The government's failure to justify reform has left the public short of options

I have always understood why parts of the NHS resist competition. If you are in a monopoly position it means that you can look inwards and feel in charge of the world that you see. No-one can come up with an important innovation from outside that will turn your cosy world upside down. You are in charge of your own pace of change.

Successful competition brings innovation and change that is beyond the control of those who prefer their monopoly world.

Occasionally, this opposition to competition looks a bit strange. There are conservative individuals in the British Medical Association arguing against the very competitive processes that have developed the consumer goods market that has created their lifestyle. Opponents of capitalism who drive Porsches have never been very persuasive.

This eccentricity reached its apogee just a few weeks ago here in HSJ when BMA consultants committee chair Mark Porter said: “The BMA is not opposed to capitalism”. Weird times indeed when the BMA has to clarify its position on models of economic organisation in this way.

A lot of this debate was thrashed out during the ‘noughties’. The challenge that the Labour government from Alan Milburn onwards laid down to opponents of competition was: why do you want to restrict patient choice?

Of course, unions such as the BMA were against competition because it makes those members who are in monopoly positions feel uneasy.

But by the time of the last election that was not a raging issue with the public. Most people accepted that providing a choice of provider added to the experience of the NHS. Then it followed that if a patient was allowed to choose, the money would follow their choice. And if patients had the possibility to choose, then surely it would be a good idea to have different organisations for them to choose between.

So much, so normal for our society.

Up in arms

But here we are 13 months after the election, with a Conservative-led government, and parts of the country are anxious that the Tories are going to privatise the NHS. So they are up in arms against competition.

Everyone – including the government itself – is now saying that the problem is the coalition failed to provide a compelling vision for why it is carrying out the reforms.

Given that they won’t tell us, this left people to find their own explanation for the upheaval.

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In January, after a few weeks of the public scratching their heads as to why a government would change something without reason, an explanation emerged that the public took hold of and developed – the government is selling the NHS.

The public think that no government would be daft enough to start this scale of change without a good reason, and since privatisation is the sort of thing Tories do, that must be it.

After a few ritual denials that no, no, they are in love with the NHS, the government has recognised it is in a fix. The four words of Tory, NHS, cuts and privatisation have been formed into a sentence in the public’s mind, and taken root.

Everything the government now does will be scrutinised against the charge of privatisation. The secret rationale will be uncovered in the smallest of actions.

This leaves the government with no choice – it now has to spend every day proving that it is not privatising the NHS. As it will find, proving a negative is hard.

One example is its attempt to say that it will stop price competition. This is the measure of the chaos. We have a Conservative led government trying to put through legislation that will ban the variation of prices. 

How will it achieve this? Will there be a hundred NHS Commissioning Board price police combing through all the commissioning invoices searching for an illegal bargain? How many NHS bosses (so loved by Andrew Lansley) will it take to stop a price market?

If you are in the third sector organisation, thinking of developing some services for the NHS, this all makes an uninviting sight.

On the one hand you are encouraged to develop value for money to help save the NHS; on the other you are told that value for money is not welcome here.

Those of us who believe that choice for NHS patients is an important way of proving that socialised medicine can provide the same offer as private medicine will have to recognise the government will not be capable of making that case.

Patient groups will have to find ways of making that case against the monopolists who want to deny NHS patients the rights that private money can buy.