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Guest editorial Friday 4 February 2011: The risks of market Stalinism

Irwin Brown of the Socialist Health Association suggests that NHS healthcare commissioning and market Stalinism are inimical bedfellows.

The enthusiasm amongst some GPs for the 'liberation' proposals has now been replaced by scepticism as the contents of the Bill reveal the actual proposals.

The Bill is designed to achieve a full market in health; a proper market with price competition, and most services subject to the any willing provider model. This is not what most GPs want.

The Bill is not about patients or quality. It enacts the belief (not supported by evidence) that a full market system will magically deliver improvements.

Building bureaucracy into commissioning
It is right to bring the knowledge and experience of GPs and other clinicians into the commissioning process.   But, far from 'liberation', political and bureaucratic interference is being built into every facet of commissioning.  

Consortia can be instructed what to do, how to do it, what services to commission and not commission, who can be in the consortia or not in the consortia and the boundaries.  They can neither employ nor dismiss the only specified key official. The amount allocated to consortia is determined by the Commissioning Board.

Consortia can be instructed and will be directed about how to commission, and intervention can occur through the new NHS bureaucracy - but also by a powerful economic regulator, there to ensure the supremacy of free competition.

Just to make things worse, and to show the disparity between the emollient words of the Ministers and reality, we have now heard the Chief Executive (of NHS England and NHS Commissioning Board) talking to the Public Accounts Committee about how tight financial control will be exercised over consortia, at every stage.

This will be possible through the sub-national structure of the NHS Commissioning Board, formed from the 50 clusters being set up.  You can already see the way consortia will be inspected, reviewed and monitored at every stage; the empire that is the NHS bureaucracy has fought back and won the day. This is top-down in spades.

In the true spirit of localism, around 25% of commissioning will now be national; the rest subject to detailed national regulation.  

What freedom means
Liberation should make local bodies properly accountable then let them flourish.  Commissioning bodies must include, by right, both independent non-executives and patient representatives alongside the clinical professionals.

As they are allocating public money, they must be publicly accountable – open and transparent in all they do – free from any suggestions of conflicts of interest.

But balancing public accountability should be flexibility: they should be able to do what they think best for the community they serve, so long as they use proper decision-making processes and are open to scrutiny. Innovation and imaginative development of services requires the freedom to use whatever tools are most appropriate, and this will vary widely between locations and populations.  

There are services that are appropriate to market mechanisms such as the any willing provider model; where there is episodic care that can be relatively easily specified and priced, the quality can be measured, and there is little interdependence with other services. As preconditions, you need high volumes; good information supporting choice; patients prepared to be mobile; and low entry costs for new providers.  

In the greater part of the NHS, these features simply do not apply and the purist commercial market approach risks damaging the quality of care.  Some services are natural monopolies, such as national or regional centres of excellence.  Much of emergency care, such as ambulance services, will best be delivered through a single provider, through a long-term contract, maybe after a tendering process.

In other cases there might be a pathway approach where a number of providers collaborate in delivering the best care. Sometimes, making might be better than buying.  Sometimes, block funding gives stability and restricts unintended consequences.  It is complicated.

But top-down prescription and compulsion is wrong - and the enforced imposition of a preferred model to satisfy some mantra about competition is dangerous.

What is needed is a more subtle and nuanced approach. Competition needs to be used in a tailored way and only to solve particular problems.  

Above all, these should be decisions taken locally openly and transparently by clinicians, in partnership with providers, patients and the public.  That is not what the Bill provides.