Your views: Choice and competition

How can we best ensure that competition and patient choice drives NHS improvement?

We are interested in your views on this area, including:

  • Which are the types of services where choice of provider is most likely to improve quality?
  • What is the best way to ensure a level playing field between the different kinds of provider who could be involved?
  • What else can be done to make patient choice a reality?
In Conversations, Listening exercise: Get involved, NHS Future Forum: Pausing, listening, reflecting, improving | Tagged ,

241 Responses to Your views: Choice and competition

  1. ruth butterfield says:

    i think competition can prevent services from being complacent but there is a point at which this must impact upon the quality of service that is provided.

    from what i understand where options are provided many patients will choose the service closest to them or the one they know about rather than an unknown service offered by an alternate provider.

    • Beryl Walkden says:

      I do not know how patients can have sufficient and detailed information to make informed choices, even if geographically this is, in reality, a “pipe dream”.
      Another point, many hospital admissions happen at very short notice – on these occasions any thought of “choice” becomes a nonsense.

    • Dr Simon Abrams GP says:

      Competition needs to be a balance between holding providers to account and ensuring patients have a service they can feel is theirs. I have worked for an independent social enterprise service provider with a good reputation. I know it can work. But people want a quality local service that provides for them. Others on this site have also said this.

    • Malcolm Swinburn says:

      This is a debate only for those people who have the time, interest and mind set to engage by means of the internet.
      Is it not a fact that those who currently have ‘choice’ by means of private health insurance just use the same people the NHS pay but at a much higher rate.

      Should the population as a whole not be given a say on this very emotive yet important issue by means of a referendum.

      We are being asked how we wish to elect our MP’s so why not ask us how we wish our NHS services to be delivered.

      I totally agree with a previous person who said it is our NHS MR. Cameron and not yours to sell.

    • Dr Julian Sims says:

      Nationalised dinosaurs like the NHS have never outperformed private practice in a competitive environment. The NHS falls short in most areas giving the people of Britain second rate healthcare. For all the pockets of excellence, the devoted and hard working individuals are let-down by a monolithic nationalised industry that is unwieldy and grossly inefficient. The NHS is the second largest employer in the world after the Chinese army! The managerialism that has been eating away at it for decades reflects the Peter Principle – excellent nurses and doctors are promoted to managerial positions they are ill equipped to serve: we lose an excellent practitioner, and gain a poor manager. The alternative models in France, Germany, and Switzerland have been ignored: the UK must start to look at what more successful healthcare systems do, break up the NHS, and adopt a successful model.

    • Ruth says:

      choice discriminates against those unable to choose for reasons of geography or socioeconomic circumstance. Enabling access to services of an agreed standard of excellence and finally allowing those services that fail to meet that standard to close might be better.
      competition is ok, it does get innovation of service delivery – but does the public really know exactly how much of their money is spent on tendering processes for competitive services and how long it takes?

  2. Rheum says:

    I have seen how private providers cherry-pick easy profitable cases, and distort local healthcare.

    Our service is suffering from such a scenario. Our straightforward one stop patients have been taken away and given to a local private provider. We have been left with only the complex cases who require a lot of tests and follow up appointments.

    At the same time the local commissioners want us to be as cheap/efficient as hospitals in other areas who still see a mix of straightforward and complex cases. We took this case to the commisssioners, but no allowance has been made for this problem. Ultimately, our patients are going to get a raw deal as our service’s budget is reduced for our apparent ‘inefficiency’.

    Either the funding system needs to be significantly more flexible and clever, or strict rules to prevent cherry picking need to be introduced. I would prefer the latter – in fact i would prefer a single NHS to provide services rather than to commission them from a variety of providers.

    • A Roberts says:

      You are obviously supporting the interests of those working for a monopoly supplier. I assume that is where you are employed. The interests of the taxpayer – largely ignored in this discussion and “listening exercise” – are that there should be some competition.We know from history that nationalised monopolistic industries are largely incapable of reform.

      Living in France, I find that the state/insurance funded but privately provided model works quite well. After all, GP’s are private contractors, responsible for their own business. I don’t see any proposal’s to make them salaried state employees.

    • Juniper Connal says:

      I completely agree once the easy cases have been cherry picked like cateract and hip ops the main hospital will loss its income and then nopt be able to treat the expensive hard cases like the car crash or problem birth or dementia in the elderly. The most vunerable people will suffere the greatest loss. This will lead to increase health inequalities not a reduction. The porrest will be sicker and the rich will live off private insurance

    • I Collier says:

      I’m rather surprised at A Robert’s reply to this comment, they seem to be putting the interests of the taxpayer ahead of the interests of the patient.

      They also seem to be confusing ‘industry’ and ‘health’ the two are different.

    • Pauline Neild says:

      I agree with you Rheum, but feel that strict rules would be difficult to impose.
      Far better to have an efficient NHS than bring in private health carers who do not really care….

    • J Noton says:

      My view is that competition can focus the minds of managers within the NHS to improve service, but it needs to be a level playing field and it is not. Private providers will cherry pick the easier cases so that they can make money, so we need the tarriff adjusting to recognise that and the more difficult cases need better funding.

      the other problems this brings with competition is training, the private sector have no commitments on doctor/nurse training.

      the removal of certain volumes of elective work at NHS hospitals may undermine their ability to deliver acute work

      Finally I do not believe you can have competition and co-operation working unless you have a complex monopoly where it is in everyone’s interest to do so

  3. Sean Ferrer says:

    Last week, when I suffered a post-tonsillectomy bleed, the paramedics asked me, while I was gushing blood in the ambulance, which of four hospitals I’d like them to take me to. I had no idea – I just wanted the hospital – any hospital – that would sort my bleeding out. This notion of ‘patient choice’ is something that politicians are getting their knickers in a twist over and I, as a patient, don’t want. The paramedics, doctors and nurses are the experts, not me, and I don’t want to have to consider the merits of various hospitals myself – I’m quite happy to take advice. No-one in my considerably large social and professional network opposes my view. This began with Blair and is being needlessly perpetuated by Lansley. We don’t need patient ‘choice’, we need reliable expert recommendations!

    • Chris Martin says:

      @Sean Ferrer: Exactly.

    • Sue Brand says:

      Choice is one thing expertise is another. There seems to be a general assumption that the majority of the public are well informed about thier condition, what treatment intervention they need and where best for this to happen. This is not the case . Most patients like to be informed by a specialist, who has the knowledge and skills to undertake the treatment/procedure, has the backup of a team of nurses and Healthcare professional befitting their condition in a sensitive and individual way. Where best for this to happen but in the NHS where the services are already provided and in most cases, provided very well. Why try to mend things that are not broken, yes, look at how savings can be made, look at efficiency, look at patient empowerment, but the private sector! Good profit making out of health, not sure they go hand in hand.

    • Jeff says:

      Choice is only good if there are qualified doctors and healthcare professionals available. I find that the GPs I’ve visited do not listen to the patients any better than the government listens to people who are experienced where they are not. They have a preconceived notion of what’s wrong far before any real investigation has been done. If the GPs pay little attention to what their patients say, how can they possibly lead the NHS?

  4. Sarah Jackson says:

    From personal experience I don’t want choice of health care professional I want choice of location and choice of date and time so I don’t have to ring to rearrange or take leave from work as it is only between 9-5 mon-fri. I would be happy to see a GPSI or specialist nurse etc rather than a consultant or their team if it meant being more local and at a time more suitable for me.

  5. Mike Griffin says:

    The problem with “choice and competition” is that private sector providers will compete for the choice services; the services that will generate the most profit. Typically, this means they’ll choose the kind of services like hip replacement or cataractectomy, that are quick and profitable to deliver, leaving the NHS saddled with the complex, difficult services which are difficult to turn into revenue, thus exacerbating the NHS’s financial difficulties and creating a two-tier system.

    My experience of working with private hospitals is that they discharge patients with rarely a second thought about how they will cope on the outside. They are far, far worse at referring on to community rehab, intermediate care or social services, as these referrals generate no income for them. The result: poor outcomes for their patients due to a complete failure of joined-up working. Health and social care are just too important to be left to the anarchy of the market.

    • Michelle Doyle says:

      I work as an occupational therapist in an integrated comunity NHS and social services setting, and I see lots of cases of what Mike describes.

      I also know that we often become co-ordinators and facilitators of many hopsital discharges and complex cases within the community, which is not necessarily part of our job description, or something that is recorded in our monthly targets and statistics.

      I do not believe that most private companies will entertain carrying out the breath of work I am currently involved in, as liaising with other professionals will not generate profit.

    • Pauline Neild says:

      I agree with you Mike Griffin . A friend had an operation at a private concern which had a contact to perform a range of operations for the NHS.The aim was to improve waiting list times.The presentation they made when the facility was opened was very impressive promising amazing success rates. However the promises were not the reality.My friend needed an addition operation in and NHS hospital when the first operation was not successful. This was not an isolated case.

    • Caroline Terry says:

      I woulds reiterate the comments about discharges from private hospitals. After care is non- existent. Is the service agreement for any after care? They don’t think past their front door and income generation. So they will bid for the most lucrative business. Abolishing PCT, I also have major concerns about GP commissioning. Is there not a conflict of interest here as they are private business. Will patient choices be side-lined by GPs purchasing those companies who can bid the cheapest. We know cheap is not always best. Who will monitor GPs and will they be held to account if the provider does not deleiver on quality, patietn safety etc. Who will be monitoring governing at a local level. No disrespect to CQC. At least PCTs were held to account and had infrastructure in place to ensure the quality was there. Where does training of staff fit in to all this? Are GPs going to commission this too?

    • Gareth Everton says:

      enforcing competition with the two tier code will just result in a race to the bottom with staff being paid the lowest wages possible. This will result in poor morale, a lack of development and increased stress and sickness levels.

  6. Robert Irving says:

    I do not want choice or competition. I want one good hospital, dentist, GP close at hand so that I don’t have to travel. I want some spare capacity so that I don’t have to wait too long or have an operation cancelled due to emergency.

    • Robert Strudwick says:

      ….and I want world peace but I am a realist. I realise that the NHS pockets are not bottomless, changes have to be made somewhere, care costs money.

      Unfortunatly if an emergency occurs, routine operations etc must be changed, we cannot have excess empty beds just in case you need one at some undisclosed time, and how sad that you cannot wait a little while for what you want, go private and when they kick you out of the hospital early because you are no longer finacially of benefit to them you might find that the NHS is not a bad option.

  7. Robert Irving says:

    Why is moderation in place on this site? Do you only want supportive comment?

    • web editor says:

      Thanks for your question.

      We publish as many comments as we can, regardless of whether they are supportive or critical. We ‘pre-moderate’ comments to ensure they are not, for example, offensive, spam, or off-topic. The site is monitored regularly during normal working hours, and we aim to process comments as quickly as possible. Please see our moderation policy.

  8. andy mcgeeney says:

    I dont want these choices of provider brought in (particularly US style private health care in the NHS) I want a quality service that is properly funded locally. Competitive pricing will bring down quality. Id rather we paid a bit more and had a quality service.
    I want GPs to be doctors and democratically accountable health administrators to run the NHS.
    I want free free health care including dental care. We have the money in our society to have a fully funded NHS if we can fund three wars at the same time.
    None of these health changes were in the Con Dem manifestoes. This is a right wing coup by stealth.

  9. Patrick Carroll says:

    I have no worries about competition provided it’s a fair process. Don’t allow private providers to cherry pick services as that leaves all the complex stuff with the NHS services who have no “easy” work to balance the contract.

    Before this “choice” agenda and choose and book a GP could if they chose send a patient anywhere now they are restricted by the commissioning process and I doubt that will change.

  10. Mike Townson says:

    How much does the management and implementation of choice and competition cost? what additional support services and non clinical people are needed to meet this agenda and how much more of £80bn gets taken out of front line services. Invest in high quality leadership, strong managers and enough clinicians and patients will have choice on their doorstep as services will continue when gaps caused by sickness, maternity and other leave. Junior staff will have the support they need to become autonomous quicker. Choice and competition is putting more money into the back office functions.

  11. Nigel Rowell says:

    On the side of our local buses is a stepwise path for Out of Hours care:
    Self Care > Pharmacy> OOH Centre>Emergency GP>Casualty
    Some of my patients see this as a challenge and manage to get through all of them in one evening. By providing multiple choices for care we create demand, not reduce it.
    Then they come to see me the next morning!

  12. Gill Watson says:

    Doctors spend 5 years at medical school and then several more years learning on the job let’s not waste their precious clinical skills and time on commissioning work. ‘Manager’ is not synonymous with ‘bureaucrat’ and the NHS is performing many healthcare procedures every day and needs people to ensure that there is lighting, heating, medical supplies, staff education (to ensure the most up-to-date skill levels) and so on. Let trained managers do this vital work and agree and monitor the contracts that deliver the things that clinicians need to their work. Lets not fragment the NHS and whoever thought that introducing the profit motive into healthcare was a good idea just look what happened to hospital food and cleaning when we gave it to private providers who want to squeeze the maximum profit margin from the contract.

    • NHS Manager says:

      I agree. As a patient I want my GP to be a GP. I don’t want my GP to be in meetings, dealing with commissioning services, dealing with performance management of providers and all the things that I do each day. I am an NHS manager and I am proud of what I do. I’m not a clinician. Whilst I support more clinical involvement in commissioning and re-design of pathways, I do not think that GPs should be involved on a day to day basis and from the scores of GPs that I’ve spoken to, they don’t think so either.
      The real issue with all of this is not AWP, because it’s been around and successful for a long time now, but the fact that the government has completed failed to comprehend exactly what NHS managers, PCTs and even SHAs do.

  13. I believe that patient choice is a bad thing. Patients do not make rational, impersonal decisions about what they want at the time that they want it. These decisions should be made by health care professionals in possession of the facts eg NICE. Internal competition is artificial and wastes resources – eg marketing/advertising.
    Parts of the health services that are not doing well should be given more help/money, not punished by funding being removed!

    • Deborah Milburn says:

      The government is abolishing NICE. A lot of that is due to the fact that NICE made the difficult decisions about what the NHS could and could not afford strictly, as you say, according to the evidence base.

      Unfortunately, the government got all hot under the collar about expensive cancer treatments refused to individuals whose sad tales were splashed all over the tabloids and NICE took the flak. Hence their abolition.

      So now it will be down to your GP to make that decision and he/she will be expected to have in depth knowledge about every pharmacological and therapeutic intervention on the market so that he/she can guide you to make an informed choice. No wonder they don’t want this poisoned chalice.

  14. Judith Nicholson says:

    I don’t believe ‘patient choice’ is a meaningful end in itself, if I go to the doctor and need an operation, I believe the doctor is in a better position to decide than myself. What is desirable is for the doctor to make this choice based on who will provide the best care, rather than which provider has approached his consortium with a good deal on price.

  15. David Fowles says:

    Patient choice is an awful idea that just causes a lot of problems and costs us, as a country, more money rather than saving it. Any drive should be put into making sure every part of the NHS provides the best possible service through support and investment rather than punishing them by removing areas to the private sector who will cherry pick and profiteer. If there is profit involved it is money that is not going to patients who need it.

  16. Steve Ranger says:

    I am unconvinced that choice and competition will drive improvements in the provision of health care. As a patient I expect all health providers to meet the required standards for quality of clinical care, driven by professional ethics and clinical audit; and by bodies such as NICE. Whilst I might like a degree of choice in questions of timing and location, I expect health professionals to guide me in matters of clinical benefit. In too many areas of modern society competition means a race to the bottom in terms of price at the expense of quality. This is unthinkable for health care.

  17. Dave Eyre says:

    I do not want choice for choice leads to surplus. I do not want surplus resources in the NHS.

  18. Charles Russel says:

    Personally I do not subscribe to the almost religious belief that ‘competition’ is a good thing in every situation.
    What the last Conservative government’s ‘infernal market’ brought us was MRSA!
    To go down the route of the United States, where the health care is the most expensive in the world, would be a major mistake.
    I have experience from both sides of the pond and can honestly say that the NHS is superior.
    This all seems like an operation to enrich the Insurance companies who see an opportunity to parasitise populace to even greater extent than at present.
    What I want to see is competent and caring medical staff able to provide the care the nation needs.
    Have a look at reducing the armies of Management Consultants stalking the Hospitals perhaps?

    • Jayne Edgar says:

      I want a public health service, provided by our existing hospitals and staff. I do not want privatisation .

  19. Jake says:

    Most people, when prompted, don’t want choice in the NHS in any substantial form. Instead they want a good local hospital. It is also true that the majority of the public don’t have a clue when it comes to the performance of various different treatment options, and prefer these decisions to be left with trained professionals. Moreover, the whole process whereby we have a plethora of different health providers within an internal market is incredibly inefficient. Stop trying to promote the choice agenda and start listening to the people who actually work in these services.

  20. K Udagawa says:

    Scrap the bill – if 99% of nurses have NO confidence in Andrew Lansley, it’s not just an imperfect bill, it’s a trainwreck.

    Choice and competition won’t help – it’s not for patients to choose, it’s for doctors to do so. GP-based commissioning will dump lots of admin on them and cost a lot of money to implement. Doctors should be caring for patients, not filling out forms …

  21. Richard Rice-Grubb says:

    In the context of healthcare, choice and competition are not ideal. As has been mentioned before, medical professionals are best informed as to what a patient needs and where best to get necessary treatment. Competing on cost will shift the focus from best care to cheapest provider. I am concerned that the reform plans are going ahead with little obvious support from patients or clinical staff.

  22. Anthony Rodriguez BSc Health Studies says:

    There is a difference between “choice” and full-blown commercialisation of the NHS. Having some element of “choice” is essential for all practitioners, the best drug, the operation, the best consultant, etc. but few would welcome the NHS heading down the path of rail privatisation. That was meant to introduce “choice” but instead ended up with monopoly private train operators providing a poor and expensive service. Empower patients by giving them more say over their treatment and input into health service organisation but do not privatise the NHS to become Railtrack in a white coat.

  23. Professor Paul Bywaters says:

    Competition is the basis of health care in the USA, the world’s most inefficient and costly health care system in the world which produces very poor and unjust health outcomes. We do not need more competition, we need collaboration between different elements of the NHS and with social care services. Choice is not what patients want most – what we want is good quality services, readily accessible, near at hand.
    The questions set above show that far from listening about whether we want choice and competition, the government only wants to hear how they will be ramped up. Are these core principles of the NHS? I don’t think so.

    • Anthony Rodriguez BSc Health Studies says:

      Patients deserve a say in determining their health and well-being, with the vast majority of health care for ailments such as colds, headaches and aches and pains being self-treated outside of formal health service provision. So patients should be able to prove themselves to be the best “doctors” for all but critical and emergency care by exercising an element of choice and participation in their treatment alongside health professionals. Passive healthcare is no longer an option.

  24. Clare Pearson says:

    Choice and competition do not work for healthcare. Services should be combining efforts to treat patients not to compete against each other. Most people would prefer treatment in their nearest health care centre, rather than have choice, I don’t understand how the practicalities of this would actually work.

    • Anthony Rodriguez BSc Health Studies says:

      The rule out any element of “choice” is belittling and patronising to patients. They need to be empowered to make the best choices as active participants in their health and well-being. In the online age, an NHS resistant to patient choices would belong in Stalin’s Russia, not Britain in the 21st century. But the solution is not to give GPs all the “choices” by controlling the lion’s share of the NHS budget.

  25. Mark says:

    Prior to the introduction of the internal market the NHS was rated in the top 10 of financially efficent healthcare systems

    There is also evidence that healthcare outcomes have been improving at a greater rate than most western nations for the last 20 years.

    Since the internal market we have plumitted in the financial efficency ratings.

    From my experience as a nurse competition has caused some efficency in departments but often of the order of 1-4% but this efficiency has been grossly overwhelmed by the cost of administrating this market.

    My department has saved £10,000pa by changing some of the tests we take but we employ someone at £30,000 plus pa to administer the payments from the PCT and I am sure the PCT pay someone a similar fee to administer the payments to us.

    The best thing that could be done is to dismanyle the internal market not expand it.

    There needs to be decent regu;lation of efficeincies but also of quality of care the NHS needs to maximise calue for money and this internal market wastes huge ammounts

  26. R Norton says:

    I am not terribly interested in choice, what I want is an effective health service something I believe these reforms are jeopardising which will threaten the service provided and undermine the principles of the NHS.

    In terms of competition I am against increased private sector involvement in the NHS, healthcare is too important to be left in the hands of private businesses whose motive above all other things is profit. I do agree that could potentially lead to improved service but constantly repeated in numerous industries things like safety, quality of service, obeying regulations are pushed aside for profit. I do not want more competition in the NHS.

  27. Dr Sara Dew says:

    As a GP I offer choice to my patients each time I refer via ‘Choose and Book’. The majority want to be seen and treated in their local hospital and expect this to provide them with excellent outcomes. Only very occasionally do they choose to go elsewhere and this is usually only if there is a significant reduction in waiting time. In fact many patients prefer to wait longer to be treated locally than have to travel. Choice may have a role in the large metropolis where there are numerous NHS providers in a relatively small area but for those of us not in that environment it seems barely relevant and even before the advent of choose and book I could refer a patient to hospitals across the country if this was appropriate or desired. The internal market caused the reduction in choice when PCTs commissioned services from specified hospitals for each locality!

  28. Nicky Norriss says:

    I agree totally with patient choice regarding location of treatment and choice of healthcare specialist. I also agree with healthy competition between Health servcie providers to provide the highest quality and most cost effective service. However i do feel that ‘Any Willing Provider’ has the potential to result in 2nd rate healthcare for patients and cause the destruction of the NHS as we know it.
    Within the NHS we strive to provide a high standard, cost effective service and seek to support staff in their learning and development so that they can provide the highest quality , ‘evidence based’ practice and services.

    ‘Any Willing Provider’ has the ability to undercut NHS services by using less experienced and less qualified staff. It is unlikely to provide a such a supportive learning enviroment for staff and and thereby the standard of service given is likely to suffer. The nett result could be a poor quality of service to patients and patients not being able to reach their full potential.

    • Anthony Rodriguez BSc Health Studies says:

      These a valid points, especially regarding the “any willing provider” concept. There is a place for choice, but not if it undermines the quality of treatment and opens the doors to full-scale commercialisation of the NHS.

  29. H Jackson says:

    I do not want choice. Competition is a context.

    It’s much simpler than that. I want universally good-enough doctors, hospitals, medical staff and care.

    (Where did competition in education get us? Good local schools are all that people need. Take heed!)

  30. Helen Thomas says:

    I do not believe that patient choice is a good thing. What matters is patient care and choice and competition do not drive that in healthcare.

    I do not want to be in a position where I can’t trust my GP because he might be making a decision based on cost as opposed to what is best.

    I do not want my health care to make money for shareholders.

    These reforms are a terrible idea and instead of ‘listening’ they should be scrapped

    • NHS Manager says:

      Your GP has been making decisions based on cost for at least the last 10 years.

  31. Anon says:

    The notion of competition will only have one outcome in the medium term, and that is decreased choice for Patients. A good example is Opthalmology. Most of the activity undertaken in acute hospital Opthalmology departments relates to cataract surgery. This is high volume, straight forward surgery which is ripe for private hospitals to take from NHS hospitals. The problem is that once this work goes to private hospitals, the volume of work the NHS hospital Opthalmology deparmtent will be left with will be loss-making. The result? The NHS hopsital will close it’s Opthalmology department. If you need cataract surgery, fine you can go to the private hospital. But what if you need something more complex? The private hospital won’t do it and your local hospital has closed it’s Opthalmology department. So great, you get to travel 50 miles to the next nearest hospital. But what if that one has also decided to close it’s Opthalmology department too? 100 miles?

    The NHS has to make savings, meaning NHS hospitals, like any commercial thinking organisaiton, will look to decommisison loss-makign services. It is already starting to happen.

  32. S Lenane says:

    As a patient I want high quality care delivered locally in a reasonable time. I want my local hospital to receive sufficient investment to make this possible. I don’t want the option of travelling 50 miles. I want NHS bureaucracy to be reduced. I want the wasteful internal market scrapped. I don’t want one hospital competing against another. I want them all to work together, sharing best practice for the benefit of society as a whole. I don’t want the organisation looking after me to be motivated by profit and I don’t want ideologically driven reforms.

  33. Danielle Walker says:

    Last year, I undertook a consultation of 2,500 people with Multiple Sclerosis in the East Midlands. One of the key findings was that many people are not aware of the healthcare services they can currently access. As a person with MS, I feel that widespread provision of information about how to access existing services must be addressed before choices are offered.

  34. Chris Lawrence says:

    What I want to see is a consistently high standard of care and I just do not see that at the moment. I think the NHS should provide good general health care not peripheral issues such as IVF which is a life style choice. Also there has to be some rational with regard to hip replacements. My great aunt was given one at 95 and died the next year. Is that good value for money?
    The other situation I have noticed is how top heavy the NHS is these days. Back in the 1970′s the NHS in Hampshire was run from one small office block. Now it seems to be run by an army of nameless managers.

    • NHS Manager says:

      We are not nameless and we do a hell of a lot more work than you care to realise. Who exactly do you think has been doing all this commissioning for the last few years? Who has managed the out of hours services? Who has been responsible for making sure you have all the services that patients need?

  35. Ian Cole says:

    How does competition benefit a patient, I mean really realistically benefit him? The cheapest surgeon? The hospital with the best food? The hospital least likely to leave a swab sewn up inside a patient?
    All I want when I have my operation later this year is to be assured that I am in the safest hands and that my care/recovery will be second to none. Does this mean that I should ask my surgeon to include me on his NHS list at a private hospital? If “yes”, why?

    • Anthony Rodriguez BSc Health Studies says:

      There is a difference between competition and choice. The patient should have the option to play an active role in determining his (or her!) well-being and be guided in making the right choices by doctors, consultants and other health professionals. Some hospitals are excellent, others simply dreadful and patients should have some element of choice to enable them to avoid the poor performers and get the best treatment.

      This is where the GP consortium and “any willing provider” model is a worry as GPs may be under pressure to choose the cheapest alternatives to balance the spreadsheet each month. That is why quality of treatment must the primary consideration in a “choice”-driven NHS.

      Yes, you should be prepared to make sure that your surgeon is making the best choices for your treatment and be prepared to seek a second opinion at an alternative hospital to ensure the best outcome. We need a patient-focused, flexible, proactive NHS, not a privatised one.

  36. Tess Harris says:

    In consumer goods markets, choice has just led to vast fragmentation and brand extensions of what are often the same core product.

    A crisp is still the same nasty deathly salt-ridden product event if it purports to be from organic potatoes or differently flavoured.

    Will we see “new and improved” NHS services appearing on our high streets soon?

    • Anthony Rodriguez BSc Health Studies says:

      I think you are wrong here. All crisps (and many public services) may have been “nasty and salty” in the 1970s but consumer choice has drive down salt and saturated fat levels and there are all kinds of “healthy” alternatives available, just look in any health store. Most sociologists are hardly right-wing ideologues but they have long recognised that choice is a potent social phenomenon in the modern age. Let us hope the NHS “crisp” that emerges from this Bill is a high-fibre, oven-baked, low-salt healthy one, not a high salt, high fat processed “disc” made from dried potato. It is a mistake to dismiss the importance of choice in health care as having some element of control over one’s health is beneficial to well-being. Passive patients are the ones whose outcomes are usually poorer. Passive health care is no longer an option.

    • Marcus Hughes says:

      I agree. I think there is ample evidence (eg. see the work of the economist Nick Barr at LSE) that in markets providing a “complex” product such as healthcare, most consumers do not have sufficient information to make choices that are in their own best interests. This is not to say that choice is a bad thing, but to put it at the forefront of reform is ill-advised, because the risk is that a lot of public money will be spent offering a gimmick that will not actually benefit the population’s health.

      I think Anthony’s point about crisps is not quite right. Improved uptake of healthier eating has, I think, more to do with education than with the availability of choice. Informed consumers will demand better quality products, and “providers” will shift their product range if they want to stay in business.

    • Anthony Rodriguez BSc Health Studies says:

      Talking of the LSE, sociologists (not usually the most right-leaning people) agree that consumer power “from below” has been one of the most significant drivers for change in the last few decades. Consumers have driven the food industry away from hard fats and high salt through their own pressure aided by the information given to them by scientists. That is how “choice” should operate in health care. After all, the disabled are now free to employ a carer of their choice funded by the state so why should patients not have similar choices?

  37. CLare Andersson says:

    No patient has ever asked me for a choice.They simply want a good local hospital to attend.I believe competition should be about standards and holistic care not cost.

    • Anthony Rodriguez BSc Health Studies says:

      Agreed on the need for holistic care but when patients are exercising “choice” with almost every other service and product they use, why should health care remain a service-led, not user-led activity? After all, the patient has exercised choice in attending one health centre over another and signing up to one GP over another, so surely this is just an extension of these existing acts of choice in NHS services? Eye care patients exercise choice in choosing to opt for glasses, contacts or laser surgery and styles of frames so why do they need to accept a “one size fits all” approach in primary care? And yes, I think optician services (and dental) should also be free at point of delivery! We only have a partial NHS, our eyes and mouths live in a privatised free market already!

  38. Mrs. Susan England says:

    I do not want choice. This bogus “choice” the government is attempting to impose on us is simply an effort by politicians to reward the private companies who have given them money. Unfortunately for the politicians and the private companies, the public know what you’re up to. Price competition is good for supermarkets but devastating when applied to healthcare. I simply don’t see a way to prevent cherry picking from private companies. They are all about profit. They will only want the services that are profitable. This is a truly horrific bill that should be scrapped outright.

  39. James Looker says:

    Simple, no private providers in the NHS. Problem solved.

  40. richie krueger says:

    Stop the patchwork privatisation of our public health service. Choice is part of the cute propaganda of a market driven ideology. The idea of competition within healthcare contradicts the ethos of healthcare. Keep Our NHS Public.

  41. a veall says:

    I believe that the general public have no understanding that their healthcare is some areas will be provided by “private companies”. There will not be an option to choose NHS primary care as it will not exist, therefore this is not competition, but a removal of services.
    NHS foundation trusts within primary care will give the option of NHS care providers, along side private companies, but PCT areas should not be allowed to have only social enterprises, or private companies offering community health care provision as this limits competition and could destable the NHS care in areas without an alternative option. The options shoudl therefore be NHS foundation trusts or private companine/social enterprises, not exclusive to one or the other. PCT’s shou8dl not be allowed to become social enterprises if there is not al alternative general primary care NHS fo0undation trust within the county area.

  42. Nic Price says:

    Anyone really ‘listening’ to the people on this forum should be able to see that no-one wants a wholesale change to the current model. I’m fairly sure the ‘listeners’ (if anyone even is bothering to read the public view) will wisely decided that each of these opinions is ill informed/guided by self interest/missing the big picture/a minority view.

    Let’s be clear. There is no-one who genuinely thinks these improvements are going to make the NHS better or more efficient. Please stop.

  43. R Carter says:

    My family has had the very best of the NHS, my wife has had stem cell treatment to cure her cancer, I was in a car accident and in a coma for two weeks. my eldest son recently had a staff blood infection.
    The NHS works. we do not want it to be privatized in any way, we will stand up and be counted.
    We must never allow profit before people, the NHS sets us apart, as a public service, it is a shining light, that we will not let carpetbaggers rape for profit.

  44. J Carter says:

    Stop this vile NHS reform bill now, can you not understand plain English, it is not yours to sell Mr Cameron,
    We the people do not want this wholesale privatization of our NHS.

  45. R Carter says:

    We can afford a public NHS, without the corrosive creeping cancer of privatization, we can not afford, more wars, PFI scams, tax dodges,
    to bail out banks, large standing armed forces, sort out these, and we can afford our very special NHS and free uni educations for our young people. Scrap this bill now.

  46. PaulF says:

    This is a listening exercise?!

    The listening consultation document is leading in the extreme. It makes no attempt to manage outright objections to the HSC bill, only for minor alterations that are superficial at best.

    A typical question from the document is:

    Q3) What else can be done to make patient choice a reality?

    This is outrageous and it is published by the Department of Health! Perhaps the best use of this resource in the first instance would be to research and demonstrate that there is any evidence in fact that these changes will be beneficial to patients and taxpayers. Mr Lansley has categorically failed to provide any proof but has used dogma and anecdote in its stead. He has also cherry picked (a shadow of things to come?) a snapshot of numbers to suggest unsatisfactory health outcomes when a glance at the bigger picture illustrates how distorted these are.

    This hasty and politically motivated attempt to drive through a baseless agenda will be looked back on with incredulity.

  47. Anon says:

    As an experienced individual in healthcare I was surprised to find that when I was offered ‘choice’ I felt I didn’t have the appropiate information or ability to make a choice and fell to the normal stance of ‘what do you think doctor?’

    In reality there isn’t choice for the majority of helathcare it only applies to cold elective surgery, any other healthcare is based on availability ie where is the nearest bed available, where is the shortest queue for A&E. In primary care patients do not have the freedom to change GP’s easily as they cannot find out where the good ones are. In reality if Choice plays out it will require services and/or a hospital to close, where will choice be then? and can the politicians really face the concept of their local hospital closing?

    where I would like choice is in the realm of the day of clinic, the time slot, availability of services in the community, a longer working day and true 24/7 services

  48. Jan says:

    With Commissioning Support being provided to GP Consortia by private Companies where will the checks and balances be to ensure that these commissioning organisations do not end up ‘buying’ their own provider services?

  49. Health Economist says:

    The principle of choice and competition is essentiall a good one. The hard part is how you measure them.

    On the whole choice of hopsital works well in large conurbations but does not work well in rural areas or towns not large enough to have more than one provider, that’s why Scotland and Wales have not adopted this model! It is entirely up to patients as to whether they exercise their right of choice of provider, but at least they have one.

    We will never really have true competetion because it seems that organisations can not compete on price. Competiotion on quality is fine, just too many variables.

  50. J Moore Primary Care Nurse says:

    Most people would choose to use their local service if it was of high standard, so national quality standards are key. Care must be rationed, as however large the budget is, it must be finite – NICE has provided guidance which is easy to access and really helpful to frontline staff. NICE ensures some parity of rationing decisions across the NHS.

  51. J Moore Primary Care Nurse says:

    The current “reforms” have knocked staff morale and in my workplace many good nurses have left. Nurses and other healthcare staff have mostly opted for these professions because we get job satisfaction from providing the best quality care. What is needed is a system which supports staff who are providing the best care and does not leave them feeling undermined and isolated. The reality of competition for services is that I loose my job security – I have witnessed this leading to the collapse of staff morale – this then impacts on the quality of patient care. If I apply for a job in a “social enterprise” I will no longer get NHS pension, or the national pay scale. If, as will surely happen, some of the arrangements to transfer from PCT fail (partly because everything is so rushed due to the very tight timescale imposed), the private sector are poised to move in on the tasty bits.

  52. J Moore Primary Care Nurse says:

    When I started my nursing career Mrs Thatcher was in power, the existing cleaning and catering staff at my hospital were sacked and the services were commissioned from the private sector. Cleaning and catering staff working within the NHS thought they had job security, stayed for long years and felt part of a team who were providing quality care. Now there is a high turnover of cleaning staff and if something is being missed in the cleaning, or not cleaned correctly it is not simply a question of having a word with the cleaner – I would need to ask my health centre manager, who can bring this to the PCT commissioners, who can pick up the issue with the firm who employ the cleaner as a temp, in my experience the reply from the firm is often “Oh that is not within our original spec. we can do it but it would cost more.” I think we are at a stage again where we don’t know what we’ve got till its gone – in 5 or 10 years time I hope we won’t be saying “it used to be the case that you could build a relationship with your local nurse / doctor, now I have no idea who will be there next time.” High turnover of doctors and nurses will also impact on the development of high quality services.

  53. J Moore Primary Care Nurse says:

    I received from our local PCT prescribing committee detailing how the work of the committee saves £7 for every £1 spent on prescribing management. The whole thrust of the email was not “how can we spread the word to other parts of the country?” but “how are we going to manage to protect and maintain this work when the organisation we work for is abolished?”

  54. J Moore Primary Care Nurse says:

    The ideology which has led to these changes holds that public sector equals British Leyland equals inefficient, costly, old ways of working. This is not the NHS I know. The scale and speed of this change smacks of this ideology, rather than a wish to find and promote good practice. I would prefer to see a system which recognises the importance of staff morale to providing quality care, which looks for examples of best service in one area of the country and then pushes to replicate those improvements elsewhere.

  55. J Moore Primary Care Nurse says:

    Rather than commissioning what is needed are clever systems which reward quality care – I think QOF (Quality Outcomes Framework) does this. The reward does not need to be financial as with QOF it could be that local teams who achieve the quality standard are given greater autonomy – this would be excellent both for staff morale and quality care.

  56. Isla Dowds says:

    The government have got hung up on “ choice” as some sort of holy grail – in fact it is more of a red herring. From my extensive experience of engaging with patients and carers, “choice” per se, is rarely high on a patient”s agenda. If it is important to people it is often becuase of factors such as convenience around time and location of treatment. The things most people are really concerned about are quality of care, patient safety and timely care, provided with clinical excellence and with compassion. They do not want to HAVE to choose in order to be sure of accessing healthcare that delivers on those things – they want it to be available to them at their most local hospital. They do not want to have to trawl around websites ( if they can, and if they have easy access, neither of which is universal) looking at data, which they may or may not understand and interpret correctly.

    • Isla Dowds says:

      (2/7) If offered choice, for example by the referring GP, the most common response is, I believe, “ what do you think Dr” and so people not only do not use that choice, they defer the decision to the person they perceive as having the appropriate knowledge to make that decision based on the things they really care about – quality, safety and how long they will have to wait to get the care they need. Incidentally this pattern of behaviour also raises issues around conflict of interest in the proposed future commissioning process and how it might affect referral practice.
      The choice mantra has been waved as some kind of gold standard, but I fear it actually detracts from what our time, attention and indeed our money should be focused on: making every hospital a centre of excellence so that no matter where you are referred to you can be sure of that quality, that safety and of a clinically appropriate timescale to be seen.

    • Isla Dowds says:

      (3/7) I would add that there are dangers there of a narrow clinical focus and accepting a slide back to waiting for an appointment for such a length of time that, whilst not necessarily clinically dangerous for the person, they do experience an unnacceptable reduction in quality of life and sometimes on ability to function e.g. because of pain. This needs to be borne in mind as well as more critical clinical factors – e.g. waiting 6 months or a year for a kneee or hip replacement may not kill you but it would almost certainly have a huge impact on quality of life, ability to function, including working and possibly on mental and emotional wellbeing.

    • Isla Dowds says:

      (4/7) The SoS of course claims that competition is they way to ensure that this quality, safety and speed goal is achieved. But I have not seen a single piece of evidence offered (and, in the interests of validity, I would want to see a lot more than a single piece!) as an evidence base that competition and choice drives up quality. If this is the case why have you not been trumpeting it from the rooftops? I suspect the reticence is becuase there is no evidence base to justify this approach, which seems to be pretty much the basic driver of the shape of this reform.
      If I and the many, many other individuals and bodies who have questioned this are wrong – please do show us – bring forward your compelling evidence that choice – in health care provider, not in another area of life, let”s have a valid comparison please – drives up quality.

    • Isla Dowds says:

      (5/7) Even if there was such a compelling argument and evidence base, it is not the end of the story. What will happen, for example if a provider, left without the critical mass of patients necessary to keep a speciality or procedure or department viable because so many are choosing to go somewhere else that is alleged to be better, then has to close a ward, a deparment, or offer a particular treatment? That will reduce choice not increase it, and for some patients, that may mean for example undesirable effects – having to go much further for treatment, which could be difficult for all sorts of reasons, or wait longer for it because the number of providers has decreased. Should the focus not instead be on providing whatever input is necessary to the provider who is not meeting the mark, to enable them to be just as attractive an option, thus maintaining choice?

    • Isla Dowds says:

      (6/7) What about the patients who are not equipped to makesuch a choice – will they not still allow others to “choose” for them and what will that do to the theory of the best will survive and get the business?

      I also fear that to say that competition will only be on quality and not price is just not realistic in an increasingly cash-strapped NHS. It will put those who commission, with an eye on their own budgets, in an invidious position when chooosing a provider – of course price will be a factor in that process no matter what policy says. You have 2 potential providers, both making very similar claims on the quality of their outcomes, but one is 20% cheaper than the other. What will be the final factor in that decision? Most probably, the cost. How many times have we seen providers fail to be able to deliver the service at the standard specified becuase they have undercut on price? Sadly, by that time, patient care will have suffered.

    • Isla Dowds says:

      (7/7) “Choice” is over-rated – let”s instead focus our policies and our purse on making every UK hospital one where there is such quality, such safe, timely care on offer that the need for choice will become redundant.

  57. Pauline Neild says:

    I only hope that the RT Hon Andrew Lansley takes the time to read the above comments. I am against private providers being brought in.
    Local experience of this has been damaging to patients and extemely expensive.It has definitely not improved quality of services.
    I hope time will be taken to look at positive work already present in the NHS and build on its strengths.

  58. GP says:

    The problem with competition is that there will always be less desirable/profitable people and procedures.

    Who will pick up these operations and patients?

    • Health Economist says:

      Extremely good point, that’s why competition on quality alone will not work. Competition on price for these sorts of procedures will enable new market entrants. But the catch is, as you point out these procedures are the ones that the private sector wont touch so price is artificially inflated in the NHS. If we had a truely competitive market the NHS would go bust. Vicious circle!

  59. former cancer patient says:

    I would prefer to go to a specialist hospital for cancer treatment not the nearest general hospital. Likewise if I had a heart condition I’d rather be treated in a hospital which did a lot of heart ops and had developed expertise in that area. The idea that anyone can turn their hand to anything is silly.

    I don’t think GPs have either the time or the knowledge to commission services. My GP told me she only had three patients with breast cancer in a practice of 3,000 people (most of them under 40 years old) so I can’t see her giving much priority to my condition. I’d rather have outsiders commission. GPs are providers of services and shouldn’t muddy the water by also commissioning things.

  60. Iain Anderson says:

    I find it very difficult to make a response as the framing questions are so prescriptive. I fail to see how ‘patient choice’ in any way can help deliver the best possible quality service free at the point of delivery. How can a patient make choices? The patient should be consulting a well-trained professional, a GP, who will advise on the best available treatment or will refer on to the best available expert. There may be legitimate questions about how the best experts and/or best treatments are made available within a given budget – but I fail to see how patient choice answers those.

    Similarly I do not understand how competition between providers can deliver the required outcome – in fact competition would require a multiplicity of providers which by definition means wasted resources.

    Perhaps I’m thick.

  61. Anon says:

    Choice is a movable feast. It is held up as the Holy Grail by Government, and yet this choice is not a real concept. Choice is only choice within certain narrow parameters in my experience, that is, you may choose from whatever is on offer, as dictated by vested interest in the status quo. If I wish to use Chiropractic or Homeopathic treatments, both of which are underpinned by a range of evidence, I cannot choose these via the NHS but must use these privately. This is because these treatments may not fit into the norm of medical testing processes, and despite evidence to the contrary, they are not accepted as efficacious. It appears to me that when we talk about choice in the NHS, we are not talking about choice that represents the whole populations’ preferences, but only those sanctioned by the scientific establishment and the pharmaceutical industries. If the Government really wanted to look at choice, and to invest in prevention, self-care and long-term wellbeing, then it would look at all treatments with clear eyes and make bold decisions on choices actually offered.

    • Health Economist says:

      There is no evidence to support the use of homeopathy or chiropracty. Sorry!

    • Isla Dowds says:

      I think what Health Economist means is that there is no evidence which meets current criteria for it to be acceptable…..

    • Anthony Rodriguez BSc Health Studies says:

      The lesson to be learned from the likes of homeopathy is that just giving patients time to discuss their worries can contribute to healing. Too often, NHS doctors have their eye on the computer screen, the door and the prescription pad, not the patient. Consultations are often rushed even with a half-empty waiting room.

  62. Mental health worker says:

    It seems to me that the suggested benefits of both Patient Choice and Competition of providers are just two of the legion of highly questionable concepts developed by those wishing to justify, on ideological grounds, the reduction and ultimate privatisation of the NHS. In mental health, for instance, private companies will never pick up the bill for years of complex health and social care packages needed by tens of thousands of people. What choice will these disadvantaged and excluded people have in the future world of patient choice suggested by Healthcare by Any Willing Provider? The potential for disaster in terms of governance is also very considerable, when thinking about competition and bringing in profit making companies.

  63. Dr David Bossano says:

    Choice & Competition
    As a GP I think patient choice is important when it comes to deciding whether or not to have a treatment or to help select between treatments when there are different pros & cons.
    If patients need referral my experience is that they want good care close to home & rarely want a choice of provider unless there is a substantial difference in waiting time.
    As a referrer I do not have enough information to allow patients to make a choice between hospital on any grounds other than location and to some extent wait.

    Therefore I think the choice agenda is largely spurious and we should be working with local providers & specialists to improve quality and not rely competition and market forces which will have the opposite effect. If the quality at the local hospital is high patients will rarely want another choice.

    • Anthony Rodriguez BSc Health Studies says:

      I think this totally wrong attitude in a modern health CARE service. The doctor is the expert who should offer the patient the information to make the best choice. Feeling in control and empowered enhances a patient’s sense of well-being. After all, many patients often “choose” to flush their prescription down the lavatory and might not do so if they had more input into their care.

    • PaulF says:

      Anthony: the HSC bill does not allow for this kind of ‘Choice’. The removal of the treatment tariff opens the market to competition law and Commissioners will be forced to purchase services at the lowest price; Monitor will ensure that this happens.
      The ‘Choice’ will be with the private to providers to decide of your ailment is profitable enough to bother with.

    • Anthony Rodriguez BSc Health Studies says:

      That’s a good point, few want to see the NHS go down the path of the privatised railways or British Gas. The HSC bill needs to be modified to ensure that it puts the patient, not the private sector in the driving seat.

    • teve Howard says:

      Anthony

      Your idealogical view fits rather nicely with the politicians who seem to think that they know better than the experienced professionals.

      Just like Mr Lansley, you are missing the main point – here we have a GP who is telling us exactly how it is for him and his patients.

      Time to put ideals to one side and listen to what is being said by the people who have the experience-based facts…

    • NHS Manager says:

      I agree. It is time consuming now and will be more so. Life’s very simple when you are looking at it through the rose tinted specs of a government or academic department. Very different when you are the one having to find the time to do it.

  64. Colin says:

    It can sometimes be counterproductive.In this economic model what we are trading is people’s health and not wealth.It has pros and cons, so you may need to weigh the impact of ‘clinical efficiency’ driven by competition againt universal service delivery. A better modeled competitive environment could have a positive impact but bear in mind that the universality of NHS is what makes it unique. Its important that we separate service delivery planning from clinical care. Proper and adequate consultations should have preceded the white paper to say the least. Thank you.

  65. Isla Dowds says:

    Just to pick up on a point above – yes, choice is not absolute, is it, not now and I doubt very much if it would be so in the world of GP commissioning consortia. In a sense it is an impossibility. It will be the same as now, you will have a ‘ choice’ from a range of providers ( and no guarantee of how wide or narrow that range may be for any particular referral need) with whom the consortium has a contractual arrangement. Just as, when I needed a referral to a very specific type of specialist, I could not get referred to the specialist I needed, as the PCT did not have a contract for that speciality in a particular NHS hospital in the region – and I had to see him privately. It’s an illusion, and not a helpful one.

  66. Trisha says:

    What is the best way to ensure a level playing field between the different kinds of provider who could be involved?

    To insist that any private hospital treating NHS patients sets aside a number of beds specially for the 80 year olds with dementia who have ‘gone off their legs’ for the third time this month.
    To insist that any private hospital whether treating NHS patients or not employs and fully trains student nurses, foundation year doctors etc. at the same level as the NHS currently does.
    To insist that any private hospital treating NHS patients has full 24 hour appropriate medical cover, and appropriate high dependency and emergency facilities so that if it all goes horribly wrong the patient doesn’t end up landed back on the local NHS hospital at no notice
    (And I do understand that the government currently believes that the slope of the playing field is actually in the opposite direction)

  67. Caroline James says:

    Private provision does not mean better provision. My experience of private provision for children with complex health needs has been extremely concerning and worrying. Private providers glossy brochures and promise of a good quality service has never equated to anything like a safe and satisfactory service. You would be horrified at some of the practices I have seen. It is inconceivable that the government would encourage private providers to compete for NHS run services.

    • NHS Manager says:

      I quite agree. I had an (NHS funded) op in a private hospital last year and the lack of care was shocking, examples included having my BP taken with a cuff that was so large it was loose even when inflated, having my oxygen removed when my sats were low (as they would be after GA and morphine) and being released when I could barely walk without collapsing. Luckily the local NHS A&E was within a mile….I ended up there and was kept in overnight.

  68. William Perrett says:

    In my experience what is more important to patients is excellent local services when they need them rather than a choice of provider.

    I doubt we will ever achieve real competition with numerous providers to choose from, instead we could finish up with a small number of providers dominating the market.

  69. Crazedalamo says:

    Choice is a myth, the only thing people want is a professional, quality, first class service close at hand. Competition is divisive, leads to duplication and creates lowest common denominator services.

  70. Andrew Flint says:

    The question asked is hopelessly tendentious and begs the question “how can we best ensure that the NHS improves?” It is assumed that competition and patient choice will succeed but I don’t think this is proven. It would have been better to have sought views on this fundamental point, and perhaps even a democratic mandate, before launching legislation.

  71. What daft questions. Quality of what exactly? There’s the basic treatment, which is likely to be the expensive bit, with anaesthetic/ medication/medical/nursing care. Surely this will be standard, or do you get sewn up with gold thread if you ‘go private’? So is ‘quality’ having your own room, an extra comfy bed, lovely food, flowers on the table, newspapers? Being in hospital is not the same as booking into a hotel. If you wish to pretend it is, pay yourself. Otherwise, be grateful we have an nhs. What might help is having medics who are interested in finding out what is wrong and not dismissing the patient as an unintelligent malingerer.

  72. Dr Jeremy Platt - GP says:

    A lot of posts say that choice is illusory. I agree, and I would rather that you politicians pay more heed to quality than to choice – in my experience patients go for geographical location of services and waiting times.

    Quality – at least in terms of value for money and access – is best achieved in low cost high volume specialties eg ENT, Ophthalmology, dermatology – they need less in the way of expensive investment.

    A “level playing field” is v difficult because of irreconcilable structural problems eg high overheads of NHS Trusts. I would be inclined to limit the type of provider – for example can you favour in some way socail enterprise, or charitable venture?

  73. Kerry Lawrence says:

    I have had a chronic illness since childhood. I used to be able to go to my consultant who could look at my health needs holistically and refer me to the relevant specialisms within the same hospital an my notes would all be in one place. Now for some reason this is not possible. Any other illness or problem impacts on my disease so it was helpful for me when going to see the consultant as he understands this. Now though, I have to go to 4 different hospitals because each have different specialisms, each time referred by my GP, each of the hospitals have different systems that don’t ‘speak’ to each other so I spend much of my time and theirs explaining what procedure, medication changes, operations etc I have had and giving them a full history. My choice would be to go back to how it used to be, but I doubt that’s possible, I don’t feel their is much ‘competition’ as only certain hospitals now have certain departments/specialisms.

  74. Medical Student says:

    Choice is already available in the NHS. I’ve seen an endocrine patient in Leeds referred to King’s College Hospital to see a consultant who he had researched as being a world expert on his condition. He had asked for this himself and it was provided free of charge by the NHS, needless to say he was very satisfied. What more does the Government want to give patients? They have all the choice they need! Most patients don’t even want choice, they just want good local services.

    As a future clinician I want nothing to do with commissioning of services, I want to treat patients. And I don’t want to have to refer them to a second rate private provider because the NHS hospital has been put out of business.

    Oh, and I don’t want to work in a privatised health service – ever.

    • Anthony Rodriguez BSc Health Studies says:

      @Medical Student. This is just the sort of patient choice that shoudl be encouraged. The argument is less with commissioning as such, it is the dogma of handing the majority of commissioning and funding to local surgery-based GPs.

      They will need to spend around 10 mins per day on patients and the rest of the week on admin for the local hospitals, mental health services and midwifery services on their books. And if the GPs spend all the money outside the consortium’s area, will the local hospital have to put up the “closed” sign? Don’t turn docs into paper-clip counters!

      The best person to commission surgery is a surgeon, let hospital consultants become NHS commissioners too!

  75. mr c carr says:

    choice and competition are irrelevant to the acute medical and surgical patients who are the main reason for the existence of NHS hospitals. They are patients, sick, passive and dependent, not customers, and they need looking after, not offered choices. Always will be like this. Our choice is either, look after them, or just let them die.

  76. S Risdale says:

    Patients tell me they need specialist services for hospital care near to where they live, so that close relatives and friends may visit and assist on discharge. For example a hospital where surgery, radiotherapy and chemotherapy for cancer is available within the same hospital and nearby is surely a better option than a patient travelling to several different places for each treatment (i.e. one place for surgery and another district for their radiotherapy). Why not recognise the strengths in the facilities available, including equipment and staff and ensure patients have access to this.

  77. Ross McCaffrey says:

    Competition in a public service, especially one that focuses on the wellbeing of others, is quite frankly disgusting.

  78. Mike Vinten says:

    I think more attention to customer care and having some competition is good. However, the constant change in the NHS is costing a fortune and leaving the organisation in a constant state of flux.

    This flux has other hidden costs in the massive uncertainty and stress across the NHS as well as not allowing the great performers to shine, take responsibility and of course be shown to be rewarded for their good work.

    It’s an environment that allows the poor performers to take more not less advantage and lets poor management practice flourish.

  79. A.Brown says:

    I am not convinced by the arguments for competition, but even allowing for health services being subject to a degree of competition, something must be done to stop health and social care budgets being leeched away by tendering processes and consultancies.

    Experienced practitioners are having time wasted that would be better spent on patients, meanwhile posts for senior clinicians are cut (such people along with managers often leave the NHS only to return as contracted “consultants” – what a waste).

    • Sally - Physio says:

      Having worked in the NHS for 10 years, Canada for 1 year, and now in my own private physio business, I’d like to ask what would happen if there were more transparency in what we have already? We fund the NHS, not the government of the day. I agree that the NHS, where it’s good, is excellent, but there is huge waste and ineffiency also, which needs to change. My experience is that when we are aware of the value of what we’re getting, we are more engaged with getting the most from it. We need to change the belief that we have no responsibility for our own health and well-being and given that funding underpins our medical care, knowing what it costs us, is giving us choice. From my 15 year experience of working with private medical insurance I can also confidently agree with those who say they will promise the earth and not be able to deliver. That includes ‘not for profit’ organisations.

  80. Jim Phelan says:

    Competition where private companies are allowed to bid for services with the ability to exclude complicated and more costly cases is not fair competition. This places a greater financial burden on the NHS and actually makes the NHS less cost effective. Allowing companies to make a profit from delivering NHS services is wrong. If services can be run more cheaply or effectively (as long as patient care is not affected), this should be done within the NHS, and tax payers money should not be allowed to boost the profits of private companies.

  81. Barbara Havlin says:

    Patients will surely be signposted to service providers by their GP. So in my opinion this gives GPs the ultimate power as to who provides the service. The GPs can choose the cheapest providers of services and any money left over they will get a pat on the back for saving money and will then be able to do what they like with the cash.

  82. Anthony Rodriguez BSc Health Studies says:

    New topic: why shouldn’t other health care professionals also become commissioners and form consortia? For instance, a team of midwives could form a consortium to provide specialist maternity services and a hospital consultant could become a commissioner to provide cancer care. Share the NHS budget out more fairly between the range of health specialists now working for the NHS.

  83. I think that all this discussion about competition ignores the sheer professionalism of the people in the NHS. Competition is not needed to make the service better; the cost of all these changes would be better spent on the existing services.

  84. Robin Sheppard says:

    There is currently not much choice in the NHS. You can not choose a GP as zoning is in place and in many areas you are resticted to the GP of the area. People are afraid to move lest they be excluded from the other practices.
    Not much better in hospital either. You can choose a hospital but the important choice is the consultant you see. Can not be done here.
    Generic “Dear Dr” letters for referall are the orders of the PCT. So no choice.

  85. Tim Hopper says:

    I have just been discarged after six weeks as a patient and found that the quality of care in each of the three wards visited mostly depended on the patient to staff ratio. In the less specialist wards, a particular junior doctor’s training was a major concern, (they insisted on taking blood from my arms when I had an Hickman line already inserted!!!!). I’m not sure where competition come into this.

  86. Roger Hughes says:

    Competition = End of the NHS, health insurance will be a must, health care has to be provided in a proper facility, we have to have every type of care in a facility, it is called a hospital, not individual companies only providing profitable services, it is time to think again.

  87. Chest Physiotherapist says:

    What clinicians want is for patients to have the best care possible within the NHS without having to wait for long periods of time to get it and to have the reassurance that the standard of care they have recieved is the best.
    Change all of that with shifting boundries, changing management, etc – it costs more, frontline staff will be lost and gues who will end up lossing out or falling through gaps in the system – the patient!
    Tot up the cost of changing names of organisations, e-mail addresses, paperwork, signage, etc and imagine how many nurses, physios, clinics/services, that would pay for.

    Currently I watch the prime minister and his deputy talk about protecting frontline jobs on the news, but on the ground, nurses etc are loosing jobs, being made redundant or being TUPE’d over to organisations outside the NHS.
    I think if we do not speak up, we will loose what so many people have fought to achieve over the decades – a healthcare system that is free but of the highest standard for the people who need it.

  88. David Beresford says:

    The proposed reforms are a recipe for a disaster. Competition has never worked for the NHS and will not do so. What patients want is good quality local services not services miles away from home. Competition, if allowed, will fragment the service and lead to cherry picking with the the resultant loss of local services. As a result hospitals etc. will run up huge deficits leading to eventual hospital closures etc.

  89. Yair Domb says:

    I have spoken to many GPs who have great reservations about GP commissioning. From the past we can learn that very few decided to become ‘Fundholders’. This is mainly because GPs like to concentrate on what they do best, i.e. look after the patients.

    When PCT were introduced, it took them about 2-3 years to understand their role and set things up.
    I am sure that the present change will cost over £2 billion (some of it hidden cost) at a time when there is no money available in the NHS and when front line staff are being reduced.

    The PCTs in their present form has been reduced to a skeleton service of people who do understand about commissioning. Why not keep them and involve GP in that stucture.

    Finally, it has always been difficult to have GP on commissioning groups in the past. Why would it be differnt now?

  90. Nick Kosky says:

    Several observations

    1. Application of the market philosophy to the NHS with the values it has is misguided – a true market should allow enterprises to fail. When was a district general hospital allowed to go bust? When was a GP practice shut down?

    2. Competition will mean that expensive patients will receive a second class service from failing providers. If its managed compettion, its not competition

    3 Who will train our future workforce? This one is soluble, but if you base it on lots of providers doing this privately, its not going to be cheap

    4. I have no faith that replacing 150 not particularly good organisations who are just about beginning to sort themsleves out (the governance structure in world class commissioning could work -although quite frankly Id be happy with county class commissioning) with 500 who have no track record lead by interested parties who in the last round got a huge pay rise is a good idea!

  91. Gareth Everton says:

    It’s ok having choice for the profitable areas of the NHS such as hip and knee replacements, but where is the choice for the essential and difficult operations which the private sector don’t want to touch?

    Enforcing competition will destroy the NHS as we know it leaving under resourced teams left to pick up the pieces and the operations and difficult cases that are left.

  92. Keith Cowell says:

    It wasnt that long ago that revision hip surgery was commonplace because inferior (cheaper) materials were used. It is obvious that profit margins will be put before quality if private company`s are allowed into the health service. The reforms should be stopped in their tracks with immediate effect.

  93. Steve Howard says:

    This bill will result in fewer options for patients:

    1 ) Private providers will cherry pick the most profitable procedures
    2 ) NHS Hospitals will cease to offer those services
    3 ) As a result individual trusts will be forced to specialize in a handful of services, closing the majority of services they currently offer
    4 ) Patients will be forced to travel to find the treatment they need because there will be fewer places offering the required service.
    5) People will die because their local A&E departmetn has closed as a result of the lack of funding.

    For the politicians who need to have it spelled out again, that means patients will have fewer choices than they currently have. But your friends in the private health industry & banking / insurance sectors will make huge profits.

    What was the rationale behind this bill? I’ve forgotten…

  94. carol clapham says:

    Everybody has a vested interest in the NHS and will find it difficult to be objective in making changes.
    We do need reform because so much money and time is wasted in the NHS but there has been too much change, too quickly and too much time has been wasted on management and not always for the better. The patient and professionals often get lost in the process. The NHS is to supposed to be there for patients. There should be pilot projects before change is swept across the entire NHS. This should be researched and then audited to find out the pitfalls and learn.
    No one group should be given control of the commissioning process. It should be a consortium of lay/patient representatives and a variety of professionals- primary and secondary care nurses as well as doctors, public health representatives and managers. No one group should have dominence. What is wrong with democracy? This will then give a more holistic view of the needs of the service.

  95. Michael McNeill says:

    I dont want choice, – Patients would like to see all hospitals brought up to the same standard so that whichever hospital I am referred too I can expect the same level of treatment.Obviously this would not include specialist procedures as the patient would be directed to the specialist hospital according to need.
    Competition is an anathema to health care. Profit should not be the motive for treating anyone.
    The NHS would be in danger of becoming a meaningless logo,much the same as British Gas.

  96. H Basson says:

    competition already exists – it’s called ‘Choose and Book’. It is awful for some patients. For the rest it generally makes no difference. When I asked Simon Burns what the research was that this premise of desperately needed competition was based upon, I was sent a few references that pointed to Kings Fund work done across London using choice of NHS hospitals. Morbidity rates showed it was good! Surprise! Lucky that’s the system we alresdy have then.
    As for the pt’s for whom C&B has been poor – they have their C&B number, receptionist somewhere helps them choose or they choose from home – opt for quickest wait, local private provider. Letter arrives days before appt date to say sorry, please get on NHS waiting list. Why? Co-morbidity which means they have to have ICU at the ready. Cherry picking gonna get lot worse

  97. H Basson says:

    If a patient has a long-term disease, they must be seen for all the related ailments within one organisation (NHS as this is all that will accommodate them) and if the disease is systemic, that means every ailment they have pretty much . Currently, x-rays are being duplicated, reports unable to be seen by consultant, gone-wrong procedures being shipped into the NHS from private hospitals…. Patients do not want choice so much as quality and with the fragmentation about to increase in the new system, patients will be lucky to get any fluidity or consistency in their care

  98. Nikki M says:

    Patient choice is all very well for the people who feel empowered to exercise that right. What about the millions of people in our society who do not feel they have a voice? The older generation; People from ethnic minorities; people with learning disabilities; people with mental health problems; people from disadvantaged backgrounds – without homes, jobs, families…. This is just another way of allowing the middle classes and above to get better healthcare in order that the gap between rich and poor, healthy and unhealthy gets bigger and wider. It will do nothing for the already huge health inequalities in our society. As has already been mentioned, the ‘easy’ and cheap health problems will be cherry-picked by the private companies, whilst people with the more complex problems will be left to be picked up by the NHS and Social Services – while the GP’s focus on managing their budgets. And with the severe reduction in Social Services, people will lose the small amount of support they once had that may have helped them to have jobs and to improve their health by accessing health promoting activities and services. Choice? A huge minority of people have no choices, and this health bill will do nothing to increase this inequality.

  99. A. Saunders says:

    NHS staff should be trained by the Government, the cost settled by the Government. Upon qualifications – suitable staff – Consultants, Doctors, nurses etc enter the military profession, subject to military discipline but working in the NHS Hospitals.After an agreed period ie. 10 years – staff released from the military bond.
    This system worked very well in 1960/1970 in Jordon !!

  100. Beth Durham says:

    Competition: I don’t think there should be competition in the NHS, it adds multi-million pounds of bureaucracy to a system that is supposed to treat all patients free at the point of need. Everyone should expect the best service possible. If all that administration was cut out of the NHS, think how much more money there would be available for clinical use. The NHS is PUBLIC SECTOR and not something to be shifted bit by bit into a market, private economy. Where waste can be cut it should be, but not by competition, rather by responsibility on the part of staff, patients and relatives.

    As for choice: Everywhere should offer a high standard of treatment, if one place is lacking, it should be improved. Most people want local provision where possible and expert centres where necessary, and many want continuity of care.

    Governement pressure on the NHS has caused it increasingly to have no time to consider the individual. People do not fit neatly into tick boxes and many clinicians would like the flexibility to treat people according to their unique circumstances rather than a set of remote ‘rules’.

  101. Jan Davis says:

    Choice does exist in the NHS in many areas. GP consortia can quite easily be a mechanism for reducing choice – patients will only be able to access the services that their GP chooses. How is choice being improved? There is no evidence as pilot schemes have not been run long enough to test how consortia work. The bill is too risky and seems like a smoke screen for breaking up and privatising the NHS. Health professionals and the public are well informed and have every reason to be concerned about this risky and devisive agenda.

  102. Ian Shaw says:

    Limited competition has been of benefit to the NHS. I say limited because there MUST be a uniformed tarrif – this ensures that competition is based upon Quality NOT price (the evidence is that this drives down quality). However there are transaction costs to ensure that the Commissioners of service can properly hold the provisers to account. The World Class Commissioning reviews in 1998 were suggesting that £25 per head of population managements costs were insufficient to do this properly… The GPs are expected to commission on £15 per head or less. There is NO requirement of FT’s to reduce their management costs, so there will be a huge inequality of information and management in the direction of the service providers. This cannot be good news for service quality or patients.
    I have huge concerns about the conflicts of interests inherent in GP Commissioning and fear that GP interests rather than patients will become that promoted. I note that they are already seeking huge `incentivisation payments’ from PCTs to get involved in reforms…

    Efficiency savings are best done on a health community level, not through competition (already a paraoxical feature in DH calls on the NHS! to come together to save money whilst at the same time competing…)

    Please ditch these planned reforms. Allow the PCTs to repair the damage already done to them and to increase the representation of GPs and Patients on the Board. THAT is the best way to achieve better patient and clinical involvement in commissioning.

    • NHS Manager says:

      well said. It’s a well known fact that if you want to get a GP to do something, you have to offer them money to do it. We’ve been trying for years to get more GPs involved in commissioning, service re-design etc, but with no joy. And it’s not just that they all want to see their patients.

  103. Robin Egan says:

    At the moment impossible to choose GP apart from recommendations because no preliminary chat possible without signing onto practice especially important if patient interested in homeopathy, acupuncture etc (a current GP apparently forbidden from practising homeopathy by NHS).

    NHS Choices informs me that it is up to consultants as to whether they want glaucoma listed as a speciality on website (can’t see any)

    I am a big believer in true patient choice but see above

  104. Tamsin Ford says:

    In 20 years of practising medicine, no one has expressed a wish to choose – people want to have confidence that their local services are good. Competition should be about quality and encouraging trusts to compete about cost is likely to reduce the quality of care, reduce the coverage of the population and different types of services as well as push up costs.

  105. Ian Shaw says:

    Just read The Functions of GP Commissioning Consortia:
    A Working Document. Its clear that (at the least) the PCT clusters should become the means by which the NHS Commissioning Board monitor and ensures the quality of functioning of the GP Consortia – including conflict of interest issues that may contravene EU competition laws. This `middle layer’ will be essential if the National Health Service is to maintain some quality assurance of commissioning.

  106. Lee says:

    I presently am under Lincolnshire Partnership NHS Foundation Trust and would be happy with any choice at all. I get no choice in time, venue or type of treatment – its do as you’re told or get lost. I would like to have a choice in the time and venue of my appointments and in what treatment I get.
    This would be a good starting place here in Lincolnshire.

  107. Wendy Dowse says:

    Making Doctors manage budgets is a nonsense. Doctors are medical practitioners, not accounts. Keep the PCTs and have the resources to allow patients to have their operations in an NHS hospital when they need it. Link up the hospitals with after care services as required. Don’t let the insurance companies and private firms take over health care, they are only interested in profit. If our health services are privatised, will European law prevent the UK from ever taking back those services into public control? I believe this might happen under European Procurement law once the UK has opened healthcare services up to private organisations.

  108. sarah corlett says:

    I should like Future Forum members to make a statement disassociating themselves from the inaccuracies and misuse of statistics made in the Government leaflet about the ‘listening exercise’ (see http://www.guardian.co.uk/commentisfree/2011/apr/16/bad-science-goldacre-nhs-statistics) and to set out how they will work in a way which actually enables them to listen properly (eg to the many sensible comments here) and avoids undue influence from DH and ministers.

  109. Laura Palmer, Erdington says:

    I do not want choice or competition. What I want is a good standard of healthcare, irrespective of where I live in the country, and irrespective of which hospital I choose. I want to know that the nearest hospital or clinic to where I live is as good as the next one. I want choice if I am going on holiday, or buying a television, not in my healthcare. Choice will mean differences in standards dependent on geography, which will spell the end of “national” in our NHS.

    • Doug Rouxel, Southend says:

      I fully agree with Laura – I’m not interested in choice or competition, I want good quality across the board, wether I fall ill at home in Essex or on holiday in North Uist, I want to get the same good quality care.

      Choice means that their must be waste – in order to be able to choose this or that, either someone is forced to have the thing I don’t want (meaning they don’t have a choice) or we can all choose not to be treated somewhere – which means it will be a waste.

  110. Eileen Dickinson says:

    The last time we had competition between services, it became very difficult to share information with colleagues. Everything was deemed “commmercially sensitive”. One of the best ways of improving services is to learn from others, especially from the best.

  111. Corinne Camilleri says:

    Patient choice and competition are largely myths that detract from the more important issues. They only come into play in elective procedures, and they lead, as others have pointed out, to cherry picking by the private sector. We have seen plenty of this in the last few years. What we need is good care at all hospitals, with a reasonable availability of choice of time/date for elective admissions. Please listen to those of us who know.

  112. Paul Gibbons says:

    The problem here is neo-liberal economic dogma. Alas all three political parties believe in it. It is, like religion, a question of philosophical belief.
    The danger lies with “Any Willing Provider”. Suppose that Capitalist Hospitals Ltd. builds a district general hospital in Alfreton. It will attract some business. Probably, it and the three district general hospitals nearby (Kingsmill,Calow and the Royal Derby Hospital) will all start making losses. This will attract political attention and one of them could cease trading. The Royal Derby Hospital is PFI, so £ 30 M a year has to come from somewhere whether it treats patients or not. Is there a government guarantee on this £ 30 M ? If there is, it would suit Whitehall to pay for losses up to £ 30 M.
    The question arises ofa level playing field between PFI and non-PFI hospitals.
    There is doubt about “Money Follows the Patient”. If a GP consortium has a contract with a particular hospital, will it send all its patients there ?

  113. Adrian Lambourne says:

    As already noted by several others, I – as both an NHS Patient and as an NHS employee – do not believe that choice and competion are the best drivers of a national health service. They may work for private independent companies but not a single health service organisation whose objuective is to provide the best health service within the resources available, rather than maximise both personal income and company profit.
    What we need is co-operation among all services to give the same high quality service to all patients. Once you go down the competition route, you will end up with a postcode lottery and widening of the current inequalities gap between rich and poor.

  114. Giri Rajaratnam says:

    The questions as posed are not useful. And you cannot include competition and choice as part of the same package. Choice for the pt and in particular informed choice is a must for every user of health service. However, exercising such a function does mean that the health care professional including GPs need to be able to spend more time with the individual. In the context of choice – primary care is not fit for purpose and needs to be reformed.

    Competition is useful for improving quality of care and should be used whenever, it is required. However, it is foolish to base a whole system such as the NHS on competition because as other commnetators have said, in many instances, it isnot appropriate to use competition.

  115. tim says:

    I don’t believe it’s a productive use of public money to have competition in the NHS, because we’ll end up with slack in one service or another, meaning not only more job uncertainty for those involved, but duplication of services.

    Further, competition will never extend to all the NHS services which are provided, and I don’t believe that most users of the NHS want to have to choose one service over another: they just wanted to be cared for well, as and when they need it. Since the provision of choice will never be spread evenly, geographically, it’s wrong to suggest that choice will somehow solve the issues the NHS faces.

  116. Celia says:

    What will happen in areas such as mental health and learning disability? The local services are discharging patients into the community mental health service which can only provide one year of care, and then these patients are discharged to fend for themselves until they reach crisis point only to go through the whole process again. Where has the notion of holistic care gone and seeing the patients as numbers who have to be moved into “recovery” because the books don’t balance? Front line staff as made redundant and the managers and “pen-pushers” remain. How is that right?

  117. A Rose says:

    Competition and patient choice will not drive service improvement. Well managed, well resourced, well staffed and well educated primary and hospital care will drive service improvement. The Government’s proposals to push commissionign onto already overworked primary care providers will cause service deterioration. The notion of competition in the provision of service is quite ludicrous. When I am ill and in need of care, I want care, not to exercise choice, which in any event is largely illusory – when I am ill, and need care, I do not want the chance to go to the “best hospital” on the other side of town, county or country. I want good quality, reasonably local hospitals and other healthcare provision.

  118. Timothy Martin says:

    Choice isn’t what patients want – why do we need to choose from a number of different providers of a service when one good quality service is all that’s required? What we really want is good quality advice and care that is as close to home as possible. Having a choice of 10 hospitals doesn’t improve my patient experience – it just makes it more complicated.

  119. Jenny Nicholson says:

    I do not want choice in how and where to be treated – I want my local services to provide as good a service as any.

    The problem with ‘choice’ in healthcare is that it is not like choosing a snack or a pair of shoes – people all deserve access to good quality health care.

  120. David says:

    The system proposed will provided the biggest post code lottery for services that you could possibly imagine.

    Private providers will pick simple easy to do procedures in built up areas. Leaving the complicated work and rural hard to reach communities (expensive) for the NHS to pick up. Though I am not opposed to private providers per se, I just believe that they should pick up the whole service or non at all. It would be interesting then to see how many could actually run at a profit, and a lower cost to the NHS (bearing in mind that a lot of staff work in the NHS to help people, as well as have a pension, etc. at the end of it all, will they still do it as willingly for a private provider?)

    Choice has never been big amongst the patients in this area. Good services locally has always been the requirement, choice just pushes you further away from home. Okay for MPs who don’t mind being away from home a lot, not so good for most of the rest of us.

    Re-organisation costs in terms of money but also moral for the majority, why do it on such a grand scale again (every 5 years or so and it doesn’t make much difference each time).

  121. Nick Pahl says:

    The British Acupuncture Council (BAcC) is the largest body for the regulation of traditional acupuncture in the UK. With over 3,000 members and a track record of delivering robust self-regulation (recognised in the Secretary of State’s announcement on herbal medicine on 16 February 2011). We believe the BAcC believes that it has a significant and expanding contribution to make to national healthcare delivery. BAcC members offer over 3 million patient treatments a year and wish to expand this service work within the NHS. The inclusion of acupuncture in the NICE guidelines on the treatment of low back pain is a demonstration of how BAcC members can significantly benefit the nation’s health.

    The BAcC believes that one of the great advantages in placing the commissioning arrangements closer to patient needs is that small providers will now have a much greater opportunity. The BAcC hopes that the commissioning arrangements will permit individual acupuncturists and consortia of acupuncture to compete effectively to provide evidence based services to patients without undue bureaucratic burdens.

  122. Little Bloke says:

    Choice is a non-issue.

    I want a working – non-corporatised – NHS, for all.

    Most importantly I do not want predatory capitalism profiting from the NHS, every penny in profit is money taken away from service… this stinks.

    What about asking the General Public if they would consider paying a little more TAX for a better NHS, honestly I think the answer would be yes.

    Look at the best national health services in the word, emulate these, if it means raising taxes, do it.

  123. Rod Whiteley says:

    A specialist NHS clinic not far from here is failing to provide adequate care, I’m told. Word is starting to get around local people and GPs, but they are powerless to do anything. Patients will die, coroners will express their carefully worded concerns, the NHS complaints system will creak into action, the CQC will adjust its percentages, and years from now change might filter down through all the layers of management.

    To fix that problem fast and save those lives, patients must be able to refuse treatment there. (That’s called choice.) Other providers must be able to step in to provide proper care. (That’s called competition.) An NHS without choice and competition will just get steadily worse. The current proposals are a step in the right direction.

  124. Diana Smith says:

    I have some reservations about Patient choice, and whether this is an effective tool for driving up quality.

    I am a close observer of the Stafford Hospital inquiry and have noted the relationship between competition, payment by results, the importance of public opinion and patient choice. In the case of Stafford it could be argued that these have had a negative effect on quality.

    The move to Foundation trust status placing the hospital in competition with other hospitals. This coupled with financial pressures meant that the board became very closed, and reluctant to share anything that could be perceived as bad news.

    Patient choice means that the relationship with the press becomes crucial, as most patients perception will be formed by the press. As many local papers have strong political affiliations there is always a political dimension to this.

    Once payment by results and patient choice became a reality, buying into Dr Foster intelligence mortality data became an economic necessity for many hospitals. They needed this to be able to demonstrate that they were offering quality. The Dr Foster system may have been insufficiently tested with the large number of hospitals that joined in the system, and since Stafford the academic research carried out into HSMR have indicated that the system may not have been as robust as people first thought. It is clear that the system depends on coding, and that most hospitals, at least in 2007 when this became an issue, were coding badly. Like many statistical systems the result of this was rubbish in rubbish out!

    It is unfortunate that the Dr Foster “league tables” were published in the national press, leading to reputational damage to a substantial number of hospitals.

    In the case of Stafford this was compounded at the time of the release of the healthcare commission report in 2009 by an “interpretation” of unpublished material related to the Dr Foster data, being leaked to the press by an unidentified person and passed off as authoritative material.

    The reputational damage done by this misreporting has totally unbalanced “patient choice” and has actively damaged the service, because of the damage to staff morale and the difficulty of building a stable staff base.

    It has also cost the taxpayer tens of millions in bail outs to keep the hospital functioning effectively, and of course in the multiple public inquiries required to satisfy the public concern caused by the high level of political interest and the misreporting by the media.
    the anatomy of this complex story is shown here. http://pressreform.blogspot.com/2011/04/what-forms-our-perception-of-stafford.html

    If we are to have a system that depends on patient choice, then this needs to be accompanied by the development of meaningful systems for measuring quality; Something that both the public and the health service can trust. There will also need to be robust protocols to improve the accuracy of media reporting of the health service.
    Without these safeguards in place the damage that can be done by patient choice may outweigh any potential benefits.

  125. Noel Parsons says:

    Patient choice is irrelevant – what’s required is the spread of best practice across the NHS, thereby bringing all units up to the standards of the best. There is no evidence that competition will either improve patient care or reduce costs. In fact, using the model of the utilities privatised by the last Conservative Government, we can see that competition increases prices and reduces standards. Doing that with our electricity supply is expensive and irritating; doing it with the NHS could cost lives.

  126. Ian says:

    Choice and competition are complete fallacies where private companies are concerned in delivering public services. Thatcher promised cheaper train fares and greater choice when she privatised the network. There are ever more crowded trains with sky-high fares run by monopolies that act as a cartel. Energy companies have done the same since privatisation. How have these reforms made us better off? If this is what you want to happen to the NHS then back the reforms.

  127. Tammie Cook says:

    It is my experience, as a nurse, that patients are not too concerned about having choice. They are concerned about having decent healthcare in a local setting, provided by NHS staff, rather than a private company.
    NHS care should be equitable, that is, it should be of equal standards wherever it is being provided – however, equity is not something this Government or Foundation Trusts care about.
    Once again the Government are out of touch with what the general public are wanting.

  128. S Clarke says:

    Why competition at all. Fund all hospitals fairly across the country. Ensure adaquate staff levels in all hospitals and keep the private sector out. Paying only 30% of the cost of all emergency admissions is stupid. Cars crash, broken bones, sudden illness is just that. People want good local services, not have to travel. Keep the GPs out. I want my doctor to doctor not look at me as a £ sign he cannot afford. I believe that passing the budget to GPs is a buck passing exercise. the Doctors will get the blame instead of the condems. Gps beware your relationship with patients will deteriate quickly. England beware it will be harder to get rid of your GP if you don’t like the service than it will be to get rid of your MP. Where is the accountability. How do we sack a GP consortium. Where are the caps on wages.

  129. Anna Watkinson-Powell says:

    Most patients do not necessarily want more choice. They simply want their local service to provide good healthcare. If you introduce choice into the system, then those populations that are most vulnerable and least mobile will be left with a poorer service. There is a real danger of introducing a two-tear system, with wide variations between regions.

    I welcome more involvement of doctors in decision making, but GPs are trained to be clinicians, not managers. They will either have to spend less time with patients or contract out managerial services to external providers, introducing an extra cost.

    There is no doubt that the NHS needs to become more efficient, but introducing massive changes at a time of austerity is not the way forward.

  130. Dr Tom Yates says:

    The Kings Fund Document A High Performing NHS? concluded that the NHS improved substantially between 1997 and 2010 but that growing health inequality clouded this otherwise welcome news.

    I believe that expanding choice, particularly where numbers of clinical staff remain the same or are cut, can only exacerbate health inequalities. These arguments have already been made in some detail elsewhere (see J Med Ethics 2008; 34: 271-4). Briefly, well educated individuals with friends in the medical profession, flexible hours and access to transport, will both choose better and have access to a greater range of choices. The likely result of increasing levels of choice is that well to do patients will access the best providers whilst others, likely with greater health needs, will receive their care from other providers.
     
    I think we can learn much by looking at healthcare in United States. As Harvard Professor Atul Gawande has pointed out, in their mixed market, the best healthcare is to be found where providers group together and cooperate to improve performance (see http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande). Fragmentation and competition seem to limit opportunities for quality improvement and drive up costs.

  131. Mark Underwood says:

    The NHS works very well at the moment. As a patient who sits on many patient involement groups it is easy to see how removing PCT’s and some SHA’s from the chain is already affecting services at this stage of the venture. There will be less patient input and less democracy under Government plans, furthermore, most GP’s I have dealings with simply don’t have time to tend to their patient lists, let alone become involved in commissioning which is a highly complex affair. What may happen , if this plan goes ahead, is the the GP Comissioning bodies, mainly employing ex PCT commission staff, will simply merge creating de facto PCT’s again. WHAT A WASTE OF MONEY.

    Patients by and large don’t want this, GP’s by and large don’t want this, Hospitals don’t want this plus it was never in the Conservative manifesto and the plans have so many hole you can drive a bus through then for the Government papers I’ve read. Totally appaling plans from someone who claims to have spent years on the project. THINK AGAIN LANSLEY !

  132. Name taken again says:

    It is dangerous to naively apply standard economic principles to healthcare i.e. ‘choice’ and competition. People who are unwell do not necessarily have the luxury to travel, or to delay treatment, and are often not in the right frame of mind to consider the relative merits of complicated alternatives . Choice is an attractive word and and at first anyone would agree that they want it but the evidence suggests that we want confidence in our local providers, not the burden to choose among complex options. We would like choice of appointment times, and the option to choose a GP, to choose a hospital etc. but the priority is for good local provision.
    Competition could work for common, non-urgent, non-essential simple services but even so should not be introduced without considering the knock-on effects on other services.

  133. Raquel Ramkhelawan says:

    If the Government want to listen to the people, I agree with Malcolm Swinburn, let us choose how we want the NHS services to be deliveredby by means of a referendum. Its Our NHS not the Governments.

  134. Martin Rathfelder says:

    How will competition and choice help those patients who are taken ill and are not well enough to make a choice? Or those who do not have a diagnosis?

  135. Dr Jones pathfinder clinical lead says:

    The ability to deliver improved services and reduce inefficiencies by developing more integrated care, within the timescale that QIPP challenges, is presently in danger of being seriously undermined by the requirements of procurement and competition. Old systems are remaining in place as long drawn out procurement processes are considered, service redesign is prevented as stakeholders consider whether the redesign will require tendering and procurement procedures, possibly with the consequence of significantly affecting their own position in delivering the service, and local initiatives, often involving existing primary care or federated working in primary care or social enterprise, are undermined by the ability to participate in complex, potentially expensive and time consuming tender and procurement processes.
    If the aim is “competition” then full steam ahead, if the aim is improved patient care and value for the taxpayer, pause, and think again.

  136. John Lloyd says:

    Choice is fine but it seems likely that private providers will cherry pick cheap services – like joint replacements – and the difficult matters, like geriatrics, will wither.
    Also, those of us in country areas, seem unlikely to be provided services in our local hospital or anywhere near. My GP, who is on the steering panel, seems confident that we can keep services local.
    My deep fear is that services will be subject to European competition rules, which means the cheapest will win, not the best or nearest.

  137. Dr Helen Jones says:

    I agree completely with the above comment by Dr Tom Yates. I also want to point out that most hospital admissions are emergency admissions and therefore choice does not in the majority of cases come into the picture, the ambulance takes you to the nearest hospital. It is therefore important to have a well set up hospital providing comprehensive emergency services within each area. If choice and competition take the profitable services eg. elective surgery from general hospitals, where will the surgeons be to provide the emergency operations? A hospital to provide emergency care has to work as a whole.

  138. Eleanor Jones says:

    Leading questions much?

    Personally, I don’t want choice in health care provision, I want a professional medical opinion about what care I need, and where I should obtain it. The last thing I want is a fragmented service where I am constantly having to make decisions about what, which and where my health care will be provided. There seem to be two possible scenarios:

    - The choice is likely to lead to a different outcome in terms of my health. In this case, I want a trained medic to make that choice for me.

    - The choice will make no difference to the outcome in terms of my health. In this case, I don’t care, just get on with it.

    At the moment, I trust the NHS and the people within it to make decisions based on what is best for me. My trust is likely to go down once competition is introduced into the system and if the system becomes fragmented.

  139. Tamer Abdelrazik says:

    I am worried that NHS managers now are conveying to us (consultants) that NHS is going to loose lots of surgical cases mainly becouse of the competetion which is unfair. for example in my trust now there are many cases which have to go to the ISTC even if the patient is asking for her operation to be done locally.
    We are asked to send all simple hysterectomies there, imagine the impact on our funding and on the training if the trainees will have no chance to perform any simple procedure.
    We are asked now to put down our theatre sessions this will on the long term de-skill us so what we are doing now which is performing complex cases will be extremly dificult in 5- 10 years time. and then all these cases will go to the private sector.
    I believe that NHS Leaders are Deskilling their Staff and heading towards privitization which is also against patient choice.
    How disappointing to witness a great organisation being delibrately put down to fail.
    I hope some one will answer my fears if they are wrong

  140. Ann Forrester says:

    Some questions:

    How will the government ensure that best practice is shared across providers if they are in direct competition with each other? Will private companies happily share all their ideas with NHS providers, and vice versa? Will money be wasted on services having to advertise/promote themselves?

    Will patients be told about the whole package different providers are offering – care after treatment, further appointments, liaison with other professionals, reports etc as well as waiting times and the easier to measure parameters, before making choices? Will the GPs making the commissioning decisions also bear the whole package in mind?

    How will good practice around information governance be maintained if a patient ends up “choosing” a variety of providers, some NHS, some private, for a complicated condition? I hope the”any willing providers” are signed up to have all the stringent procedures the NHS has.

    And a last point: I don’t see how private companies generating profits from tax payers’ money can be a good thing. It’s not what I think I pay taxes for.

  141. Jonathan Folb says:

    The starting premise, that competition will drive an improvement in the quality and efficiency of the health service, is misguided and will cause irreparable harm if pursued in the way being proposed. If passed, this bill will result in a fragmented and unequal service, with a loss of public accountability, and a damaging focus instead on services which are financially profitable. It will mean that resources are diverted towards the self-promotion of healthcare providers within the market, and towards the transactional costs of administering such a system, which will include the costs of defending legal challenges arising from the tendering process.

    At a meeting of BMA members held to discuss the health bill in Liverpool last month, attended by GPs, hospital consultants and public health doctors, I did not hear a single positive comment expressed about the current plans. This is not about protectionism or vested interests on the part of the medical profession. It is much more important than that – it is about the guiding principles of healthcare provision in this country.

    What the health service does need to improve its efficiency is more collaboration, not more competition. And there is no doubt that difficult decisions must be made about how resources are to be allocated and rationed. In this, NICE must have a leading role, and I find it concerning that its powers are to be reduced.

    This legislation has been presented as a “done deal”, whose details only need to be ironed out, to the public and healthcare professionals (including GPs, who have been given no choice but to go along with it). In fact it has no electoral mandate. It is being forced through at great cost – both financial and in loss of expertise from the PCTs, despite the serious concerns of healthcare experts and professional bodies, without being piloted, and with no good evidence that it will work.

    Please drop this ill-conceived bill. It will mean the end of the NHS as a public body in all but name, and I sincerely believe that our generation will not be forgiven if it is allowed to proceed.

  142. Bob says:

    I remember when I needed to go to hosopital last time, I was ill, in pain and needed an urgent operation. No choice was offered, they just made me better… the only choice i would have expressed at the time. Leave the NHS alone, stop the £20bn savings and keep NHS funding as secured by 2009/10 + add at the rate of inflation. Efficiencies will need to be found, some treatments will stop but all we want is a well run, public not private health care system. The idea of choice is a lie and a myth… hobson invented this one.

  143. Diana Iordanova says:

    The whole thing is a complete joke and masquarade. It is no different to privatising the forests. Greed and avarice will lead us to a point where healthcare will be affordable to the rich only, and all the rest will be simply sidelined. Privatising public sector industries such as NHS, Railways, council services etc. is done for the sake of securing profit for a bunch of people who already have more than they can spend in a few generations and not out of good intentions, and we, the people, know that.

  144. Fi says:

    Competition has the potential to fragment joined up working, create protectionism and hand offs and slow the process of the patient through the system – none of this will help improve quality. It is interesting to see that in America since Obamas healthcare reforms there is consolidation of hospitals through M&A as a way of ensuring continued financial viability. Smaller hospital are being taken over and in some cases closed – I do not think this is a bad thing to see in the UK – certainly where Darzi was successfully implemented (Stroke and Cardiac care in London) and where Cancer networks have encouraged sensible redistribution of services outcomes have improved. Unfortunately the Health Secretary is taking a too “top down” approach to provider landscape reconfiguration – as seen with the Barnet and Chase Farm debacle – he is still too politically involved in healthcare – even when local GPs and Consultants are reccommending this is the right way to go. Patients want to choose high quality services – even if it means travelling!

    • NHS Manager says:

      It is easy to make that judgement in London, or other large urban area. I live in a rural area where there is one major hospital in the county and few transport links around the county. The next nearest hospital is nearly 100 miles away in the next county. Patients in my county don’t have choice because basically there isn’t any, and they would not want to travel to the next county for treatment (we had an issue last year where some procedures were being transferred to the hospital in the next county….it caused a major scandal). How many times does it need to be said for people to listen? All patients want is good healthcare close to home.

  145. Lizanne says:

    Competition only works where there is a real choice, have you asked people if they want to research, travel and possible wait longer when they are unwell or have you just assumed competition is always king. NHS should mean excellent care for all not a post code lottery. Accident and Emergency care is about the nearest hospital or the nearest specialist service how do you expect children’s hospitals to compete against each other they 50-100 miles apart. The bill is ill thought out it undermines the principles of the NHS. GP practices are private business but you rarely see people moving because another practice offers something else because the majority of people don’t need to see their doctor weekly and just want to be treated when required.

  146. Chris Austin says:

    Choice requires information, relevant information. E.g. does a local service improve the health status of patients who are treated there? Do patients subsequently get back to work? Do they subequently live in the community? If they have a progressive condition, are they supported to optimise their level of functioning and quality of life?
    The current arrangements do not routinely collect the information that is relevant to answering the above questions. Instead the focus is on the busy-ness of staff – how much is done, and not whether there are long term benefits to individual patients and their carers.
    Activity data may be useful locally, forinternal management purposes, but ‘choice’ requires new sets of data to be collected some time after interventions/treatments have been provided – to see whether they made a difference to someone’s actual life.

  147. lois orchard says:

    No good as ever come so far by bringing in external providers to sit on top of exisiting NHS services ‘to run them better’ . There is huge potential to streamline NHS services and make cuts in expenditure, without cutting services. Unfortunately with the curent policy these will be realised by private companies, probably not even UK ones.
    Suggest you stop the practice of emptying the coffers on the 31st March every year as a start, then reduce the burden of endless, mindless, and often meaningless reporting to the centre, which costs PCTs millions to do. Getting PCTs to pay other NHS bodies to manage thier provider services for less than a year is another blinding piece of nonsense from the DoH

  148. George C.A. Talbot says:

    The Cost Conundrum in The New Yorker thoughtfully supports those who value cooperation as I do. See the post by Dr Tom Yates above.

    This section assumes competition and patient choice will improve the NHS. Capitalism requires competition to curb the self interest of its free operators. But religion advocates restraint, concern for others and cooperation. I urge government to deploy in the essentially socialist NHS, emulation to improve efficiency and subsidiarity so services can respond to local circumstances including, of course, what GPs advocate and what patients want.

    As several posts note, patients value good, local services over choice. Note, prior to the money following the patient, anyone could ask to be treated elsewhere. Then many fewer were in admin!

  149. karen naylor says:

    Competition and patient choice will not improve the service. Well managed, well resourced, well staffed and well educated primary and hospital care will drive service improvement. The Government’s proposals to push commissioning onto already overworked primary care providers will cause service deterioration. Patients do not want choice they want good service accessed locally.

  150. It's a public service and should not be for private profit says:

    Choice is important in so far as patients and users of care services should be seen as equal partners in the outcome of delivering good health. Too often this is not the case. There are still massively outdated attitudes in the medical and nursing professions of ‘we know best’. Having said that the NHS is a fantastic serice run and staffed by many, many fantastic people in a very efficient way that needs continued support and funding and absolutely must remain public. We spend far less on administrating health services that other countries but this would change if more and more providers are enabled to skim off profits at the expense of patient care. What we need are more responsive services, better joined-up working between departments and professionals, more sensible patient pathways, better customer service and genuine involvement of patients, better patient experience, better public health and prevention and more support staff to let clinicians do what they do best. The public will never forgive you if you sell off their NHS.

  151. Gill G says:

    I think people want their local health providers (NHS) to provide effective, prompt, high quality services. They do not, as a rule, tend to value choice – people think that their local doctors, hospitals, clinics etc should provide them with the high quality care they need, when they need it. They want to trust their doctors and consultants to make the right choices for them, based on their expert knowledge. Privatisation, choice, further opening up the market to private providers will allow the above mentioned cherry picking and will further undermine the NHS that the nation values so much, until such time as it is completely unsustainable – and at that point its demise will be inevitable. This should not be the direction of travel, it is idealogically unsound and will not serve the people of England well in the future.

  152. LJW says:

    I have a number of concerns which I will detail below but the real frustration is that the amount of missing details and areas where further clarification is needed makes it impossible to really understand the true implications of these reforms.
    1. The removal of the duty on SOS to provide a comprehensive healthcare system and only to promote it must be changed. This undermines the underlying principle of the NHS and relinquishing this duty sounds the death knell. This duty must be retained.
    2. Monitor should be responsible for ensuring the cost/clinical effectiveness and value for public money of service provision , not for promoting competion. Competition should be a by product of providers demonstrating they are providing high quality, clinically effective, value for money care.
    3. The quoted figure of 30-40% of the NHS budget being retained by the NCB is a realistic % but the maths/actuality of the figures simply do not add up. Local comissioning will be responsible for more than 60-70% of the care. Clarity is need on this based on real costs before budgets are allocated.
    I genuinely hope you are listening – but I doubt it!

  153. Linda Shrewbury says:

    Choice is a luxury we can no longer afford. The general populus are clear that they are happy to have quality local services above choice.

    getting it right first tiem is more important that choice. Not duplicating and therefore creating waste is more improtant than choice!

  154. A Christopher says:

    People choose to have good quality health care, to have an nhs that they can trust and to know that health care providers are not motivated by profit. When you are ill you do not want to be asked how you want to be treated, by whome and where! Choice is about being able to choose a system of health care that is open, transparent and honest. This cannot be achieved by free market forces where you have to undercut to survive.

    Personally, we do not want choice in health care provision, we want, and ‘deserve’ a professional medical opinion.

  155. Jon says:

    We need better quality which requires understanding of the health system – something lacking from this stick up job. Privitisation, choice and competition will not give us a better system under the ham fisted changes being proposed. GPs and clinicians generally don’t have a clue how to commission services but they do need to be involved. They don’t understand what their patients as a whole need – they only see the sick patients coming through the door. Not the same thing.

  156. Stephanie says:

    Service users want reliable, properly funded local services. Choice is a chimera: how many users really have the expertise to choose properly between particular providers, particuarly when all the PR of the private sector is brought into play to blur the picture?

  157. Andrew Foster says:

    I believe that the greatest threat to the NHS arises from a dogmatic assumption that competition is always the right thing to do.

    As a Hospital Chief Executive, my main concern over the next four years is to be able to maintain quality whilst also having to make 25% efficiency savings against a trend where demand rises at the rate of 3 to 4% per year. This is an extraordinarily difficult challenge and I believe that no modern healthcare system has ever managed savings on this scale. The best chance of meeting this challenge is to keep as many people as possible out of hospital, by organising all health and social care services in a way that seeks to look after patients in their own homes. The evidence shows that this can be achieved provided that there is very strong collaboration between all of the providers of care. For example the Kaiser Permanente Healthcare system in California is a fully integrated care system and has roughly one third of the hospital beds compared to the NHS.

    Not only is collaboration the only solution to our challenge but competition is at best at distraction and at worst could force some hospitals into failure.

  158. Margaret Hannah says:

    What good is choice to a patient with an urgent condition or emergency? Patients want good treatment by a reliable provider as close as possible to their homes. Competition may work when there is the potential to grow a market, although in healthcare this leads to duplication of services. But when money is tight, competition will hasten the collapse of what is evidently an unsustainable configuration of services. We need a proper strategy for healthcare in the UK, which grows the collaborative capacity of the NHS rather than destroys it.

  159. t davidson says:

    Choice is not essential..people want to be treated in a clean hospital by competant staff in an area close to their home – travelling miles and miles for treatment is not what is wanted.. Choose and Book has never worked… won’t work in how it was truly meant to be used – very few hospitals actually have opened up their slots to direct booking (particularly specialist hospitals where capacity is a huge issue already; last thing they need are inappropriate referrals eating up valuable slots).

    privatising healthcare (because, let’s face it, this is where it seems to be heading… american model) is not the way forward… being american, i have first hand experience of this system and it favours those who can afford it.. or have the appropriate insurance to recieve the best care – countries should take care of their people,

  160. Gary Walker says:

    Time after time the evidence (which has been reinterpreted since) is that patients don’t want choice they want high quality local services. The precept that choice improves quality is based on consumer purchasing not healthcare provision of which there is little international evidence. In supermarkets people can make choices over quality and price by spending more for Heinz or less for own brand. This is not a model suitable for healthcare. The choice agenda has already cost the NHS £billions in higher payments to private sector providers and part completed contracts that have been fully paid. The excuse was that this was about funding the private sector market entry costs. No other ‘market’ system would do that. This is a flawed plan from a flawed policy based on flawed and deliberately misinterpreted evidence.

  161. Jon says:

    If just 10% of the NHS worksforce has spent 10% of their time on the *transformation* then over the last year anything up to £1 billion has already been spent in the last 12 months on something with no evidence base or evaluation. What would NICE have to say about that?! How many more scarce NHS resources will be wasted in this manner? What a shame the taxpayer hasn’t had any improvement in service from this waste.

  162. Elaine Tamkin says:

    Many of my patients are very happy with the alternative to our local trust. They enjoy the ease of parking, face to face consultant care, short waiting times. etc I encourage patients to use this service when they are mainly seeking reassurance or need a quick diagnostic and opinion. I do not feel this detracts from our NHS provider but rather gives them space to deal with the more complex conditions for which they are ideally placed.
    In the future , Gps as commissioners will be setting the specifications for all providers factoring in such issues as training, clinical standards etc. We have an excellent local trust but not all the services it provides are excellent. Just because it is local and NHS does not always mean it is the best place for my patients to be seen .I welcome this opportunity to raise standards

  163. Baze says:

    Question – would it be possible to arrange this page so that the most recent comments are at the top of the page & be able to leave a reply at the top of the page to save scrolling through all responses?

  164. Jon Holt says:

    ‘Choice and competition’ is not a panacea and focusing on them as a silver bullet to cure all ills is mistaken. More important than choice is access to good quality local services which is what most people want. More important than competition is collaborative working between different agencies and services to provide quality care across the whole patient pathway. Competition can have negative consequences where it impedes information sharing and leads to quality being undermined to deliver low cost services.

  165. Rory O'Conor says:

    Some of my views as a Public Health Consultant are:
    that choice and competition are probably not the right levers to deliver the required improvements in the NHS;
    that the current appointment at Monitor appears to be even more of a potential liability for the future of healthcare than the health secretary;
    that pushing through an ideological reoganisation of the NHS without any manifesto pledge puts the Conservatives in a position which they are going to need to do a lot more than “stop digging” to extract themselves from;
    that I havent really got a clue as to how I would recommend getting out of this mess but it really is a bad mess – I would probably ditch the whole bill; appoint Steven Dorrell as health secretary and try to aim to regain the status quo ante as the least worst outcome.

    Wider than the NHS, I consider the ditching of all regional structures as equally barmy, and another area where the government will need to revisit.

  166. Tom says:

    Choice in healthcare is important to me, but not choice between providers.

    I would like my local GP practice and hospital to deliver safe high quality services (and be subject to external inspection), genuinely engage me in the planning of my care (e.g. explain the choices of treatment available to me) and to offer me choice of appointment time.

    I don’t want to have to ‘shop around’ between providers in the way that I have to shop around between utilty companies.

  167. james says:

    In answer to the question how can we best ensure that competition and patient choice drives NHS improvement. We have to ask ourselves if it is appropriate when patients are at their most vulnerable are they always capable of making an informed rational decision, when the drivers for the providers is financially driven and not driven by quality. PCTs or GPs referring to a ‘centre’, not because it is the best care, but the best price creates a huge conflict of interest (real or perceived) which will damage the trus in the relationship between NHS professionals and patients. So the question should be – is it right to create competition in the healthcare sector?, and what impact will this have on patient care and professional integrity and training?
    Provider organisations working in partnership, not competition will allow professional integrity to remain intact, the appropriate professional training to be delivered, whilst also ensuring patients receive the right care at the right time – and this should be the priority.

    Competition can drive improvements in the market place – up to a point, but then the quality, cost or time will begin to suffer, and that will reflect directly on patient care. It is understanding the end point that no more efficiencies can be achieved in an area that causes the greatest concern. The question should then focus on priority areas for the health service – what is in and what is out of the NHS – i.e. should cosmetic surgery of any sort be provided on the NHS? e.g. tattoo removal, vary veins, breast augmentation if there is no physiological rationale – should IVF or PGD be NHS provided? – there is no doubt there are economic benefits for fertility treatment, but wider health benefits can be challenged? We need a public debate on this!

  168. Paul Meadows GP says:

    Competition will not work in the balanced healthcare economy – it risks distorting service provision – competitors would need to offer the same or equivalent ranges of products and that is not built into models – and the consumers/customers do not have enough information and do not necessarily have a reasonable mindset to made rational or reasonable choices

  169. Tony McGough says:

    Bad question. It assumes the answer it tries to solicit.

    Public-owned institutions can be very badly run – patients drinking from flower vases in Mid-Staffs and so on – so the ability not to choose such a place can be valuable. But much more important is the provison of local services, whether private or nationalised, which are paid for in advance out of our taxation, meet most of our needs, and are administered with a human face. Thus – get the GP surgery to be open 12 hours a day, with a pharmacy next door, and a hospital and minor injuries place within a few miles.

    I don’t mind whether the money to build facilities comes from private shareholders or government-borrowed funds (for which they pay interest). Let the NHS be manifest near me as a Local Health Service as good, in its own way, as Marks and Spencers and I’m happy.

  170. james says:

    I have concerns that as a listening exercise, comments are edited? Is this really listening?

  171. Concerned NHS manager, patient and carer says:

    Quality not choice
    Collaboration not competition

  172. Peter Lakin says:

    In answer to the question “what is the best way to ensure a level playing field between the different kinds of provider who could be involved? “, the playing field will not be level unless all providers wishing to supply NHS services do so with the same pay, terms and conditions for staff as other providers. Otherwise, providers can undercut each other in the commissioning phase which will mean less qualified and experienced staff. In addition, there would be a risk of clinical staff moving to a different area precipitating a ‘brain drain’ if one location offers superior pay, terms and conditions such as pensions.

  173. Peter Lakin says:

    I think that increased choice will express itself as increased choice for commissioners rather than patients. There will be a larger number of organisations willing to provide services, and commissioners will choose between them. I do not believe that there will be a greater number of hospitals, dentists etc for patients to choose than is currently the case. Commissioners will then try to choose the provider that they think will best meet the needs of the local population. This will reinforce the image of the dreaded ‘postcode lottery’.

  174. Anon says:

    Choice is meaningless in such a highly regulated business, the capitalist model doesn’t work when everyone has to do the same thing or get struck off. The concept of competition is only useful when you have a monopoly that is working on a 10000% profit margin. This is not the case in the NHS, its run on a shoestring. By breaking up the NHS you stop co-operation and sharing, the two things that make the NHS so cheap. People don’t want a choice, they just want good healthcare.

  175. Concerned commentator says:

    Is this a genuine listening exercise? Who judges what is off-topic and how quickly is the moderation done? Why wasn’t there a 5th question such as “Is there anything else we need to know about how to make these reforms work?”.

    I’m concerned that the phrasing of the 4 questions can be used to set aside a whole tranche of legitimate concerns about the reforms, like how the way the internal market rules are managed is likely to really make GPS frustrated that they can’t actually properly fulfil their role.

    • web editor says:

      Thanks for your questions.

      The site is monitored regularly during normal working hours, and we aim to process comments as quickly as possible and usually at least hourly. We are publishing comments on issues other than the four specific themes and these will be fed back to the Future Forum as part of the listening exercise.

      In this context, ‘off topic’ generally means something that is not related to the modernisation of health and social care.

      Annelise@DH

  176. barbara p says:

    This is a leading question, making the assumption that choice in healthcare is a good thing and is something that people want. the concept of choice in healthcare is a figment of the imagination of politicians.
    All we want is an assurance that good quality services are available locally. It is impossible for most people to access sufficient comprehensible information to make an informed decision based on “quality”.
    The Choose & Book experience showed that most people chose either a service with the shortest wait or one with the easiest parking.
    Giving a choice of providers is likely to fragment healthcare and give a poorer service overall.

  177. Irene Murray says:

    Need to look at co-operation and collaboration to provide the best care and services at optimal costs to both customer and supplier. Its called partnership and is a win-win!

  178. Sheila Foreman says:

    I believe that creating a competitive environment within the NHS was the first step to its demise. Recreating an atmosphere of team working at all levels would improve the situation for patients and staff alike. A genuine sense of working together to provide the best service possible not only gives a sense of pride and achievement to staff but also ensures that patients needs come first.

    Contracting out services like the cleaning of hospitals is a good example of what happens when competitive tenders replace a sense of ownership and commitment to a hospital team. Hospital infections increased dramatically when services were contracted out because the sense of being a vital part of the hospital team was lost.

  179. Rob Harwood says:

    Choice and competition are possible in UK healthcare but come at a cost, a cost that would have to be borne by the UK taxpayer. Costs are incurred because choice is by definition wasteful – to be a meaningful choice there has to be more than one alternative available, this means that some alternatives would be left unused – hence the waste. Market enthusiasts will say that only the less popular providers will be left unused and they will either have to change or fail. However, resource from somewhere in the system must still be expended to provide the unused choice – in a taxpayer funded system this will ultimately be from all of us.

    Can services be allowed to fail? It is difficult to see how this could be permitted in health since patients may be left without essential healthcare provision. If a service did fail – become insolvent for instance – there would need to be a safety net, we are assured there is to be such provision, to ensure that no patient suffered. In other words these services are too important to be allowed to fail and so must be bailed out – just like the banks in fact, which is how we got into this mess.

    Competition implies a market, markets have costs – their transaction costs. Market transaction costs are made up of the costs of accounting, generating bills, sometimes gaming around billing, marketing the organisation’s services together with profits to shareholders in private organisations. These costs can be substantial even in healthcare – please examine transaction costs in the US healthcare market, they are enormous. Transaction costs in a healthcare market mean money that is part of the health budget that is not spent on delivering healthcare, it is spent on running a competitive business. I am far from certain that, in such cash strapped circumstances as we currently find ourselves, that it is sensible to waste our resources on establishing a competitive business environment rather than spending the money to help sick people.

  180. Jayne says:

    I agree with the many other people on here who have said that patients do not want a choice of health providers, they want good local services.
    I also do not want a privatised health service. The raison d’etre of any private company is, by definition, to make profit. How can you possibly think it is conducive to introduce profit into a system that is supposed care for people?
    Millions of poor Americans have been unable to access decent health care under the terrible US system and now, just as Obama is trying to reform this, you are proposing to destroy our great, world-famous NHS.

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