Comment Blog 22 March, 2019

Throwing the baby out with the bath water

Earlier this week I was lucky enough to speak at an event organised by the Independent Healthcare Providers’ Network, the body that represents private sector organisations working in partnership with the NHS. The event asked whether the NHS can do two things that look contradictory: deliver a more responsive NHS with greater patient choice (for example through personal budgets); and deliver an integrated NHS with no internal market.

Speaking for NHS England, James Sanderson, in charge of patient choice, denied there was a contradiction. He said that the NHS remains entirely committed to patient choice. The only difference is that the Service is trying to find a more sophisticated form of choice (“personalisation”), based on informed conversations between patients and clinicians. Patients will then access the right services for them within a more joined-up service that is much easier to navigate.

James is right that the Service is committed to giving more power to patients via a greater use of personal budgets. He explained this at Reform’s 2018 health conference. Recent Reform research showed that personal budgets can give patients more control over their services and their lives (but need more evaluation of value of money before a big further roll-out).

The question is whether this new patient power can exert much influence on an NHS that, in other respects, is rejecting the ideas of competition and pluralism. The internal market is being abandoned, in favour of local health economies run (I predict) by big hospitals. The NHS authorities want to change legislation so that there is less requirement to ask which provider can run the service best, including the private sector. At the event this week, private providers reported that the NHS is already restricting their access to the market, in contravention of the current rules.

At a Reform event earlier this month, David Prior, the incoming Chair of NHS England, said that the internal market needed to be swept away along with many other policy initiatives (such as targets) which were dividing or distorting the Service. Certainly the method of operation of the internal market can be bureaucratic (which, I think, has led to the opposition of some Conservatives such as Nick Timothy). The question remains, however, how the Service will be held to account in the absence of key measures of performance and value for money. Furthermore, it is hard to see how a closed market of NHS-only providers can be innovative than a mixed market.

My guess is that the NHS is about to throw the baby out with the bathwater. In an attempt to make the Service easier to run, it will strip out many of the safeguards that prevent NHS organisations acting in their own interests. It will remove pressures for value for money and innovation just as it is increasing the budget by £20 billion a year. It will also hinder the development of ideas like personal budgets which James Sanderson is rightly encouraging. It may well be that the Service’s leaders come back to the ideas of choice and competition before too long.