Competition, choice and commitment

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Photo © Lee Jeffries flickr 500px

People who were least able to take advantage of competition and choice were,

less educated, less well-off, more likely to describe themselves as struggling financially, less likely to own their own home, less likely to have internet access, more likely to be disabled or a single parent.

They were also more likely to stick with providers with whom they had an established relationship.

They were identified in the Competition and Markets Authority (CMA) report on competition and choice between energy suppliers. Because of the associations between poverty and ill health these vulnerable people also stand to benefit least from competition and choice in healthcare.

Dr Smith was well past his due retirement, but was unable to find anyone to take over his surgery in a pretty rough part of town where he had been a single partner for nearly 40 years. His wife had been the practice manager until she had a stroke and then had to be cared for in a nursing home. He had been struggling to make money from the surgery for the last few years due to the cost of locum GPs and a locum manager. The building was desperately in need of repair. Dr Smith was tired and struggled to keep up with the paperwork, coming into work every weekend and staying late into the evenings. He hadn’t had a holiday in the last 3 years. He had survived his annual appraisals and revalidation by the General Medical Council and he was allowed to continue working even after the Care Quality Commission made a long list of recommendations after inspecting the practice. Like many GPs it was his considered opinion that the only things guaranteed by regulation and inspection were time taken away from patient care and low professional morale. Dr Smith was loved by many of his patients who known him for years and trusted him unquestioningly, though his treatment regimes were often out of date and he was tended to be pretty blunt.

One day, at work, Dr Smith had a heart-attack and died at his desk. When Dr Jones and partners took over his list, they found that the patients were more likely to be,

less educated, less well-off, more likely to describe themselves as struggling financially, less likely to own their own home, less likely to have internet access, more likely to be disabled or a single parent.

They were also more likely to be over 65 and have cognitive-impairment, learning difficulties or long-term mental illnesses. Other patients had changed GP long before Dr Smith retired. They didn’t need Friends and Family tests, NHS choices feedback, ‘I want great care’ or any other on-line rating system to recognise that the shabby waiting room and the ever-changing locum GPs weren’t ‘great’. But many of those that remained valued the long relationship that they had with Dr Smith and everything they had been through together. A fair few had been born at home and delivered by Dr Smith – twenty or thirty years ago it was common for GPs to deliver babies. He had cared for their parents and grandparents, their children and grandchildren. Personal care from a doctor they considered a family friend was of more significance than anything that could be measured and listed on a GP comparison site. According to the CMA report, energy consumers who valued long-term relationships based on trust and familiarity were also not served well by competition and choice.

The NHS is founded on the basis of equality and fraternity but liberty, as defined by competition and choice are new values for the NHS. ‘Liberating the NHS’ was the name of the 2010 government white paper that preceded the NHS Act, and the focus on liberty has increasingly eclipsed equality and fraternity. Competition and choice are enforced by a new NHS organisation called Monitor and strongly advocated by government advisers including Tim Kelsey, National Director for patients and information and Andrew Taylor, founding director of the NHS Competition and Cooperation Panel and now adviser to NHS providers on competition issues.

A situation where there is less transparency and no choice between providers cannot reasonably be defended, but questions need to be asked such as, What is the point of competition and choice in healthcare? Why must it be enforced? Who will benefit and who will lose out? What if patients don’t want to behave like consumers? What are the alternatives?

The point of choice is that it demonstrates respect for autonomy. Proponents argue that since quality between providers of care varies, patients have a right to know who is best so that they choose accordingly. They argue that if patients choose the best or cheapest providers then all providers will have to increase their quality or reduce their costs to stay in business. When choosing energy supply the cost is not the only consideration, though you wouldn’t know it from the CMA report. Other issues include ‘green energy’ and customer service and the confidence that comes with staying with an established provider.

When choosing healthcare, measuring quality is extremely difficult. Other factors like access, location, continuity or ‘customer service’ may be more important or even conflicting. For example, a service with better continuity of care – assuming such a thing is measured, may be hard to access. Quality, whatever that means, may not be the same as ‘what matters’, because what matters to a young mother joining a GP surgery may be very different for a working man with diabetes or a frail, elderly couple. ‘Choice’ when you are having a miscarriage, when you’ve broken your neck, when you have cancer or when you’ve got depression, hepatitis and diabetes all together or if you are housebound with severe agoraphobia and heart-failure may have very little to do with choice of healthcare provider and a lot to do with the quality of the relationships you have with health professionals. Leaving Dr Smith who has looked after you for 20 years because Dr Jones has got a better CQC report doesn’t make so much sense when you think about the importance of therapeutic relationships.

Healthcare is, for the most part, dependent on the quality of relationships between patients and professionals. It is interactional and cooperative. It is full of uncertainty about the nature of the problems and what should be done. More than ever it is about the care and support of patients with multiple long-term conditions in which long-term therapeutic relationships are most important. At other times care is for emergencies in which speed, not choice is key. Less often health care is transactional -for example when a patient has a clearly defined problem and is in need of a standard procedure for which outcomes are relatively easy to measure and relationships relatively unimportant. Here competition and choice may have value. But for most health care, the relationships between patients and professionals are both complex and caring and depend on mutual trust and respect and time to get to know one another.

Both the CMA and those directing health policy are of the opinion that the problems of choice and competition can be overcome by offering more choice and making it easier to choose at the same time as increasing competition. Underlying their bullish confidence is the morbid conviction that online league tables are more trustworthy than human relationships. Even more disturbingly, because choice and competition can be taken advantage of by the powerful far more easily than the vulnerable, the gap between them will be forced ever wider.

See also:

Competition, choice and quality in general practice

Patient centred care, rhetoric and reality

What’s the point of patient choice?

What’s in a name? Patients, clients or consumers?

High profile public reporting of quality doesn’t affect choice of maternity services

3 responses to “Competition, choice and commitment

  1. This seems like a very London-centric, doctor-centred post. Your statements about “equality” in the NHS don’t hold true, as many patients find they do not receive “equal” treatment, but rather treatment according to what postcode they live in. The postcode lottery doesn’t refer solely to availability of drugs but also to the availability of competent HCPs with whom patients might actually want to have a working relationship.

    I invite you to join some patient forums to find out and explore just how difficult it is for vulnerable, disabled and housebound patients who are forced (due to boundaries) to attend a single, given incompetent GP surgery because of the patient’s postcode. As it stands, patients don’t get “equal” treatment – they get the luck of the draw based on their address. Among the most vulnerable, sick patients I know, are those who have struggled to go abroad (with the help of family and friends) to seek care in order to avoid the poor local provision via the NHS.

    You assume that continuity of care is most important to patients but continuity of care isn’t helpful when the doctors you see are patronising, paternalistic, incompetent and badly educated. Who wants to be stuck in a long-term working relationship with a doctor who is incompetent and who is harming you? This is all that’s on offer to some patients due to boundaries and the status quo deleteriously affects the most vulnerable. As if boundaries aren’t bad enough – even worse is gatekeeping where an incompetent GP can prevent a patient from accessing life-saving tests or treatments. Maybe what patients want is to choose to have continuity of care with somebody who they actually want to work with, not somebody forced on them due to the area in which they live. There is a major difference.

    Rather than arguing to restrict patient choice and autonomy and to maintain your monopoly over local services (you don’t mention your vested interests in keeping the status quo), why not fight for independent advocates to support vulnerable patients to get the best care for their needs? You present GPs as though they only have patients’ best interests at heart whereas in reality it is clear that GPs often have other agendas (QOF, income, CCG directives, referral targets, ego, status) that have little to do with patient needs.

    Patients in other countries, be they vulnerable, housebound or severely disabled exist and are cared for in a system that respects the patient’s right to choose with whom they have a professional working relationship. Why argue to deny this right to British patients?

    • Thanks for your comment. I was careful to say that ‘less transparency and no choice could not be reasonably defended’ and I strongly believe that where patients do not get the care that they need, they should be able to change GP. When I first wrote this post, Dr Smith was much worse, but still (as usually happens) he looked OK on all the usual measures and had plenty of patients. The point of starting with the CMA report was to show that the worst providers end up with the most vulnerable people, even where they are free to choose and there is no ‘postcode lottery’. Where patients are disadvantaged we need to think of other ways to help people who are unwilling or unable to change GP. My feeling is that no GPs should be that bad,and the aim should be to improve the GP if the patient cannot/ will not change, because nobody deserves a bad GP. As you note, in rural areas practices are too far apart for patients to register at a different practice if theirs isn’t to their liking. Practice boundaries have some disadvantages, but on balance I think they are protective of vulnerable patients- I’ve written more here about them https://abetternhs.wordpress.com/2010/12/12/what-is-the-point-of-practice-boundaries/

      I’m pretty critical of QoF and have written about it in several posts, for example https://abetternhs.wordpress.com/2013/02/12/listenin/

      I’m also concerned about the use and abuse of power – some thoughts here: https://abetternhs.wordpress.com/2012/10/05/medical-power/

      Since all GPs are bound by roughly similar contracts, I don’t know how a patient could choose one that was influenced less by power or incentives.

      As far as independent advocates go, some of my patients have them but I’m not sure if that’s the answer and haven’t looked at the evidence. Likewise I have family in Germany, Australia and New Zealand and know these aren’t the other countries you’re thinking of. Where do you mean?

  2. When you talk of ‘choosing’ healthcare, I think it is important to say that it is really difficult to know what good healthcare is if you are not an expert in your condition – that is where patient groups are so important. After all, the majority of people seeking advice or treatment are not experts in that field. How would you know if you were getting fobbed off or if your provider is only offering a cut-price service/treatments because the provider is budgeting so tightly?
    As an allied health professional, I often see people who have had care elsewhere, assuming it to be ok, perhaps as good as it gets. They are often surprised how much better things can be. Sadly, I often see people who have not had the best care and for whom too many wrongs can not be undone. How can the consumer know they are getting the right care?

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