It is vital that the government listens to those professional bodies that have warned against these proposals.
From daily practice, Ido not see many patients eager to exercise a choice of provider. The main issues when having to choose between appointments are waiting times and personal comitments which may conflict with possible appointments. In fact, I am often asked which service I would prefer, which of course takes the ‘patient choice’ back to me.
With regards to competition, I am not aware of any scientific evidence that competition improves anything but profits. The sad truth is that some patients are more profitable than others, and that competing for those patients will create a glut of services, with short waiting times, for some patients (otherwise healthy people requiring e.g. a hernia repeair or varicose vein stripping), leaving less profitable patients (elderly, mental health patients, or those with complex needs) facing more difficulties accessing help. These are the realities of a privatised service. If the DH has evidence that says different, I would love to see it; please have downloadable versions posted to the DH website.
It is time that Mrs Cameron and Lansley come clean and admit that their ‘reforms’ are not at all about improvement, but are about cutting costs, reducing the role of the state and keeping any complaints about the sercice away from the goverment, driven by ideology rather than evidence.
How can a person who is not medically trained really make a proper informed decision on which location to be treated? I’d like my GP to have all the expertise and knowledge to ensure that I was referred to the most suitable treatment centre for my condition.
A lay person is only going to choose on grounds of accessability and gossip from friends and neighbours or worse what’s been written in the local press.
Ideally all hospitals would be equal in the state of the care provided, with centres of excellence for particular, specialist conditions, which smaller units would be unable to provide due to cost. eg, if you wanted your broken arm set you would want to be seen quickly at a local unit. However if you were in need on major heart or brain surgery you would have to expect to be sent to a larger hospital with state of the art facilities and highly experienced surgeons.
As for competition – like I said above ideally all hospitals would provide the same standard of care depending on their size and location. As I understand an appendix operation will cost the same to perform in Exeter as in Lincoln, why do we need competition?
When my 90 year-old mother was found very ill at midnight choice was the last requirement – we wanted fast and effective treatment from the nearest hospital. We would not have had time to check their ratings but should be able to rely on a common standard of excellence in medical and nursing care. Ensuring we have a fair and equal service countrywide should, surely, be the only function of any NHS review.
Mark Britnell’s reported remarks don’t give grounds for optimism.
The NHS costs a lot of money to run, and costs will continue to rise. The United Kingdom has a limited amount of money to spend. So let us not confuse the arguments with talk of patient choice. This is a political decision about how to spend a limited amount of money on a hugely expensive service. The average patient would choose to have a correct and early diagnosis, timely and comfortable treatment and a successful outcome. The average relative of an elderly person needing constant care would choose that that relative was able to live out their days in comfort with dignity. It is my unshakeable belief that the average British citizen would choose the above ahead of the £37 million cost of one Apache helicopter, for instance, or the £10 million it costs to keep it flying for a year.
This Government has chosen to attempt to off-load some of the cost of the NHS to private companies whose interests and motives will not be the same as those of its customers i.e. the patients and the average British citizen.
For a guide on how not to undertake reform in the National Health Service we need look no further than the NHS National Programme for IT. So far it has cost £6.3 billion and according to Richard Bacon MP ( National Audit Office) it will “never fly”, while Simon Burn MP has called the programme a “farce and utter waste of money.” From the start there were serious objections from clinicians at the lack of consultation and involvement from healthcare professionals and, despite the competitive tendering for suppliers, Accenture abandoned their role because of rising costs and falling profit, Fujitsu were sacked and of the two suppliers left standing BT has so far been forced to write off £1.2 billion. This is not an outcome that patients would have chosen. Suppose one of the healthcare companies chosen to run any aspect of the Government’s current plans decided that costs were rising too far and profits falling too fast, what choice then is open to patients? Ultimately the only choice will be to pay for the service or to have no service. Not much of a choice.
The NHS may, or may not, be the envy of the world for healthcare provision and the challenges it faces are real and will be forever changing, but the changes this Government proposes would so fundamentally undermine the founding principles as to dismantle the service entirely within a few years. Given the choice, this patient chooses to reject the proposals utterly.
Choice and competition are meaningless unless we have a NATIONAL health SERVICE. Unless the duty of care to every citizen remains we will only be left with health, no SERVICE and it will not be NATIONAL.
The duty of care must be kept or all other discussion is pointless.
I am deeply concerned that there is in this proposal, a movement which will cause a gradual degredation in the service provided to the patient and an open-market ethic that will eventually infest the National Health Service changing it into a profit driven organisation. The ethos of the NHS has always been driven by the need of the patient not the profit margin. I am totally opposed to the suggestion that GPs should be responsible for the budget of their region of the NHS and firmly believe that tendering out to external providers will only serve to mirror the debacle of the cleaning and maintenance contracts of recent years in which service declined dramatically as the lowest bidder achieved the contract and cut the standards of service.
Choice and competition are meaningless unless we have a NATIONAL health SERVICE. Unless the duty of care to every citizen remains we will only be left with health, no SERVICE and it will not be NATIONAL.
The duty of care must be kept or all other discussion is pointless.
Other discussion is a smokescreen to cover the removal of the duty of care. This must not happen.
It has been announced that a group of Conservative MPs, led by former public school-boy Nick de Bois, are drawing-up a list of “Red Lines” – points on which the Tories will not compromise with respect to public opposition to NHS reforms and privatisation. The “Red Lines” are, by definition, the points on which the Conservatives REFUSE TO LISTEN.
Since work on drawing-up these “Red Lines” began before the NHS listening exercise was even finished, that proves the exercise always was a PR stunt. There is no clearer way the Conservatives could have indicated that they are not interested in voters’ views, regarding the issues of Choice and Competition, or regarding any other aspect of NHS reforms.
Competition and increased choice are not the way to maintain a quality NHS for many reasons including the following.
There is no evidence (from research from many countries) that choice enhances equity of access to health services.
Patients and their families understandably focus on their individual experiences, needs and priorities. If their needs are not met, the Government proposals are that patients will have the opportunity to ‘shop around’ for services to a greater degree. However ‘shopping around’ will only benefit those who have the time and resources to do so. There is an assumption that everyone can make ‘the right choice of hospital or clinical department.’ However greater ‘choice’ is likely to benefit younger, better educated, and more affluent patients. Patients living in poverty, or who have chronic illnesses or complex health problems are far less likely to be able to make their voices heard, and people without a car, funds to travel, access to a computer, or time to research treatments and services will not have an equal choice. All the indications are that greater choice will increase inequities.
Foundation Trusts are expected to compete for patients; one additional disadvantage of this it that it threatens the sharing of good practice and prospects for collaboration in research and development.
The experience with commercial providers has for some time already raised serious concerns and has illustrated the limitations of ‘choice’. In the case of Independent Sector Treatment Centres, the costs have been higher and the quality of the service lower (for example in terms of emergency backup) than in the NHS. In some cases systems had to be set up to actively encourage patients to use the Centres – rather than waiting for them to be ‘chosen’.
The Government’s proposed reforms may even reduce choice. Putting services out to tender for a specific contract period, like railway franchises, gives no guarantee that the franchise holder will continue to employ the same teams, so in this case it will be the Government and the franchise holder – not patients and their communities – who will make choices about healthcare services. If local health services are merged into polyclinics, this will reduce local choice even more. At the present there is some ability to choose GPs and services we know and trust; and many are content simply to attend their local health centre.
I am extremely concerned with the proposed NHS reforms. As a medical student, I would like reassurance that my future career will be serving the needs of my patients rather than private business. The NHS provides the framework for this service and the government should take extreme care not to damage this.
I understand that consortia will give GP’s a stronger voice to make decisions which best suit their patients, however the involvement of private health providers in these consortia is deeply troubling. Medical care is not comparable to telecommunications or gas and water providers. Many of those people who work under the NHS do so through a sense of care and duty to their patients. They work antisocial hours and go beyond what is asked of them because it is a vocation rather than a job. Private companies are motivated by profit and not the well-being of the population and as such I am highly sceptical of the introduction of an open market in healthcare providers.
There must be clear unequivocal evidence that the role of Monitor is to maximise the standard of care for patients rather than promote competition with private providers. Moreover I can not see how the involvement of these private multinational corporations can do anything positive for healthcare in this country. They stand to fragment the NHS which is the envy of developed countries around the world (Mr Obama isn’t reforming healthcare in the US for nothing). By handing healthcare over to “any willing provider”, the government is simply selling off a highly equitable system to private industry. Claiming that this is “liberating the NHS” in any way is farcical.
Please remove the creeping privatisation from the health and social care bill. There can not be an open market in healthcare because the open market doesn’t “care” about health.
If private enterprise is allowed to compete with the current NHS hospitals, the only driver for it is PROFIT, which will be an extra burden to the taxpayer. This is what is fundamentally wrong with the provision of healthcare in the model proposed. In the long run, the choice will be less, because in time, the private sector will have taken away all expertise and experience for the more complicated (read profitable) procedures and thus leave patients no alternative but to go for (expensive) private treatment.
This situation already exists in dental care, and to allow it to happen to general healthcare is in my opinion criminal, because it will leave the less well-off part of the population with nowhere to go in case there is treatment requred that is (in the future) not available on the NHS.
History will repeat itself again and again if we do not learn from the mistakes that were made:
Privatisation of railways, PFI for schools and hospitals, etc, etc.
It is a plan that is ill-thought-out, and to cure it, it has to be removed, else we all will be worse off in the future.
People do not want choice. Good quality healthcare should be available for all and locally. Private companies will always be driven by profits and will not prove reliable, cost-efficient or indeed efficient in the care they provide. Likewise competition will not improve the services.
Our healthcare system is revered worldwide, please do not change this. The same doctors and consultants treat people whether on the NHS or with private healthcare so it is not a question of expertise. Those who pay may be treated sooner of course, or just put at the top of the queue to be operated on at NHS expense.
Please listen to the doctors, nurses and other health professionals who are giving you a resounding ‘no’ to these changes.
Private companies have always been free to compete alongside (and with) the NHS but only ever achieve a few percent of UK healthcare turnover. If they could provide NHS-level comprehensive quality care they would already be doing it. This bill is the government’s gift of a leg-up without which private business could not compete in this field.
I do not want choice or competition because, history shows, it does not drive improvements in services previously provided on a national basis. Just look at, for example, rail services where the so called choice is no choice at all because you still need to get from A to B at the time you need to travel; and telecoms and utility providers with their confusing and therefore anti-competitive and anti-consumer pricing structures.
The NHS should be about providing patient care at a local level. Patients are patients, not consumers. Doctors should be doctors, not consumers. A central bureaucracy should exist to ensure the vast purchasing power of the NHS is used to secure best value in the provision of supplies and that facilities are well run and managed. These are not matters that should concern patients or the medical profession when care is needed.
I hope these proposals will be dropped.
“How can we best ensure that competition and patient choice drives NHS improvement?
The question is very leading and unfit for an open-ended listening exercise – is this a methodological error or an intentional device?
It unduly links “competition” and “patient choice”. This rhetorical strategy is designed to make readers, who overwhelmingly will agree with the idea of patient choice, agree with the much more controversial concept of competition.
On Patient choice
– The idea of choice here comes from a consumerist idea of choice: in a market, say for garden tools, people know what they require and are best placed to choose the tool that suits their needs best etc. But even here they will rely on some expert advice whether or not they should pay a little extra for a better quality tool.
Medical treatment is about as complex as decisions get and making the wrong kind of decision can result in ill health and in some cases, death. There is a reason doctors train for years to become experts in medical knowledge, being able to make sense of the raw information and acquiring experience with similar cases. There is thus a strong argument for “expert choice” in consultation with “patient choice” on medical treatment. Medical treatment is much more complex than most choices, and thus a simple free market model of choice is not appropriate for healthcare.
In healthcare, we also need to distinguish between “choice of providers” and “choice of treatments”. Investing in giving patients a choice between different NHS providers (choice of GP and hospital) would make a lot of sense. Developing these NHS providers to provide the highest quality in an environment of patient choice would be a much better investment than the changes proposed in the current bill.
On competition:
You can have “patient choice advised by expert choice” without increased competition. There are also instances in which competition can lead to less or worse patient choice:
- Introducing commercial competition in a context where GP consortia also become purchasers can create conflicts of interest which skew the expert choice that people rely on for their own decisions.
- Competition requires failure among the providers who are least able to compete, i.e. least able to make a profit. NHS services are not designed to make a profit, while private companies are. The best way to make a profit is not to offer as universal a healthcare service as possible like the local hospital, but to focus on the most simple, high-volume, low risk services, i.e. cataracts. This is where private companies will enter the market and “compete”, most likely offering cheaper prices than NHS providers.
NHS providers like hospitals practise some degree of internal cross-subsidy – administration, facilities, maintenance, from such “good value” procedures to less frequent, more complex, more expensive cases. If the simple cases are cherry-picked by private companies, the more universal NHS providers may become financially non-viable.
With the NHS providers focusing on good coverage of services across the country and private sector providers focusing on profit-making procedures, it is hard to see how any amount of regulation can create a “level playing field” as the question suggests. The British people are overwhelmingly in favour of a not-for-profit system of healthcare guided by public benefit and patients’ needs – Mr Lansley is not listening.
Private providers have to make a profit beyond the cost of the service provided, and this will have to come out of taxpayer’s money. If they are listed companies, they have to make enough profit to pay dividends and satisfy stakeholders on a quarterly basis – their accountability will be to shareholders first and patients second (at best).
There is no public interest (but a whole lot of lobby interest) in increasing the market share of the private sector in healthcare in this country. Thus we have to question why we should be ensuring “a level playing field” as the question implies.
Solutions:
- Make it clear in the remit of the health care regulator, Monitor, that it is not their role to increase the market share of the private sector in healthcare.
- if you want to improve the imbalance, factor the fact that complex operations will become more expensive when they are no longer internally cross-subsidised into the tariff paid to NHS hospitals. Patients have an interest in making sure more complex procedures that the private sector has no interest in remain available.
When I’m ill I don’t want choice, I want certainty; certainty that I will be treated by people who:
1. have expertise in my particular condition
2. have the equipment and facilities to treat me
3. are kind and considerate and
4. keep the place clean.
I don’t want to have to ‘choose’ where that is, I want people who know to get me there as quickly as possible.
Everything else is less important than the above.
Where the NHS purchases goods and equipment – healthy competition between private companies/suppliers can help drive down costs ie provide value for money as long as such products are fit for purpose and quality is not compromised.
Presently, if one sector of the NHS makes a profit, this can be reallocated to support a less profitable sector. How would this happen with private companies? Profit generated would be paid to their shareholders, they would not invest back into the system for the benefit of patients.
Specialist commissioning teams would need to be set up, not only to contract with private companies but also to monitor services provided ie a need for safeguarding. Is this not a function similar to that of PCT’s? If PCT’s work well in some areas – could these not be retained or modified? If you destroy or disestablish an infrastructure there is a danger that companies can then increase charges – you no longer have an option but to trade with them, plus there is a danger of price fixing.
Some private companies try to drive down the wages of lower paid agency staff to the minimum wage or just above. Benefits often have to be paid to such families to bring their living standards back up to an acceptable level – a hidden cost to the tax payer which could cancel out any saving to the NHS.
Most patients do not want (or are not in a position) to travel miles to obtain medical treatment – a good local hospital is an essential. Carers and relatives when working, can often struggle to visit patients This problem can be compounded if travelling time and travel costs are increased – practicality can often limit patient choice. The importance and input of carers should not be underestimated in helping to ensure patient welfare.
Choice:
Irrelevant: The vast majority of complaints received by NHS services over the past three decades relate to withdrawal of services from local hospitals [ A/E, Maternity, Children's etc... ].
People DO NOT WANT alternative providers. They WANT good quality local NHS provision.
Competition:
Irrelevant. The vast majority of complaints in this area relate to the LOSS of co-operation between local providers CAUSED by the requirement for them to be in competition.
It is therefore clear that UK politicians, of almost all parties, are very guilty of deliberate misunderstanding of their role in these processes.
Yes the NHS has problems. However NONE of the existing problems can be nor will be solved by the proposals currently on offer. I would advise everyone to stop readng the LIES being propagated by politicians in speeches and interviews and actually to READ the draft legislation as it becomes available. Anyone who then votes for it should be held personally responsible for the breakup of the NHS which will follow inexorably from this legislation should it make it onto the statute book in anything approaching its current state.
We have choice, you can have NHS, Bupa (or equivalent) or pay as you go. In theory the Americans have even more choice (yet in reality they have one extra choice – have nothing, and one less choice -state health care), yet they pay far more for their health care than we do – ask any ex-pat American (all of whom that I have met think the NHS is absolutely wonderful).
Competition has bought us few benefits, e.g. in gas we do not have bills cheaper than the rest of Europe. However, before privatization the gas board would fix leaks (now they give you a list of corgi fiters if the leak is your side of the meter), so now we pay the same for less of a service. Similarly, if we hadn’t opened the telephone area up to competition we would have fewer mobile telephone masts but greater coverage.
My motto is cooperation not competition. Lets hear it clearly -quality not choice and competition, keep the private sector out of the NHS completely.
I realise I have left a comment, but I’ve just looked up Dr Julian Sims, and unless there is another whom Google failed to find, this person is a lecturer in management rather than a medical doctor. I think people should know that.
THE NHS MUST ALWAYS REMAIN THE PRIMARY PROVIDER who provides services to the customer through the GP (you and I).. Whether the NHS chooses to commission services from private companies and create competition to provide those services is up to the NHS and is possibly a good thing. But the NHS MUST NEVER BE PUT IN A POSITION WHERE IT HAS TO COMPETE WITH PRIVATE COMPANIES.
It is not a question of cherry picking – this must not happen.
Doctors should be able to CHOOSE services for a patient WITHIN the NHS provision. This would instigate a more natural raising of standards within the NHS.
Choice can be a source of stress at a time of crisis. It is more important to maintain wellbeing by providing a relaible service that gives top quality care. Choice can raise doubts about the relative value of the pros and cons of options. Service users I have soken to say they want to know that their local service is as good as it can be. They are not campaigning for choice.
I DON’T want choice if that involves the private sector becoming involved. The choice I want is for the NHS to be allowed to build on what it is currently doing without having to spend Billions on a re-organisation we do NOT need.
Surely the question should WHETHER not HOW. I just want the hospital and NHS service in my local area to provide a quality service when it is needed. The last thing I want to do when ill is to try to sort out which is the best part of the country to travel to – even if I had the relevant information. Choice is only relevant when you are not being offered the best.
How to ensure that the best that can be provided, is being provided can surely only be done
a) by ensuring that managers actually earn the money they are paid by constant checking of their own provision by actually walking the wards and talking to patients and asking for feedback on doctor’s services on a regular basis. Time consuming, tiring and boring yes but the senior manager being visible does make a difference (ask any business that wants to ensure its staff aren’t slacking).
b) being audited
c) having an independent body (the King’s Fund?) compare taking account of different local variances that may affect outcomes and then offering advice on improvements.
d) holding those in overall charge to account if improvements do not happen after failings have been flagged.
I’m not claiming that with such a large organisation, this is easy but it can not be right to start paying a third party to do something. If there are people employed by the private sector who are capable, there are people who could be employed by the public sector who are capable and there would be no profit element to be taken out. Using the private sector does not seem to have reduced the cost of energy in any way. All it does is to remove responsibility from government.
This is the wrong question. It should simply be… How can we best drive NHS improvement? Why is competition seen as the answer when all the options haven’t yet been considered. I do not want competition in my NHS, I don’t want some services or some locations better than others. I want to build on the positive improvements that the NHS has already delivered and continue to have a ‘national’ health service that we can continue to be proud of. Do not break up the NHS.
The flaws in this consultation pattern are clearly set out in responses on this site and elsewhere. David Cameron’s determination to implement changes rapidly and avoid “Mrs. Thatcher’s mistake of leaving it too late” has turned his policy approach into an incoherent shambles. No sensible management couild treat the manipulative questions in this consultation as an adequate basis for long term development.
The choice I want is to have a real say, with all other citizens, patients and carers (professional and family) in the continuing improvement of a service which is already widely respected. The current rushed approach should be stopped now and a genuine process of wide and continuing public debate started. As well as professional bodies we have a range of organisations involving patients, carers and other social groups which could contribute to this process, as indeed they do already. This approach could re-invigorate existing commitment to the NHS and encourage further improvements with earlier effects than is likely with the current divisive approach.
As someone who worked alongside NHS staff for many years as a family carer in meeting the increasing care needs of a wife with a progressively disabling illness, I believe this approach would better fit the attituides and needs of patients, carers and committed professionals, as well as the ethos of a genuine health service. This view is also encouraged by substantial experience of working with health professional in bringing about performance improvements and general organisational and personal development in NHS organisations.
I am sure there is a place for private and voluntary sector input as there always has been – but through a sector run by public bodies for the benefit of the popiulation, NOT on the basis of competition characterised by the raw greed, self interest and incompetence which has brought our national and international economy to its current damaged state. Perhaps there is scope to increase income to the NHS by using its successful experience to inform better approaches in some other less sucessful sectors?
Finally, I have been a volunteer in care work for many years from practical field work such as driving patients to hospital appointments to chairing a not for profit care organisation. I do this because I believe in the importance of the work and in the value of community approaches from which I and others have benefitted for so many years. I do not have the same enthusiasm for work which will move money from the NHS to the pockets of intertnational businessmen. I know that other volunteers are also determined not to be used simply as cheap labour.
Let us remember that the NHS was created for the public good with a massive mandate from the people after world war two and drew on ideas from all political directions. There is no such mandate or common ambition for the current propo
Choice & Competition are 2 different beasts
Choice- Most patients overwhelmingly want to attend their local hospital – choice is only important when they have a complex medical need ( eg needs tertiary centre ) which the local hospital cannot provide. Even in these cases patients would prefer to go locally if the service was available.
Competition- by definition has winners & losers . Private providers main motive is profit , hence they will choose high volume low complexity procedures & under cut the NHS which has to provide ALL services . Private providers have no interest in providing an ALL encompassing service for local communities .If they walk away after 1 or 2 years it then leaves the NHS to pick up the pieces and redevelop the services again ! Private providers have no long term commitment except to profit & dividents.
The premise of this listening exercise is that patient choice and competition will produce improvement in the nhs.
Neither competition on commercial grounds or patient choice can deliver high quality care.
The excellence we aspire to is dependent on proper understanding of true quality. This is complex, and understanding can only be achieved by systematically looking at the evidence surrounding healthcare. This understanding can be achieved through cooperation, not competition.
Patient choice is a poor substitute for proper engagement in a collaborative and informed healthcare system.
I had hoped to be able to engage with this listening exercise as part of a constructive process. It appears that the key issue as to the ideology underlying these reforms is not being debated, just how to best implement these flawed ideas.
The heavily loaded questions being put to us on choice and competition are as insulting as they are inappropriate. This “listening” exercise looks increasingly like a desperate PR stunt aimed at gathering any submissions which could be spun expressions of support for highly unpopular policies the government is determined to push through at any cost. Genuine debate is not possible when the issues are framed and stage managed in this fashion.
When it comes to health care, quality beats choice hands down. I don’t want a choice between different providers who answer to the market. I don’t want private enterprise or lobbyists. I want an assurance of quality care, provided as a duty of government, by health workers who care about the needs of the patient.
Competition could lead to fragmentation of our currently hugely appreciated NHS (the NHS had the highest ‘patient satisfaction rating’ ever in the last year) Currently patients have confidence in, and familiarity with, their local hospitals that generally provide a comprehensive range of services. The White Paper will compel GPs to commission services from ‘any willing provider’ which will lead to this comprehensive care being fragmented. Local NHS hospitals will be forced to compete with private providers and because EU rules state that no preference can be given to NHS providers, any GP consortium which gives their local hospital preference could be open to legal challenge. Consequently NHS hospitals will have no choice but to concentrate on profitable departments and close other less profitable departments which are nonetheless essential (for example geriatric departments) in order to remain competitive.
“Cherry picking” by private companies:
One of my biggest worries is the possibility of “cherry picking” by private companies. This must be fully ruled out, and a mechanism for preventing this must be clearly stated. According to the Health White Paper, all providers will be expected to make a profit. Hence there is a serious risk that the best care will be diverted to those people who are most profitable to treat, not those who need it most. A fit and healthy young person with a single medical condition can be treated quickly, efficiently and “profitably”. But patients with long-term conditions cannot be cured. Their illnesses cannot be managed with efficient medical interventions. They need expensive, often unpredictable, ongoing hospital and community care. Health-care based on profit will fail these, the most vulnerable patients. According to the WHO Committee on Social Determinants of Health, “it is the public sector rather than the market place that ensures equitable distribution of resources”.
I am very concerned that the legislation proposes to remove the Secretary of State’s duty to provide a comprehensive health service. I think the duty to provide a comprehensive health service is crucial and should be retained. Dropping this duty would erode the foundations of the NHS and inevitably mean privatisation, which in turn means that some money for health care would end up as profits for private company’s rather than for its primary purpose of health care.
Good quality healthcare should be available for all and locally. The NHS is revered worldwide. The proposals in the White paper will destroy it as a public service providing comprehensive care for all on the basis of need. Please don’t allow this to happen
I remain unconvinced that the idea patient choice should be the holy grail of the reforms. I agree with others: we want our local services to be excellent. What we really need if we are ill or have a long-term condition is clinical excellence (as opposed to the snazziest-looking building, or even the shortest waiting time). Most patients do not have the knowledge to judge this: we trust our GP to refer us appropriately, or we hope the A&E we are taken to is up to the mark.
I have 20 years experience as a practice nurse, and even more years as a patient with chronic disease. I can remember life before Primary Care Trusts, and was there at the birth their forerunner: the Primary Care Group. In those days, both practice and district nurses felt involved: we had elected representatives on the board, who held regular meetings with us. Hence we felt we had a real voice in developing the invaluable services we now enjoy, (eg respiratory care team, diabetes services, continence service). I am very concerned that we might now lose some of these services. Specialist nurses in hospitals also feel threatened; eg the MS trust, who support MS nurses nationwide, are expressing concern. We have gained so much in chronic disease management in the last decade or so.
Really, I can see no good reason to abandon PCTs and set up new structures around GP commissioning groups – who will of course need to buy in commissioning expertise and administration. PCTs do need to change: they need more clinical and patient representation, including nurses and other health care professionals. In some cases, they may need to be smaller -as they once were. But disbanding them altogether and setting up something not dissimilar to GP fund-holding seems an unnecessary waste of money
One final point: if patients can choose to register with any GP, they will not get home visits if they choose a practice away from their home. Is this the intention -to do away with GP home visits?
Whilst I understand that choice and competition can in certain arenas drive quality and improvement, I do not believe enough thought has been given to the overall aim of trying to improve the health outcomes of the most deprived and reducing health inequalities. These communities, in the most, do not have the means, knowledge or access to a choice of services and would not benefit from a competitive NHS. As far as I can understand this could only result in these invaluable services receiving less and less support, both in terms of service provision and with regards to finance, widening the gap between the rich and the poor and increasing health inequalities.
Choice and competition are issues which seem to me to be largely driven by a London agenda. As a GP In Newcastle, the vast majority of my patients want to be treated at our local hospitals. In more rural areas this must be even less relevant. I fear that competition leads to fragmentation and creates great difficulty for local clinicians tyring to work together to create co-ordinated patient pathways. Certainly I am completely opposed to the idea of Monitor enforcing competition, which would make this all but impossible. .
How can we best ensure that competition and patient choice drives NHS improvement?
Unfortunately we cant. We know that patients generally want to be treated near to home and currently have little voice about local services since CHCs were abolished and decisions about health services have become more and more shrouded in secrecy with managers being less accountable to the public. For example, after promising ‘no major NHS reorganisation’ in the election manifesto we have suddenly seen the most fundamental reorganisation being proposed since the inception of the health service.
Competition is inconsistent with equitable access, and maintaining a comprehensive service. Price competition is know to drive down standards. It is wasteful (as demonstrated very clearly in the American model) and serves only the interests of shareholders in the private companies that will come to successfully bid for those parts of the NHS from which an easy profit can be made.
Let those who argue in favour of competition driving up standards of care provide the evidence; I have not seen any as yet.
Most people do not want ‘choice’ in health services – we want our local hospital to be the best, run by and for local people and available when we need it. What is the point of choice if the alternative is hundreds of miles away?
Also, we do not want any more ‘privatisation’ of services – here in Cornwall one private firm has already made a mes of GPs out of hours services!
Look at railways, energy supply etc – this is enough to show that private firms are not better, nor do they operate for the benefit of the consumer! This needs to be even more the case in health provision – private firms will just ‘cherry pick’ the services which make them the most money!
We do not want to end up with an expensive and unfair system as operates in USA.
STOP THE STUPID CHANGES PLANNED TO NHS – They will not work for patients, only to mainly foreign contractors!
Listen to the people!
Lance Dyer
* Which are the types of services where choice of provider is most likely to improve quality?
In my opinion these are areas such as, well none of them. If people are unhappy with a service they receive then there is plenty of local alternatives to choose from already. For instance if you are not happy with a GP then you can use a walk in center and get the same quality of care and service.
* What is the best way to ensure a level playing field between the different kinds of provider who could be involved?
Oh if this really must go ahead then by having a democratically elected independent body which can regulate and oversee the different providers. All the providers should be following the same rules/code or law not only locally but nationally. Also every local NHS user has a vote in saying not only who the regulator is but also just who can compete in that area. Similar to a general election as such only without the party lies. And it should be absolutely free from government and political interference.
* What else can be done to make patient choice a reality?
Ideally it would be a reality because the system we have works already!
Sure it can be improved but better staff training and tighter regulations that all pcts follow is the way forward and not messing about with what has worked fine all these years!
I’m routinely offered choice of hospital by my GP but am not in a position to exercise meaningful choice. I believe the point where choice is meaningfully exercised is in choosing one’s GP. After that it’s the responsibility of the NHS to ensure hospitals meet proper standards.
As for competition, this is the nature of the operation in a market where people compete for profit. I can’t see how it’s appropriate to public benefits such as health and education, which are a mix of sensible investment by a society and human rights. People who work in these fields are not motivated by profit or competition in a market sense, though they will cheerfully compete with each other on quality (which is where sensitively designed league tables may have a role).
Competition will not drive improvement. Competition means that the cheapest service provider will be chosen, and that will not necessarily be the best for the patient.
‘Patient choice’ is a fiction. How do I as a non-medically-trained person have a clue who is the ‘best’ service provider? I just want the nearest one. And what does ‘best’ mean? If I have a broken leg I want it to mend. How can one service provider make it better more quickly than another?
I agree with Carol Holbey who says:
I do not want choice or competition because, history shows, it does not drive improvements in services previously provided on a national basis. Just look at, for example, rail services where the so called choice is no choice at all because you still need to get from A to B at the time you need to travel; and telecoms and utility providers with their confusing and therefore anti-competitive and anti-consumer pricing structures.
The NHS should be about providing patient care at a local level. Patients are patients, not consumers. Doctors should be doctors, not consumers. A central bureaucracy should exist to ensure the vast purchasing power of the NHS is used to secure best value in the provision of supplies and that facilities are well run and managed. These are not matters that should concern patients or the medical profession when care is needed.
I want these proposals to be dropped.!
As NHS consultant, I am against more private competetion in NHS. Most likely it is going to lead to more cherry picking by private providers. MHS trusts will increasingly be left to deal with more complicated and risky areas of health.
It is also going to break down NHS Trusts, to lead to continuous efforts of reshaping it new forms
Private healthcare will reap profits that could be better used to invest in the NHS. Private enterprises are there to make profit and will cherry pick the least complicated and most profitable illnesses to treat. The NHS will be left with the most diffficult cases and hence risk acquiring a reputation for not providing effective treatments. And who will work for private enterprises? NHS trained staff?
General Comments
Very difficult to capture the broad range of views with the way each question is structured –leading questions. The choice of the average patient is to receive the best treatment (as judged clinically) at the nearest hospital. The overhaul could not have come at a worse time as NHS should be concentrating on making savings
Choice and Competition
This is a leading question – it assumes that competition as well as patient choice should drive NHS improvement.
In almost all other economic areas price has been a key vector of competition, modified by users’ experience of quality. In health care the consequences for patients of price driven competition are more serious than in soap powders.
Even patient choice is for many, particularly in rural areas, severely constrained. Only one GP practice may be convenient, although now that out of hours home visits are not normally provided by the registered GP the traditional relationship with the GP has been weakened. Only one hospital may be accessible with public transport.
Patient choice if it is to be an effective driver of improvement depends on informed patients. GPs will always be the preferred source of information, but need to be supplemented by readily available information on providers’ performance and cost.
As many others have said before me – this is not the right question. It assumes that competition and choice will drive quality improvement without allowing us to consider any of the other ways of achieving the same goal far more effectively. I cannot have any faith in a ‘listening exercise’ that appears to be structured to enable to government to only hear the things it wants to hear.
Politicians and Public sector institutions seem driven by this ideal of “Choice” when all people want is to be able to use local services and received professional and prompt service.
One area where “Choice” has already damaged services is in education and school provision. Before this focus on parent choice, children went to their nearest school. Some were good and some were not so good, but that was down to the leadership of the staff and head teacher. As a result of Parent Choice families are often uprooting and moving house to be in the catchment area for a good school. As a result many schools which are perfectly adequate are now in danger of closing as they do not have enough pupils to remain efficient. We have the ludicrous situation where parents are travelling miles to take their children to a “Good” school when the local one on the doorstep is empty. In five years or less this could reverse as a new head teacher comes in and turns the school around.
It’s not the school it’s the people who lead and manage it that make it good or bad.
The same applies to National Health provision. When we are ill and in need of National Health services we do not want to have to choose where to go, we rely on our GP and other specialists to decide for us the most appropriate hospital or centre to go for treatment. No one want to travel miles to a hospital but if it specialises in a specific area then and is best for the patient then thats OK. All National Health hospitals and care centres should be of high quality and creating competition between them or external private sector facilities is not helpful and detracts from concentrating on in house standards.
The NHS should concentrate on bringing all hospitals and GP surgeries up to a common high standard of care.
WE dont need choice or competition- we need a good health care service that provides the best for everyone. If i have something wrong with me I dont want to choose between three hospitals- I want the one nearest to me to be good. I want that for everyone- regardless of where they live.
Competetion will just lead to the cherry picking of services, taxpayers paying for private profit on top of all the services we already pay for. Please stop these terribly damaging changes here!
I don’t want choice. I don’t want to have to shop around for the best deal when it comes to healthcare. I simply want a high quality service that I can rely on and trust.
Patients should not have to become experts in the ins and outs of the healthcare market. This is a public service and the same service should be offered to all, regardless of their knowledge of the system. By introducing competition and, with it the illusion of choice, I fear that many patients will lose out.
I am concerned about the introduction of market principles and the private sector into the NHS and other public services.
I work in Laboratory Medicine (Pathology) . If these services are open up totally to private companies the “competition” will not be on a level playing field. Large private pathology labs have the backing of their parent companies who are often involved in many other ventures (construction industry , food production, medical products , engineering etc etc) They can therefore afford to undercut NHS labs and thus “win ” contracts for the most profitable parts of the service (eg GP pathology services) centralising provision away from local hospitals and divorcing the service from the locality of the users. In the end they will then have a monopoly as provider and what may have seemed like a “good deal” initially, will turn out to be a very poor one in terms of Quality , adapatability to local needs and , eventually as the company seeks to realise their profit from a lost leader, cost effectiveness. By then however the local NHS laboratory services will have all but disappeared and we will be left with a commercialised, inferior, nationwide take it or leave it laboratory service replacing what was once one of the unrecognised jewels in the NHS crown ..one I have been for 32yrs very proud to belong to and work for.
The myth of free market “competition” has seduced Conservative politicians before, and it has given us a rail system that is not only inefficient but also (according to various calculations) between three and five times more expensive to the state than when it was nationalised. What use is “competition” in public transport when there can only be one provider between A and B? What use is “choice” in healthcare if I’m diagnosed with a condition that requires immediate treatment, and have no means to travel 50km to another facility?
The private sector can have only a limited role in the provision of public healthcare; otherwise the profit motive will kick in and patients will suffer.
Finally, as someone engaged in ongoing research, I am APPALLED by the bias in your survey questions. They are imbalanced, and reflect the outcomes that the government wants to hear, not the diversity of answers this “listening” exercise has generated.
To explain:
Q: How can we best ensure that competition and patient choice drives NHS improvement?
This question presumes “competition” and “patient choice” are givens. They are not. They are the very corrosive acts that I (and others) oppose.
Q: Which are the types of services where choice of provider is most likely to improve quality?
Again, who said “choice” is a given? What are the alternatives? If the NHS needs to change, let us not assume that opening services to a range of commercial operators is the only option.
Q: What is the best way to ensure a level playing field between the different kinds of provider who could be involved?
Simple. Don’t open them up to different providers. As recent academic discourse on capitalism, commerce and even ecosystems has shown, the free market never supports “a level playing field”. Weaker agents will always be overwhelmed by those privileged with stronger resources. Tesco Express kills off small, locally owned shops. Multinational healthcare corporations undercut public health facilities, etc. At the bottom of the heap, NHS patients are – unless wealthy enough to afford private healthcare or the means to travel further afield to “competing” services – unable to exercise equivalent power.
Q: What else can be done to make patient choice a reality?
Eh? Go back and read all of these comments. Do not presume that “patient choice” is either a given or desirable.
As a layperson I do not support these changes; more importantly there seems to be huge unease within the healthcare sector itself, eg the BMA, about the scope and speed being proposed for reform. I am very unhappy about the proposal to remove the duty of the state to provide a comprehensive health service.
Patients just want to know that the quality of care they will receive will be of a reasonable and consistent standard. I don’t believe introducing yet more companies will improve standards, and I am distrustful of the apparent links between private healthcare companies and these changes. The proposed system allows for share-holders and profit-making and I fail to see how this can ever be cheaper than delivering a service on a not-for-profit basis; research shows that admin costs for more privately delivered healthcare (eg USA) are a higher percentage of spend than within the NHS.
Regarding competition on quality, where there are areas of good and bad performance within the NHS, I would expect high performing departments to share experience and best practices. This will not happen with competition between consortia and/or private companies – in a competitive market, they would be incentivised to guard their successes rather than share them. Co-operation should be the driving force – that’s what “society” is all about.
I found this article very interesting: BMJ 2011;342:d1695
As far as healthcare is concerned, choice is a red herring and less relevant to me than being assured of a good standard of care in my local hospital or clinic. Within that I might want to choose a consultant but I would rely on my GP’s advice since the information about consultants is difficult to interpret for the lay patient. An emphasis on choice will also increase health inequalities since those whose health is most at risk are least likely to be in any position to exertise choice. As for competition, I distrust it intensely not least because it has to involve marketing which in turn depends in part on presentation and incentives. It’s not without reason that the UK has had restrictions on health product advertising for many years. Advocates of competition also often ignore its direct and hidden costs, both to the organisation and to the consumer.
The situation is slightly different when it comes to services offered at home or residential care. Because more personal (not just intimate) services are involved, there is more scope for the offering of different types of package and the exercise of preference. However there is a great risk of inadequate quality control and regulation.
I am a man in my mid-50s who has lived with a chronic disease since my late teens, so feel that I know the healthcare system quite well. In my early 20s I moved to the US – against the advice of my doctors – and there I nearly died because I was not able to access the healthcare system because as a chronic patient I was ‘uninsurable’. When my employment situation changes, and provided me with health insurance, I encountered a very mixed bag of provision as I moved across the country, from the very best to really quite poor. For some years I lived within a stone’s throw of one of the world’s leading research hospitals, specializing in the area of care I required, but I was unable to access it – not because I was ‘too well’ but because my insurer would not pay for me to use that facility.
I find the way the questions are framed in this section to be loaded towards a particular model of thinking. The assumption here is that a choice of provider will, by definition, improve quality. There may be an argument that in large urban conurbations, competition on quality is a ‘good thing’, but here in the westcountry it makes little sense. We have three large hospitals within a 25 mile radius, and some are better at some things than others. The GP community knows this, and my own GP has always directed us towards the appropriate hospital for a particular treatment. If that is competition (which I would argue it is not, in the strictest sense), it works brilliantly. The hospital we use most is the relatively small Torbay Hospital, a national leader in GI, which happens to be the area where I need the most support. This was one of the first foundation hospitals, and is excellent in almost all aspects. The financial integrity of these kinds of small hospitals is likely to suffer from competition, eroding the quality of overall competition, rather than enhancing it. Why? Because private providers cherry-picking the easy jobs will take away income that smaller institutions can ill-afford to use.
You also ask how a level playing field can be ensured to all providers. Why should it be? Why is there an assumption that any type of provider should have equal access to our NHS? Having lived in the US for 12 years, I have seen the corrosive effect of profit mixing with healthcare (and it can increasingly be seen here in our own dentistry provision, where the NHS has largely ceased to work as a joined-up service). Although the American healthcare system leads on research and treatment in many areas, overall health outcomes in the US are significantly poorer than in most other industrialised countries because access to care is so unequal, and because clinical decisions are being made by accountants, not by clinicians. There may be a broad range of competing providers, but most patients have no choice about which ones they can use because their insurer makes the decision for them based not on clinical appropriateness and quality of outcome, but on cost. Some accuse the NHS of the same practices, but in my quite broad experience as a ‘consumer’, I have never experienced an instance of this, and have also seen huge improvements over the past 10 years largely because of increases in capacity and improvement in management. The NHS is an ecology, and introducing corrosive and infectious organisms – like the profit motive – can only significantly harm the overall health of the system. I don’t want to see the system opened to all comers. I’m happy to see not-for-profit organisations and corporations providing services, as long as they are competing on quality, not price, and as long as the commissioning of such services remains within the NHS, not contracted out to a commissioning body which may or may not have a loose connection to local GPs.
Your final question once again makes the assumption that choice is always a good thing, and does not ask the more fundamental question: is choice necessarily a good thing, and is putting resources into providing choice going to enhance the system overall? I have always had a choice about where I go to receive my health care, except when I lived in the US where there is a healthcare systems that is supposedly based on a free market and competition on price. The notion of the NHS as a state monolith whose will cannot be challenged is a myth, and in my experience I have always been able to access the parts of the NHS I have needed. Sometimes that has meant travelling 100 miles for treatment, and sometimes it has meant being sent to a research hospital in London. I use a GP surgery who is outside my local catchment area; I use Torbay Hospital as my main hospital because I prefer it to the hospital in Plymouth, which is the one I am ‘supposed’ to use. There is – and always has been – choice within the NHS. However to assume that things will be better if the entire system has been opened up to competition – and that patients will automatically have more ‘choice’ as a result – is fallacious. There is plenty of research available showing that choice undermines rather than improves the consumer experience, and that choice does not always improve well-being. The choice agenda has been pushed for more than a decade and seems to have little effect on overall provision.
My final comment on all of this is that the one thing that will destroy the integrity of the NHS as a service is competition by price. Despite some rather absurd political posturing, the NHS remains an exceptionally lean and productive organisation. Once of the reasons for that is that it spends relatively little on administration, at least compared to insurance-based systems who must have in place a huge resource-tapping body of workers dedicated to claiming and reclaiming payments. Of course some providers will be able to compete in some areas on price, as long as they can cherry-pick the services they provide and as long as they don’t have to do costly things such as providing 24-hour emergency care. Of course, it makes perfect sense for me to pop down the road for a blood test rather than having to go all the way to hospital (a 90-minute round trip in my case)…oh, but let me see, I can go to my local GP surgery for such routine things, and if that isn’t possible because they are over-booked, I can walk in to my local ‘cottage’ hospital and receive the same services. In cities, drop-in centres serve the same function.
The assumption that the NHS is broken is the insidious fallacy behind all of this change agenda. No one seems to be questioning this underlying assumption. Of course the system is expensive (although not as expensive as most insurance-based systems), and of course it will continue to need more and more money. But unless the real agenda behind these changes is further restrictions on access to services, then breaking up a working system seems to make little sense and seems to be driven by ideology. When the voter was last given the explicit choice about whether to spend more on the NHS, they voted overwhelmingly in favour.
Over the past three decades I have witnessed first-hand many quite fundamental changes to the NHS, and there is no question that the service is now more modern, fit-for-purpose, and more efficient than it has ever been. But none of the changes fundamentally altered the underlying structure of a joined-up service providing free care for all. Fracture that, and you endanger something the people of this country hold very very dear.
Whatever you decide, please do nothing that will undermine this well-beloved and essential service that remains a jewel in the UK crown of civil society and social provision. The NHS makes the UK a better place for everyone, but particularly for those of us who have been able to live productive lives despite living with chronic disease because of the excellent care the service offers to all.
Most patients do not want ‘choice’ of providers – they want their local NHS services to be the best possible. The very nature of choice and competition means that some facilities (the ‘non chosen’) will be under-used, which is inefficient. The only choice that people want is an appointment that suits them at their local hospital, and as soon as possible. Opening-up the health ‘market’ is entirely a perceived need of politicians, not patients or doctors. There is no evidence that it will benefit patients, or if there is, the government has not published it.
Almost everywhere in the world that offers choice has a less efficient health service than the NHS, so it’s unlikely that there’s any sound financial reason to introduce it. I don’t think we need to appease private medical providers – they are unwanted and unnecessary. Let’s just make sure that local NHS hospitals and the best that they can be by using the resources for that, rather than wasting it propping-up the private sector.
As shown by the Commonwealth Fund, we have the most efficient healthcare system in the world – let’s not ruin it with misguided ‘reform’. If it needs more money then removing schemes like PFI or the internal market might be more effective.
I do not believe competition is an appropriate in a health care setting like the NHS. Competition focuses on price and volume of patients in order for the provider to make a profit thereby giving them incentive to provide the care. Unfortunately quality of care and patient satisfaction with the service tends to get overlooked if the provided is making a satisfactory profit.
Another concerning point, which I feel has not been adequately addressed is how private companies will be monitored and regulated. My biggest worry is having American companies enter the NHS and destroy it like they have done to the American health care system. The NHS is too valuable of a service to risk its destruction by American health care companies and other private companies seeking to make a profit.
At the present time, I am not convinced that the Health & Social Care Bill provides enough safeguards to protect quality of care and ensure patient satisfaction. Furthermore I am not convinced that competition will improve the NHS and it may completely destroy it if it is not properly monitored. not quality of care. I would therefore advocate that there is no competition with the NHS with patient outcomes and patient satisfaction the primary focus of any change.
Competition and choice selection criteria must be robust if this is to work. suggest:
1) Competition and choice:
o Competition criteria for bids to include the following elements:
i. Clinical excellence (adequacy)
ii. Multi-disciplinary approach with documented and implemented referral pathways and processes.
iii. Coordinated service provision,
iv. Staff training and development
v. Good value for money
vi. Strong prevention programmes
o Pay for keeping people well as well as treating people who are ill.
o Motivation for services to keep people out of hospital – or getting them there early to reduce seriousness of illness / impact.
o Payment for reduction of readmissions – to encourage good support care provision when people are discharged from hospital.
o Clear guidelines about what patients should be able to choose – not clinically based elements.
The NHS is meant to be a single collaboration of individuals and organisations striving to provide equitable, effective and high quality healthcare to the country. Competition will fragment the NHS into a local market based on what providers want to offer that is profit making to their shareholders, taking resources out of healthcare. Quality will be driven down inorder to offer competitive prices, working conditions will deteriorate into sweatshops as providers maximise throughput with extended working days.
Existing hospitals will not be able to compete fairly within the private sector mentality and have too high a fixed cost in the infrastructure. This will make many hospitals non-financially viable resulting in a drop of healthcare provision in local economies.
The private sector will only pick up the cheap and less complex cases which make a surplus on the tariffs and the more complex procedures and patients with comorbidities will have to either travel to other regions or recieve an inequitable level of care.
Competition should not be part of the NHS, if the service needs to reduce costs and become more productive that is were its energy should be aimed, not and promotions and tendering.
As an NHS Physiotherapist I have grave concerns for the future of the NHS, as has been suggested by the “doom merchants” for some time this seems to be an exercise in “back-door privatisation”. Health care is costly there is no doubt about that, and yes the country is in a financial quagmire. However I do not see how competition which would include private providers who pay dividends to share holders could possibly add value. Quality would inevitably drop, as has already been suggested companies would “cherry pick” services and leave the most costly services to the NHS, if by this point many local hospitals had survived!
Choice is a plausible policy for “one-off,” acute treatments, but there are two significant problems:
1. Take cataract treatment. Some acute care can be provided by private “competitors” less expensively than NHS hospitals. Cataract care is provided in portacabins. Obviously the same care in hospital carries overheads that do not exist for portacabins. It may be cheaper, but the logic is that all cataract care is done in portacabins because competition always makes it cheaper there.
2. If all care is subject to this logic, what happens if I need cataract care, orthopaedic care, stroke and cancer care? If it is cheaper to get each aspect of my care in different places, would the NHS expect me to get each bit separately from different “competitors”? Or would it say that it is better to have all my care available under one hospital roof, even if NHS hospitals have unavoidable overheads that do not exist for “one-off” clinics? The second option requires competition recognise the non-economic value of this benefit to me. For an economic” regulator, this would be extremely difficult.
Last day of listening. On previous form, it will have little relevance to the overall decision. Didn’t Mr Lansley say before the consultation finished last year that he wasn’t going to change anything. It is sad that consultation and listening in official circles mean the opposite of the dictionary definition and is only a “ticked a box”. It would be interesting if the replies of all 4 topics were categorised as “for the changes” or “against”. The majority, I feel, would not be particularly complimentary.
Allowing private interests to make a profit out of a fundamental necessity in almost everyone’s life WILL NOT give people more choice and improve competitiveness/standards. The very fact that people are vulnerable and uncertain when they are ill makes it easier for them to be exploited by private firms and for more limited ‘choices’ to be presented to them (it’s either this or death I’m afraid). The number one priority of those practicing medicine needs to be providing excellent standards of care, NOT providing their shareholders with yearly bonuses. There is no incentive for private firms to provide good care – they will have won contracts meaning their income is more or less guaranteed, they will therefore only focus on squeezing the largest profit margins out of each contract they win.
Health care is in the public interest, as is education. A healthy, educated nation contributes more and in the long term costs less. I appreciate there needs to be savings made in the NHS and the healthcare cost to this country is unsustainable. Privatisation is not the answer, it will drag the country back 60 years and in the long run cripple us as a nation. Look to the happy, healthy, educated countries of Northern Europe for examples of how to better run a healthcare system, not to a country with hierarchies of medical care and millions of desperately poor and ill people.
The best way to ensure a level playing field is to eliminate those who have a vested interest in making money and almost no interest in providing good healthcare. Private organisations absolutely do not consider the public good or any ethics when considering how to run a service.
“How can we best ensure that competition and patient choice drives NHS improvement?”
no
“How can we best ensure that collaboration, transparency and both patient and staff voice drives NHS improvement?”
there, fixed that for you. Because the first question assumes a false conclusion. The NHS is highly efficient by international standards; competition will drive up costs and drive down quality and level of provision. The US healthcare system is NOT something to strive for.
Stop mucking around and form a Royal Commission on improving the NHS.
I couldn’t agree more, although I worry about what a royal commission, whose members would be appointed by a government that evidently believes so passionately in competition between the public and private sectors, might come up with; the Prime Minister’s guarantee that there would be no more major NHS reorganisations under his watch was arguably the most reassuring of all recent campaign promises.
And make no mistake: the bill as published did not represent just another step on the “creeping privatisation” road; it was an unprecedented leap over the cliff that would inevitably lead to healthcare commissioning controlled by the US Health finance industry or, more likely, a Europeanised facsimile thereof . No other government in living memory has attempted to relinquish control of such a spectacular proportion of government expenditure and to place that control in private hands.
(Were they unaware that GPs are not, nor ever have been, NHS employees–that they are private contractors? Were they not aware that, after endless NHS reorganisations that have slowly turned GP practices into ever larger businesses, their own figures show that fewer than half of NHS patients would recommend their own GP practice to others?)
Such a bill cannot be “tweaked” to render it acceptable; safeguards sufficient to ensure that patents’ interests were placed before profit would just create a mess that would be more expensive, less efficient, and harder to enforce than the current system.
The bill must therefore be scrapped in its entirety. It’s no good insisting that the status quo is not acceptable if the only alternatives you can envisage would inevitably lead to the wholesale destruction the patient-oriented culture still held dear by a majority of NHS staff and so valued by the British public.
I have been a patient of a large business model practise, the kind of GP practise that will thrive under GP commissioning. However GP turnover was appalling, as soon as you got to see a GP they left, I was told repeatedly it was because they felt they couldn’t really focus on caring for people. Most GPs were part time for as little as half a day a week and if you have long term health problems it is essential that you see the same person and had to wait weeks to see your chosen GP. My care was very poor there. I had endless appointment as I was passed from pillar to post and endlessly given contradictory advise. My health suffered as a result. That practice is not in a city centre, but an affluent sea-side location.
In desperation I moved to a small, family practitioner of just 2 GPs. I have never had a better care. There is no need to repeat the long history every time as my GP knows me. In the end I need far fewer appointments as a result. It might appear old fashioned but it is actually more cost effective.
Small practises will not survive under the proposed changes, they don’t have the resources to do so. That would be fine for people with simple, one off appointment, but those of use with complex needs will again be the ones to suffer. Frankly it would a health disaster for me if I was forced to a larger business modelled practice again – they are just that, business focused, not patient focused.
Stop this reform, and promote small, patient centred GP practises if the government really want to save money and improve care.
Like many people I don’t consider Patients Choice that relevant. How many people have enough information and knowledge to make an informed choice? I would rather that all my local services were as good as they can be, and it seems to me that if the knowledgeable, influential, wealthy and the just downright stroppy people in my area have to use the same services, they will be the ones to put on the pressure if things are not up to standard. If these people are able to access a better service for themselves, then the rest of us are will be left with second best.
I also have grave concerns about handing over more and more of the NHS to private companies. They are there to make profit. That profit comes from the tax payer. The last few decades have shown that one of the consequences of this drive for profits is a huge increase in salaries for top management. Proponents for competition argue that these are all part of a drive to greater efficiency, but experience shows that this can also result in cutting corners, lower staffing levels and driving down the wages of basic staff.
As an example consider the case of Newcastle College. The Director of the college received a 32% increase in her salary this year and earns £259,772, more than any other individual college director. A further ten senior members of staff earn over £100,000 a year. The staff have been faced with the threat of 170 redundancies, and closure of courses due to the reduced government funding since February. This May the staff have been informed that they are all to be made redundant, and that they will have to reapply for their jobs, but with reduced salaries or a greater work load. The staff of Newcastle College are responsible for an excellent service. They have consistently received excellent reports from OFSTED and are a Beacon College.
My fear is that allowing more competition and private initiatives into the NHS will be yet another opportunity for a few people to make a great deal of profit. The more affluent part of the population will benefit from an excellent service, whereas those without power and influence will receive an increasingly poorer service or even no service at all……just take a look at the increasing number of people with missing teeth. That is what changes in the dental services have done to the less well off.
I do not believe that choice and competition will improve quality. Standards and clinical expertise are more likely to do this. The Any Qualified Provider model will be too financially risky for smaller providers such as charities or smaller professional groups such as occupational therapists. Commercialising services will reduce clinicians ability to share good practice which will ultimately reduce quality. The proposed removal of the cap on the amount of income Foundation Trusts can generate from private providers will reduce choice for poorer patients and accerbate health inequalities. Current loss opf occupational therapy posts reduces choice for patients. Include Allied Health Professionals at every level of commissioing and providing.
The issue of choice is obviously very complicated, but what both the previous government — and the current one — seem to want to have is ‘choice’ for the suppliers (large corporate providers can choose to compete/undercut smaller providers as they wish) and not for the ultimate customers (we’re still stuck in catchment areas).
When I last moved flat, I found that in my new area I could only choose between three providers, all of whom had *terrible* reviews on NHS ‘Choices’. Even allowing for the fact that happy healthcare receivers are less likely to post comments, the reviews relating to booking appointments, receiving care, and discussing options with consultants made it seem like my best choice was to use the local hospital’s walk-in service instead. Talk about an efficiency savings waiting to happen!
I dislike Starbucks’ coffee, but at least I can decide whether to go with them, or my local independent. So why I can’t do this for healthcare? I would travel further to get to a locally-run clinic with consistent care and long-term stability in personnel, but surely there should also be *some* penalty for providers who, year-after-year unfailingly provide bad service? But if you’re limited to two or three options in your area and they are *all* bad then what are we supposed to do? Go without? Who will put these clinics out of business?
I *did* find several well-reviewed clinics on the NHS Choices site, and they were about the same distance from my home as the ones that were badly-reviewed. It’s true that patient choice *could* reward the choosiest at the expense of the most vulnerable, but neither group is well-served by the current system in which it’s really a lottery as to whether you’re in the ‘right’ area or not in terms of care.
So ‘choice’ for the suppliers of health is utterly meaningless in the absence of *real* choice amongst the consumers of healthcare. Doctors are one group of consumers (through purchasing decisions), but patients should also be acknowledged and should be able to ‘vote with their feet’ on who (public, private, whatever) is providing the best continuity and quality of care.
Why does the government think that treating the NHS like a utilities supplier and forcing it into fragmentation is a valid way to provide good quality clinical services? Where is the evidence base? Where is the mandate for doing this as there was a solid promise NOT to reorganise the NHS in the Conservative manifesto? I don’t know of anyone who wanted this change. More fragmentation will require more people to administer the plethora of contracts that will be required, where’s the reduction in bureaucracy in that?
I think for patients to have a choice they need to have information and that’s not readily available.
Also re competetiveness, there shouldn’t be any, we should ALL work towards getting the best for our patients and workforce and share best practice openly.
If competition between potential health providers is to be based on quality only, does this mean that only the very best services will be purchased? However, the very, very best would be prohibitively expensive since, as the quality of service improves, costs to the provider will increase. Is it not more likely that when GP consortia put a service out to tender they will specify a level of quality required? If several providers reach this level and put in a tender how will GPs choose between them except by price? In this situation a private provider would be in an advantageous position as its ability to draw on other sources of finance would enable it to provide services initially at an uneconomic cost; something which an NHS hospital could not do. It is easy to say that competition will be based on quality rather than price, but is it clear how this could actually be put into practice?
The government should provide evidence that competition and choice will improve healthcare. It hasn’t improved our railways!
The Conservatives should have had the integrity to be open about what about their intentions to eviscerate the NHS as a public service during the election campaign instead of as Oliver Letwin said “keeping quiet about it because they knew it would be huge” (and unpopular).
Most patients aren’t knowledgeable enough to be able to make an informed choice – what they really want is to know that they are going to be properly cared for by medical professionals who aren’t cutting corners to save money.
the NHS should be a public service not a kite mark.
We have had much improvement in health care over the last 10 years. I speak as someone who has worked within acute and primary care, as a practitioner, and as a manager.
When PCTs were formed they could not have known of the poor clinical practice that they took over and effectively became responsible for (remember Bristol, think of Shipman). These are areas that seem to have been forgotten during the quest for competition or collaboration. Private healthcare has been poorly regulated and where pay and conditions for staff are poor there will be little insentive for staff and with more providers, where will the clinical quality gaurantee be. CQC are hard pressed at them moment and look at the problems with Residential homes presently due to financial constraints. And we still do not have a clear understanding of how well GPs perform.
I also do not understand how you think GPs should be gatekeepers for the NHS. As a patient I would like to self refer to whom I think is best placed to treat me, GPs have not in my experience been best placed to advise me.
Choice and competition is important to me when I’m buying a new phone. When I need medical treatment, I don’t want to shop around – I want my local hospital to provide the best service possible.
The market isn’t the answer to everything. Please, listen to the public, the doctors, the nurses, the medical charities: everybody opposes these reforms, apart from those who stand to benefit financially.
Private companies should play not be given an extended role in the NHS. If anything, their influence should be reduced. The do not provide ‘good value for money’ for the taxpayer and do little more than line the pockets of shareholders.
Furthermore, I want my GP to practice medicine, not become a glorified accountant. And this certainly does not mean I want administration to be contracted out to a private contractor. Neither option is satisfactory.
Finally, the last thing the NHS needs at the moment is further top-down re-organisation. Leave it alone, the vast majority of people like it as it is (in fact, record numbers of us are happy with it).
Although there are problems with communications in healthcare, between GPs and Hospitals this is not because people dont care. It is because of history. We are where we are.
We still do not spend as much as America and we pride ourselves on having a better service.
Compitition of the kind advocated is just not right. It should be working together to get the best result, not against each other to get an efficienct financial result. What price a life.
If we want more from the NHS we should be prepared to pay more. I would.
I hate being told I havent understood.That I need to be told again in a different way. I want the surgeon to be in charge of surgery, specialist in charge of specialisation, and me in charge of them. Not my GP.
Information is the best thing, though some people want others to make the decision for them. The information should be available for all and decisions then based on that.
The question “How can we best ensure that competition and patient choice drives NHS improvement?” presupposes that competition is always best for everyone. This is not the case. When the postal service was opened up to competition, private providers cherry picked the most profitable areas (often business post), leaving Royal Mail to serve the rest without the balancing income from the other areas to subsidise this. If the same happens to the NHS in the name of “competition and choice” we risk a situation where the most vulnerable in society (eg the elderly, those with mental health issues, those without transport) will have to make do with the lower end of a two tier system.
Increasing choice about access to information and health services using the telephone and internet is a critical element in empowering patients to care for themselves and their families better. The widespread adoption of telephone and internet interaction with patients can make a huge contribution to the QIPP challenge. The NHS cannot afford to ignore the huge benefits offered by web and mobile channels.
Increasing numbers of patients and members of the public are ready and willing to use digital channels for health services; in fact many are baffled and frustrated by their inability to communicate with the NHS in the ways that they manage other aspects of their daily lives. Providing more convenient multi-channel access to health services will encourage people, especially younger ones, to engage with their health and take earlier preventative action to stay well. At the same time it will protect scarce face to face resources for the people and situations that need them.
The introduction of the new NHS 111 urgent care service will improve integration of services provided that it empowers patients, increases choice and reduces the burden on face-to-face care. Improved integration of urgent care services needs to be accompanied by multi-channel access to health information and clinical advice, with a strong emphasis on supporting people to care for themselves and their families at home rather than just directing them to the nearest face to face service.
In the next 18 months NHS Direct faces competition for every element of its current telephone and internet services. There are no national tariffs for these remote and virtual services, and there is a strong case for a managed introduction of competition, to ensure that the gains from a better integrated service are not undermined by competition which is overly focused on price at the expense of quality.
The current proposals in the White Paper recognise that, alongside devolved decision-making and localisation, some services need to be commissioned at a national level by the National Commissioning Board. These should specifically include a range of digital resources which are best made once and distributed widely rather than duplicated in every locality. On-line and mobile NHS 111 services and computer-based patient decision aids are examples of resources which need particular scarce expertise and should be commissioned centrally to reduce cost and ensure quality.
People do not want choice, they want good quality health care in every hospital, clinic and surgery. Competition will not improve the situation, we need cooperation to build our health services.
My biggest concern about the proposed reforms is the handing of budgetary accountabilities to GPs, as it may lead to the kind of compromised clinical care hypothesised by Dr Macgregor in this article http://www.lrb.co.uk/v33/n05/andrew-ohagan/diary
To quote an extract: “I have dreaded the day when a patient walks into my room and there’s a pound sign in front of them. And if someone comes to see me, in the new world, and they need an endoscopy to see if they’ve got a gastric ulcer or cancer … and my consortium is telling me that last month we had too many endoscopies, [I will be required to] think twice. I will think twice about giving this man what he needs and that will affect my clinical care. If I fail to send him for an endoscopy and that man gets cancer, I will have been guilty of giving that man bad care.”
Even if this is a worst-case scenario of what would happen under a system where GPs are accountable for their practices’ budgets, I am strongly opposed to the introduction of reforms that could bring this kind of enforced daily ethical/business dilemma for GPs even a few steps closer to reality. I do not see how the overall quality of patient care could not suffer under this model.
It is vital that the NHS continues to deliver services through charities and specialist providers. I work for an organisiation that runs a Centre for young people that is commissioned to deliver counselling. This is young people focused service, it is not a clinical setting, it is friendly and welcoming – ideal for providing counselling. I beleive this is the kind of choice people should be able to make.
Please take a look at this report:
http://www.youthaccess.org.uk/publications/upload/Easing-the-Strain-Briefing-Dec-2010.pdf
The NHS quality of care has improved over the year’s e.g. shorter waiting times for cancer patient’s etc. Instead of trying to privatise the NHS the government should be trying to reduce waste through lean principles, which would help reduce costs and inefficiencies. There are a lot of managers managing managers within the NHS and I feel by reducing the amount of management and finance this would help cut costs (too many Chiefs and not enough Indians). I do not feel the current plans for the NHS is the way forward, just look at the railways and water companies as examples.
The principle that competition encourages improved standards is a dogmatic one. The gain from offering the carrot of profit and the stick of rejection does not necessarily balance out the loss of a unified NHS culture. Siphoning off simple, low-investment procedures to private suppliers doesn’t increase competition as much as it undermines the greater good of a comprehensive single service.
Two examples in the current system that signal the dangers of the proposed bill are as follows:
John Radcliffe Hospital is a great training hospital in Oxford but it farmed out its cataract procedures to a small local supplier. Surgeons training at the hospital now miss that basic and critical procedure from their training and the money that follows those operations no longer helps fund the more complex surgery John Radcliffe still has to supply.
Imagine if tonsillectomies, appendectomies and dozens of other minor operations were contracted out? Where would the money those lost procedures bring in for investing the equipment for major operations come from? Where would the clinicians train? What would happen when things went wrong and patients had to be transferred? The current system caters for this. The proposed one sacrifices the interactivity between departments for the sake of a perceived “consumer choice” advantage.
Worcestershire Acute Hospital Trust currently has its stroke rehab unit on the main site of the Worcester Hospital but they feel they can save money by moving it to a GP run facility across the city. What they do not acknowledge is that the current rehab centre often takes patients who are still unwell in order to relieve pressure on the stroke centre. This is a risk because there are no full-time doctors but it is only moments away from the main unit so the risk is small. By ignoring the flexibility this allows, it would appear that a rehab unit two miles across a busy city would make no difference, but it actually forces clinicians in the stroke centre to block beds with recovering patients because they daren’t risk sending the patients away too soon and because they don’t want to pay the resulting ambulance fees.
The problem with the bill as it stands is that it fails to account for these vital interactions that keep the NHS system going. Money and efficiency and box-ticking do not make for better management or government policy
A change to a market driven system will create a significant culture change in the health providing system, with knock-on effects to other parts. Whether we like it or not it will create behaviour changes amongst physicians and results in reduced trust all-round.
A patients, for instance, can never be sure whether the advise obtained is truly in his best interest – or influenced by other considerations. The same is the case for the physicians. If it is all about expanding your business, then the advise whether to have or not to have a certain operation will not be based on need but on business considerations.
It will be a great loss to the UK if the NHS is dismantled rather than improved.
I disagree with the premise that competition and patient choice drives NHS improvement.
What drives NHS improvement is the dedication (or otherwise) of its staff, the pressure of patient organisations, the strength of clinical governance and research structures, effective and enlightened (or otherwise) management of staff, and good financial management.
Culture is a huge part of the improvement of any organisation. Ensuring that people are well-managed, provided with timely and appropriate education and training, have high job satisfaction and are not over-worked is the best way to ensure that the culture of the NHS is conducive to good, effective, and cost-effective care.
Also of crucial importance is the willingness to discipline and sack poorly performing staff where necessary. In hospitals, ward managers are central to the culture of care, influencing in particular nursing and junior medical staff. But the atmosphere of a ward is largely down to the ward manager and senior nursing staff – this affects patients, relatives and all domestic, ancillary and visiting staff. So where there are good ward managers, we need to find ways of spreading their influence. Poorly performing ward managers need to be supported to develop in the right direction, or disciplined, or sacked if necessary.
I would say that the NHS is over-led and under-managed, i.e. huge amounts of money spent on big projects that will allegedly change the direction of the organisation, whilst the basics of getting the best out of our largely dedicated and skilled workforce are effectively ignored.
Patient choice has proven to be an expensive (though well-intentioned) mirage and the obsession with competition is driven by ideology. I note that the devolved administrations are far less interested in competition, without the sky falling on their heads.
A major reorganisation in the NHS (no more top-down reorganisations?!) is foolishness itself in a climate of cuts and contraction.
Choice is important to most people, but not as important as quality of care and communication. Choice can be a negative too – too much choice – or can mean that time is wasted – or choice is given where people do not really need or want to choose. For most people when it comes to healthcare there is no choice, and choice is not something people often want. Quality treatment, communication, clean and safe hospitals and being treated like a valuable, intelligent human being are all top of my list when it comes to healthcare – choice is a luxury.
Competition too is just not needed. Competition does not ultimately lead to better service or better quality. It is not true that competition drives improvement and can often ultimately lead to a reduction of services and choices.
As a patient I am simply not interested in choice. I just want my local provider to be good, which at present it is (East Kent). This is the same for most people I talk to.
I do not like the thought of for-profit organisations taking over any element of treatment or care provision.
There is no mention of collaboration rather than competition. I want a health serveice where the providers are united in ensuring quality services for all, not a situation where competitors can cream off lucrative services and leave the rest to a depleted rump. The public are not stupid – we know this will happen if the NHS Bill goes ahead which is why there is such an outcry against it. If this listening exercise is not just a sham, the government must act to stop the privatisation of the NHS by the back door.
Collaboration not competition – if a top down reform is needed then more collaboration should be the objective, not competition based on a blind trust in the market. The NHS staff should not be spending their time in the complexities of EU competition law – putting out tenders and assessing them will become a new NHS bureaucracy
People do not want choice. They want their local health services to give them good healthcare.
Any form of privatisation is a big mistake.
Buses did not work, trains privatisation is not working, NHS privatisation will only cost more and give inferior service.
Choice and competition are not the answer to better healthcare. A private provider’s first commitment is to its profit margins – which may or may not be the same as the best patient outcome. What I and my family are looking for is a consistently high level of care that is available within a reasonable journey time from where we live.
No private providers, corporations and the people who work for them are all about greed, just look at how poor our trains, water and hospital cleaner has become since privatisation. You cannot trust greedy businessmen with something as vital as the NHS, would you really put the same imcompentent self obessed types that caused the banking crisis in charge of providing health? As for choice does that extend to the choice not to be seen by a private provider? will the patient always have the option to be treated in an NHS hospital?
Ultimately in the long run privatisation will lead to a poorer, more expensive system just like the awful one in America.
I am very worried by the tendentious way that these consultation questions have been slanted. There is a lot of evidence from the USA that competition increases costs while reducing the equity, efficiency and overall quality of healthcare provision. The Doh and the Govt supiciuously shows no interest in these facts. Ergo, the listening excercise is untrustworthy. Furthermore you have no mandate from the electorate. Your DoH senior managers and advisors are too friendly with private healthcare providers.
You have made this decision already and you have worded the question so that ANY given answer will be the answer that you want. It is ridiculous. What will happen to frontline services such as A&E when they aren’t making enough money to pay for your christmas party centre-piece? Will people be sent to Boots to self-treat a major injury as the private companies wont want to run a service that might cost them more money that it takes in? Listen to the noise that this has stirred up and take note. You cannot go through with this. If you do, then you have failed the nation, the NHS (which most likely delivered you at birth), and you will have let yourselves down. You are endagering lives, and the livelihoods of the entire country. Have a think about it
I also disagree with the idea that competition and patient choice drives NHS improvement – this can only come about by collaboration across health service professions and the local and national community, target setting with finance to improve services to meet them, continuance of NICE and similar professional-led guideline publications etc
Choice and competition may help a minority of patients who are well enough and well informed enough to exercise choice. It will do nothing for the vast majority of patients who are in no position to be making choices.
Following the French example, privately run but externally monitored laboratories and clinics should be set up for such things as blood and smear testing, xrays, mri scanning, audiology etc. Why are these services at present only in NHS hospitals? If run separately expensive equipment can have much more extensively use (no closing of xray departments at weekends through lack of staff) and they can be made much more accessible in town centres, with no waiting lists and results available to patients quickly, cutting down doctors’ correspondence, booking appoitments etc. In France for example, I go to the doctor with a bad chest, he/she decides I need an xray and gives me a letter and the contact number for the local unit (conveniently situated next to my bank), I ring them, make an appointment for two days hence. I arrive at the unit, have my xray and leave 45 minutes later with the resultant photo and a letter with a copy for my doctor. Total cost €35 reclaimable. Equally, there are locally run laboratories which will process smear tests and blood samples (including my dog’s for the local vets) where appropriate. The doctor will direct the patient where to go for the best service, but apart from “prescribing” the treatment in a letter, he/she is not involved with making appointments or checking waiting lists, simply in assessing the patient’s needs.
Basically it comes down to the need to make the best use of our resources and piling everybody into one hospital locally for all the medical services causes these log jams, when many could be served in the community, leaving the hospitals available for their own use.
Equally, we should look towards the provision of convalescent care as a stage between hospital and discharging home. Again looking at the French system, they have provision of convalescent units for example for those recovering from strokes, heart attacks and hip replacements. This frees up acute beds without the risk of too early release home, avoiding readmission and the provision of home care. These units, which we always used to have in days gone by, could well be privately run, with patients paying a modest “hotel charge” with “free” medical treatment under the NHS.
Have an overarching commitment to quality, achieved through a commitment to workforce dignity, and tight regulation of services. Demand for health services is not elastic, for three reasons: getting sick is not a choice; sick people as consumers are not most inclined to go shopping for their care; and set-up costs create substantial barriers to market entry.
Because of inelasticity of demand and relative difficulty of market entry, the role competition can play in the market is severely limited compared to the hyper-simplified scenarios that inform theory about consumer behaviour. Therefore I see a substantial risk that the increased use of private providers will mean driving down pay and conditions in the private sector, undermining the morale and commitment of people (esp. nurses and ancilliary staff) working in private clinics, resulting in poorer care and more accidents.
To ensure improvement of NHS care in such circumstances:
* Ensure pay and conditions packages among private providers reflect those in the public sector – without deterioration in public-sector conditions!
* Have a powerful role for Monitor in demanding close monitoring of service quality and service improvement, and ability to fine non-compliant providers
I would also like to see a legislated prohibition on ‘revolving door’ employment / renumeration for individuals between private healthcare providers, Monitor and any other regulatory bodies. Without strong and independent regulation, a healthcare market will fail. (In providing freely accessible, quality healthcare to people in Britain regardless of their location, a principle I would like to think is widely accepted.)
Dear Government
You have no mandate to sell off the NHS- it belongs to the people of the UK.
Since 1948 the government has had a duty to provide comprehensive healthcare free at the point of delivery.
You plan to abolish that duty- did you think we wouldn’t notice?
This Bill will plunge us back into an era of pre-Beveridge health inequality.
• As foundation trusts and GP consortia will be free to make profits and charge top-up fees, health services in deprived areas will struggle.
• With the introduction of local pay and conditions, deprived areas will never be able to attract good staff.
• Although patients can theoretically choose to be treated anywhere, how likely is it that a patient from a deprived area will be able to travel far away from home to access care?
• “Patient Choice” discriminates against the poor, elderly, isolated and vulnerable.
Competition between all “willing providers” will not improve quality or efficiency
• Private healthcare providers are motivated by profit.
• Patients’ interests can only ever come after those of shareholders.
• Private providers will only undertake profitable work such as elective surgery.
• Multinational healthcare corporations will run “loss leaders” until such time as they have bankrupted all the NHS hospitals. Then they can charge whatever they like.
Exactly how does this Bill envisage the provision of high level specialist services, for example trauma centres and intensive care?
• By their nature, these services are not profitable
• They require large numbers of very highly trained staff and treat patients with complex needs and long hospital stays.
• The NHS will not have enough revenue to provide these services if the profitable routine work is done elsewhere.
• It is clear from areas where Independent Treatment Centres cherry-pick easy cases, that NHS hospitals are already suffering
Fragmentation of healthcare provision by the introduction of competition between multiple providers cannot possibly result in “joined-up” healthcare.
• The only way to provide a seamless service is co-operation between all the staff of a publicly owned NHS.
• Don’t make us waste money on lawyers and contracts and accountants which we should be spending on patient care
Let healthcare professionals work together: scrap the Health and Social Care Bill.
I see no hard evidence that choice & competition can “drive” improvements in the NHS.
So far Mr Lansley has been unable to provide any solid data to demonstrate the effectiveness of these notional engines of change. Unless & until he can do so, the proposals do not deserve consideration, much less support.
Fundamentally the idea, that introducing competition into the healthcare equation will improve services, is wrong.
Different providers, with very specific responsibilities, different waiting lists and limited collaboration with “competitor” providers, cannot possibly match the service currently available, unless every patient fits neatly into clearly identifiable categories – which they do not.
As age, chronic illness, and complicated health problems clearly do not fit these categories, how can anyone ensure that patients get the comprehensive, holistic care they need?
The present system can be improved, certainly, but breaking the NHS down into bite-sized chunks that private firms can cherry pick, leaving the state with the complicated, unprofitable bits is not going to help patients or staff.
I too reject the premise that competition and choice is driving progress in the NHS. What sort of a listening exercise is this, if it starts out with such a leading statement? I do hope that comments that do not endorse your original premise aren’t being disregarded. How is it possible to stay on topic if you do not agree with the premise?
I think that choice is secondary to quality. What patients want are good quality, responsive and timely treatment provided by their local hospital. They don’t want the choice of three hospitals, one of which is much superior to the others with long waiting times and two which don’t appear to be as good but you can see someone quickly. Its the same for education, we want our local schools and hospitals to provide us with the best most comprehensive care possible, not the choice of one excellent school and three below standard ones. Obviously there is still a need for tertiary referral centres which are specialists in their fields but I don’t think it is in patient interests to centralise core service such as maternity so that patients have to travel unacceptable distances/time. Finally I am not convinced that competion with the health service will drive standards up, look at care provision for the elderly, hardly a great beacon of quality in many instances and they do not undergo the same scrutiny as public funded homes, hardly a level playing field.
Doctors should have the right to use the primary care trust as the official local body on dealing with the matters they need to deal with rather than being left with the choice of private firms that have no experience of the NHS.
Would you really decide to build a British war ship by hiring a US ship building firm when they have no idea what to do or what the Royal Navy wants?
The idea of allowing cherry picking of easy repeatable surgeries and other parts of the NHS should be banned.
Such business practices avoid the hard and specialist work that the NHS does along side the services that could be cherry picked. The staff work in both areas so taking them apart would cause large cost and staff issues.
The government should also create a maximum percentage and total amount of money that a company can make in profit. With there not being enough money for the NHS already according to the government how can it let firms take money out of the NHS when the NHS can do that work itself at just as good a price?
I don’t want competition. I don’t want choice. What I do want is to be safe in the knowledge that my local GP surgery and my local hospital will provide me with the best possible healthcare.
When you are seriously ill, the last thing you want is to be presented with unfathomable choices about issues you don’t understand.
Get private business out of the NHS. Keep the NHS public.
As a health services researcher, what has been most striking about my conversations with service users about their healthcare is that very few people want a choice. I work with women choosing a place to have their babies – a choice that could be made with lots of time to consider their options, not in an emergency – and yet the women I speak to don’t want to choose, they just want their local service to be good.
Choices are not made by all from a level playing field. Reforming health services using the rhetoric of ‘choice above all else’ produces inherently unequal access to services.
It is important to note “choice” in this government’s view means removing the duty of the Government to provide health care to its citizens: this is the basis of the National Health Service and their legislation would fundementally remove the core belief behind the NHS and spell its end.
There is no evidence choice and competition drives up standards. When councils sold off their nursing homes to private companies the standard of care was shocking. As a practicing health professional I have visited many private, charitable and local authority/NHS run facilities that support our most vulnerable: although there are always exceptions, on the whole statuatory services are always of a better standard and are better at self regulating. In other sectors choice has again done nothing to improve standards: the railways for instance.
Also, whereas choosing may be easy for someone like myself who has minor health problems and the ability to sit and wade through ‘league tables’ and ‘feedback’ the people who are most dependent on our services are unable: people with learning disabilities, the elderly with no internet access, the stressed out carer. What these people need is to know that their local service is good enough to provide all they need.
It is impossible for any profit making organisation to provide a duty to its patients as its overwhelming duty is to its shareholders or profit receivers. The only way a company can make profit in health care is by either overcharging, which will make less lucritive areas of health undesirable to provide, or by creaming profit from the money that should be going into patient care. The proposed system will encourage this immoral behaviour and again harm the most vulnerable in our society.
I post not as an NHS employee frightened for her pension but as someone who trained for and works in the NHS as she believes it is RIGHT and GOOD to provide a health service that does not discriminate against ability to pay, ability to choose, where you live, and all the other disadvantages that all my patients face in their day to day life, and which the legislation proposers have no concept of what it’s like to live with these challenges. Under the proposed system health services (whom ever they are provided by) will continually lose skills as no-one will ever be in a job long enough to develop specialist skills as they are constantly under threat of re-commissioning, and this will affect moral no end. There will also develop a system where people will move jobs to get a better package as there is no incentive to ‘do what’s right’ and stay in the NHS. In the USA where the closest comparison to the proposed system the rich get good health care and the poor get poor health care. Where a system is based on what’s lucritive this will be the result. The capatilist government expects that the poor should work themselves out of poverty so they can afford the same things but for a start their own businesses rely heavily on employing lots of people on minimum wage to provide the majority of the leg work; we can’t all be the CEO so how on earth could someone on £11000 a year who is more at risk of mental health problems afford to pay if their profit making service cannot provide what they need. Secondly, if you are an adult with severe physical and learning disabilities who is dependent on health and social services meant to compete and make profit for the provider? In short, they can’t, but that does not mean they should not be supported by those that can.
OUR NHS IS NOT FOR SALE and is NOT YOURS TO SELL!
Competiton should only be between various parts of the NHS,private firms should not be involved!
It is fundamentally flawed to drive for involving private firms in the NHS.Private firms are there to make a profit,the NHS is a service not a business,rather than contracting work out,it should be done in house,like it used to be.Only when there is no choice,for example when it involves specialiat technology.
Many private healthfirms have been itching to get a piece of the NHS budget pie,and worryingly,alot of them are american!
Involving private firms becomes a vicious circle,they cost more,the NHS budget has to be increased,they private firms put up their prices,they contract out more etc …it is almost like MP’s want to deliberately run the NHS into the ground,so they can at that point say there is no choice,the NHS cannot remain a free public service,but has to become an american style health business!
Like many others I am not interested in choice. I just want one service in which those working for the service care about the needs of their patients and where care and compassion for patients, rather than success in competing with other providers, are at the heart of the ethos of the service.
Choice is irrelevant and unhelpful in emergency situations. To the extent that choice and competition are possible at all this may only be the major cities. So if choice and competition are used as the drivers of quality this will leave rural and less densely populated areas with a second class service.
Whether competition can drive up quality is an empirical question. I note that the RCGP concluded that when the evidence is looked at it fails to support the view that competition is helpful.
Choice for healthcare seems to me a fallacy, I do not want it. I want good consistent care across the country meaning most things I get locally but realising some specialism because of critical mass may require some travel. I have experienced choice and competition in the USA and it was stressful, uninformed and lacked consistency of care.
I do not have the expertise to decide what makes one place better than another so just work to them all being good. Doing this will require cooperation, something I see at odds with competition. I don’t want my healthcare run by people who need to bid for services or make a profit, Based on discussions with friends in the NHS it leads to unachievable promises, bad feeling between bidding departments and requests to staff that are counter to clinical practice in order to measure and thereby demonstrate those unrealistic promises.
Like S Cooper I do not personally want to make choices about which surgeon does my operation but to mention this is to show a misunderstanding of the role of choice in driving improvement.
I work for a private lab in the personalised medicine field and I know just how far the NHS has to improve.
I do hope you will not back down in the face of this concerted campaign by the vested interests to emasculate your reforms.
Reform is essential, more providers are essential, courage is essential. I wish you every success.
This page was closed to comments on 31 May, the last day of the listening exercise. Thanks for all your comments, which have been fed back to the NHS Future Forum to consider.
The Forum will submit its report to the Prime Minister, Deputy Prime Minister and the Health Secretary in June. The government will consider the Forum’s findings and then publish its official response.
Annelise@DH