The extent of the evidence-based, peer-reviewed, rôle of ‘competition’ in the National Health Service is limited. It necessarily has to be taken with caution, and findings should not be inferred lightly.

In a recent press release on the Civitas website, entitled “Voters back private care on NHS – ICM poll”, it is written that:

“Presented with the statement, “It shouldn’t matter whether hospitals or surgeries are run by the government, not-for-profit organisations or the private sector, provided that everyone including the least well-off has access to care”, 83% agreed while only 14% disagreed. Of those, more than half – 56% – said they agreed strongly. Just 10% said they disagreed strongly.

In addition, only a minority of voters think the NHS provides better care than systems in France and Germany which have forms of universal social insurance with higher proportions of private provision.

Asked what they thought of the idea, “People living in European countries such as France and Germany don’t receive as good a level of healthcare as we do on the NHS,” only 36% agreed. More people – 41% – disagreed. Another 23% said they did not know. Still a small majority of the population think that the NHS is “the envy of the world”, however, by 56% to 38%.

David Green, Director of Civitas, said: “It is clear that most people still support the NHS, but that does not mean they are opposed to change.

“What this poll shows is that people generally support the idea of universal care at the point of need – not the virtual state monopoly of healthcare provision that we currently see.

“Despite the apparent fears of ministers, most people would be happy to see greater diversity of provision, which would help increase efficiency and drive up standards by enhancing competition.

“The best way to raise standards and look after patient interests is to promote pluralism so that rival providers are compelled raise their game. We all know as consumers that, unless we have alternatives, producer interests come to dominate.”

This is interesting from a management perspective, if only because extremely bad healthcare can occur in both the private and public systems. This was only written recently about the “Winterbourne Care Home Scandal” on 9 August 2012:

“As the reformed health service prepares for more competition and increased use of the private sector, there are important lessons for commissioners. The serious case review says that on paper Castlebeck’s policies, procedures, operational practices and clinical governance were impressive. Yet the reality of the way patients were assessed and cared for, how staff were recruited, trained, managed, led and disciplined, how complaints were handled and how records were kept came down to “arbitrary violence and abuses”.

This does not mean, of course, that such practices are in any way representative of the private sector, and rotten cultures take root in the public sector as well. But the chasm between what Castlebeck promised and the reality means that commissioners had clearly failed to test the foundations of those claims at the outset or use them as a rigorous benchmark for monitoring performance.

A similar question arises in the commissioning of NHS services. They are more open to scrutiny and evaluation, but failure still happens.

The purchaser/provider split is intended to promote quality, drive up standards and ensure the interests of the patient are championed. But the scandal at Winterbourne View hospital demonstrates how far commissioning still has to travel before it meets its objective.”

Bad practice can occur in both the private and public sector, and when it occurs it is a tragedy for all. The irony is, of course, that it has been a stated intention of policy-makers in healthcare to “import” the best practices from the private sector, such as efficiency and productivity. Experience from the privatised utilities is not one of a market approaching perfect competition. Far from it. There are few suppliers, meaning that the bargaining power of suppliers compared to customers is huge, and there is poor ‘competitive rivalry’ as it is in the best interests of these companies in different sectors including electricity, gas, water and telecoms to keep prices relatively high and return maximum shareholder dividend. The justification for keeping these prices high is to ‘return investment’ into the infrastructure of these sectors, but this argument is much harder to pull off in the NHS, where some of the infrastructure in the NHS is being abolished (which includes national institutions such as the National Patient Safety Agency, the Health Protection Agency, or the NHS Institute for Innovation and Change), and there needs to be funding for the training of doctors, nurses and all other health care professionals. Even the most ardent critics of the NHS have difficulty in explaining how the expensive £3bn undemocratic change will improve patient safety, particularly since the market will end up being much more fragmented (as has been, for example, the experience of the privatised railways industry in England.) Therefore the press release is carefully worded, “Voters back private care in the NHS”, rather than “Voters back privatisation in the NHS”. When the question is worded in the latter version, the outcome is rather different, as demonstrated by 38 degrees. 354155 signatures have been recorded to date (link here).

It is particularly interesting that the Civitas press release contains this attack on the ethos the NHS:

“If the Mid-Staffs scandal is not to be simply the latest in a series of outrages, the government must wake up to the need for reform. The Francis report has shown that the current command-and-control regime does not guarantee a public-service ethos in the NHS.”

As a figurehead of this ‘command-and-control’ ethos, possibly a reference to the “Stalinist” nature of his leadership described elsewhere, Sir David Nicholson has become a target of the popular press. However, the private sector has some questions to answer from within itself. The vast majority of people who work in the NHS have considerable loyalty to the service, which indeed they wish to be ‘comprehensive and free-at-the-point-of-use’. People advocating the private market have always had the problem is that, despite what the general public thinks, the English NHS is in fact one of the most efficient healthcare systems in the world. Indeed, private healthcare providers are still very keen to piggyback on the reputation of and the goodwill towards of the NHS, in deliberating using their branding (such as the invaluable NHS logo). Many commentators have explained in detail why and how a privatised healthcare system will lead to a service which is not nearly as comprehensive, and that there was already emerging evidence about this as early as 2010.