THE HSJ DEBATE

Published: 24/11/2005 Volume 115 No. 5983 Page 18 19

The diversity of provision that patients will gain from choice is the key to an effective healthcare system, according to Professor Paul Corrigan. But Professor Alan Maynard argues that a contestable market in primary care will in fact reduce choice

FOR PROFESSOR PAUL CORRIGAN

Paul Corrigan, visiting professor of health policy at London Metropolitan University, was political adviser to health secretaries Alan Milburn and John Reid and is now a public service management consultant.

AGAINST PROFESSOR ALAN MAYNARD

Alan Maynard is professor of health economics at York University.

Professor Paul Corrigan: As an NHS patient I need my primary care trust to develop my health service choices in three ways. First, it needs to ensure that I can access primary care services that fit in with my life.

To achieve this, I expect it to provide me and my neighbours with choices between different styles of provision that we can then fit around how we live our lives.

Some people will be happy to register with a traditional GP practice around the corner. Others who commute to work would like to register with a practice in town where we work. And yet others with a long-term condition would like a choice of registration between providers with specific expertise in their condition. Our primary care registration is our entry to the NHS.

It is ours to place, and not the PCT's to allocate.

Second, I expect it to develop my choices in secondary care so that I have a broad set of offers for when I need it. For this, the PCT needs to understand the different health offers being made by the best providers. It needs to make sure that they are on offer to me, and that I have the information to make informed choice.

Third, for this to work, as my commissioner I need my PCT to fight for my interests in buying my healthcare and not to see itself as part of a cosy historical club of past providers. To achieve this, it needs to know more about me and my neighbours than it does at the moment. It needs to use that information actively to commission the sort of healthcare that I need.

Not the healthcare that has been provided by the primary care and hospitals of the past, but the healthcare of the 21st century.

The key word is activity. I expect the PCT to help create the offers it makes to me; not simply to wait and see what the past has provided it with. It is the custodian of our NHS and should not rest until it knows our healthcare needs and helps to meet them.

And if it proves itself to be incapable of being a good custodian of my NHS, as an active citizen and consumer I want to be in a position to find commissioners who can take on that role.

Professor Alan Maynard: Prime minister Tony Blair's NHS 'cultural revolution' is to be extended to primary care, with public investment in a diversity of production modes and increases in capacity to facilitate choice.

His diagnosis of inflexibility and inefficiency in the NHS is correct: witness the unexplained and unmanaged variations in practice in all aspects of healthcare. However, his treatment package is largely evidence-free and may damage the health of patients and the NHS by creating even greater inefficiencies and expenditure inflation.

If capacity is increased, demand may rise to match it - thus reducing contestability. With large reservoirs of unmet need in the community, investments such as the GP quality outcome framework (QOF) are turning the hidden iceberg of unmet need into patient care. This is benefiting patients (hopefully), but will not create contestability and may induce further expenditure inflation.

If capacity is increased and demand is not increased a contestable market will drive out high-cost producers, thereby reducing choice. If such producers are subsidised to stay in the market, excess demand will lead to the failure to exploit economies of scale and inflate costs. These problems can be seen in the inflated and inefficient primary care sectors of the French and German healthcare systems To undermine inflexible GPs and facilitate choice, the government has decided that pharmacists and nurses will be able to prescribe drugs and offer diagnostic services. The private sector may invest in NHS primary care practices that are largely doctorfree. This is an evidence-free social experiment: it is not known whether such provision is effective, let alone cost-effective. The government shows no signs of evaluating its social experimentation, being sadly unwilling to be 'confused' by evidence.

The NHS, like every healthcare system in the world, shows large, unmanaged practice variations in every aspect of its work. The government has squandered resources on policies such as the consultant contract, which cost billions but has brought no observable increase in individual practitioner performance or patient outcomes.

It has funded a QOF for GPs so that they are incentivised to provide some evidence-based interventions that they should have been providing anyway if they practised ethically and efficiently. The cultural revolution continues, but where is the evidence that it will improve population health efficiently?

PC: To say that the introduction of choice into primary care is a leap in the dark is to demonstrate the traditional mistrust of patients that has characterised the health service of the past. It is obvious that for some people, patients are just not up to looking after their health or their health service.

No-one is suggesting that there be an unregulated market in primary care; just that within the regulation of entry and exit they are allowed to develop the different types of provision that meet their needs. And the only way we will achieve that is by encouraging different sorts of providers to work o ut how to provide the full range of different primary care options that will fit in with the full diversity of our society.

The NHS of the past wants patients to be passive receptors of whatever the health service provides - and yet also needs those same people to be active in developing their own health.

If we want people to choose health, we need to make sure they have the right to choose their health service providers. People make many difficult and important choices in their lives.

Looking back 150 years, there were many who felt that giving people the right to choose their government was a leap in the dark: much better to make sure they were safely looked after by others than worry the people's heads with political choice. Perhaps we need a research project to show that the poor dears are up to it?

My registration with my primary care provider allows me entry to my NHS. At the moment, the people who cannot gain that entry do not have an NHS.

AM: Professor Corrigan's expressed preferences about primary care are eminently sensible and shared by all consumers. But he fails to demonstrate in either theory or practice that Mr Blair's current redisorganisation will produce what we patients want.

Religious assertion of the merits of 'contestability' produced by increasing capacity with NHS investment in private providers is no substitute for evidence of costeffectiveness.

We must expect private providers to cream off easier-to-treat patients; divert complicated patients to the NHS; and indulge in shenanigans inevitably produced by the profit motive.

Sadly, the government has produced no regulatory framework to channel these incentives in order to ensure efficiency and equity - and by the time it does so, the private horse may have bolted with taxpayers' money.

Mr Blair is rightly anxious to improve access and utilisation in primary care, where all too often providers operate for their own convenience rather than the patient's. But will providers 'act smarter' if choice can be created? In most markets, capitalists seek to destroy contestability as it threatens their profits.

The government's propensity to produce endless evidence-free wheezes that 're-disorganise' the NHS's structure and perverse incentives is accompanied by 'spin' that gives the illusion of integration of initiatives, when none exists. Sadly, this approach fails to tackle basic issues such as indefensible variations in practice in every part of the NHS.

These problems have been undermanaged for decades and are well evidence-based: see the 1976 Labour government document on priorities, still largely ignored.

These well-documented problems remain largely untouched due to managers being consistently diverted into successive governments' poorly thought-out reforms.

The NHS needs to incentivise managers to use evidence to reduce providers' inefficient practices.

Current reforms divert attention and energy from such activity.