Abstract
The arguments for using choice and competition as a strategy of health care reform have been articulated most clearly and cogently by Le Grand. In a series of publications, he has developed an idea originally set out over a decade ago, based on an analysis of the knightly and knavish behaviours of the providers of public services, 1 into a full blown argument for the application of market principles in public services.2,3 His preference for markets derives from the need to counteract the risks of self-interested behaviour by providers, the middle-class bias of reforms that rely on articulate users expressing their preferences, and the disempowerment that results from over-reliance on ‘command and control’ as a way of allocating health services.
An empirical test of these ideas is currently underway in primary care in England. To address concerns about lack of primary care capacity in some areas and services that are not accessible to patients at convenient times in others, the government has encouraged commissioners (Primary Care Trusts) to use the powers available to them to invite bids from new providers to enter the primary care market. In practice, commissioners were slow to respond to this encouragement, and as a consequence, the Equitable Access to Primary Care programme was launched in 2007.
The programme is described by the Department of Health as a ‘national programme of local procurements’. This means that Primary Care Trusts manage the procurements, working either on their own or in regional groupings, but they do so within a national framework. Under the programme, which is supported by £250 million of additional public funding, the Department of Health has required every Primary Care Trust to commission a new general practitioner (GP)-led health centre. A further 113 new general practices are being procured in the 50 areas of England with most need for additional capacity.
While procurements under the programme are still underway, an indication of the nature of the emerging primary care market can be gleaned from a survey conducted during 2008. 4 The survey involved interviews with all 10 regional bodies (Strategic Health Authorities) in England to gather information about their experience. In addition, Primary Care Trusts identified as being actively involved in procuring new primary care capacity were interviewed, as were a selection of providers bidding for contracts.
The size and competitiveness of the market varied between areas with some commissioners reporting substantial interest and others reporting a limited response to invitations to tender. A number of different types of provider were bidding for contracts. These included local general practices, GP-led companies and corporate providers. A recurring theme was whether the ‘playing field’ between different types of provider was truly level. On the one hand, corporate providers were concerned about lack of access to the public sector pension scheme for their staff, while local general practices felt disadvantaged in taking on the complex documentation involved in the procurement. For their part, commissioners were sensitive to the obstacles faced by local general practices, but were hampered in their ability to provide support by the need to ensure fair and consistent treatment of all providers bidding for contracts.
The survey also found that the procurement process was time- and resource-intensive. Consistent with other evidence, 5 Primary Care Trusts were reported to be struggling to act as effective commissioners of new services. This was illustrated by the variability and accuracy of the information they supplied to organizations bidding for contracts and their inexperience in specifying the service model they wished to procure. Commissioners also lacked some of the technical expertise needed in undertaking procurements, so in many cases they were collaborating in regional groupings to address this.
One of the major uncertainties in extending choice and competition to primary care in the English NHS is whether patients will use the new services that are commissioned. The source of this uncertainty is, in part, the high level of satisfaction with existing primary care services, 6 and, in part, the limited efforts put into informing patients of the choices available to them and how they can move from one practice to another. Government policy appears to be founded on a belief, to adapt a phrase from a related context, that, ‘if you build it they will come’, 7 but as yet it is not clear that this will be the case. There is, therefore, a risk that unless more is done to stimulate patient choice, new services will be under-used and offer poor value to government and in turn, the taxpayer.
If this happens, then it can be predicted that policymakers will seek to change the terms of the debate and argue that, by promoting choice and competition, they have succeeded in encouraging existing providers to extend their opening hours, thereby becoming more responsive to patients. This has already started to happen with over 70% of practices in England offering extended opening hours by the end of February 2009. In reality, the willingness of practices to do this has been driven as much by extra payments as by the threat of new entrants, although separating the effects of these policies is undoubtedly difficult.
The experience of primary care in England shows that in applying market principles in health care, the devil is in the detail. If the theoretical benefits of choice and competition are to be realized in practice, then much work has to be done to ensure that commissioners have the skills needed, patients are aware of the choices available to them and can exercise these choices, and there is a ‘level playing field’ between providers. Advocates of the use of choice and competition need to descend from the level of argument and theory and be prepared to get their hands dirty in working out what a properly designed market would look like.