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?

This page was closed to comments on 31 May, the last day of the listening exercise. All comments have been fed back to the NHS Future Forum to consider.

The Forum will submit its report to the Prime Minister, Deputy Prime Minister and the Health Secretary in June. The government will consider the Forum’s findings and then publish its official response

In Conversations, NHS Future Forum, NHS listening exercise | Tagged ,

887 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?

    • I believe that all acute hospitals should be at the same high standard, and financed by direct taxation. I should have a choice because all NHS hospitals should be as good as each other at the essentials, and excellent regionally for specialist care.

    • Andrew says:

      I can not believe some of the comments and opinions given in response to this post. The NHS is an excellent model which could work very well indeed with the right leadership. It has been the envy of the world for years. Yes, it has it’s shortfalls, but nothing that can’t be resolved. Breaking up the NHS is not the answer.

      Let me tell you that I have been in the fortunate position of receiving care both privately and on the NHS and I would rate the NHS as being far superior.

      A great number of people work for the NHS who are dedicated to providing a high standard of care for their patients but they are let down by services that are poorly managed, where resources are unnecesarily wasted because of the way the system is structured (Yes, I can give specific examples).

      Competition is one thing, but in my opinion, allowing private companies to provide services means that money is being sapped from the NHS to pay shareholders, something which is fundamentally unacceptable.

    • Poor Bloody Infantry says:

      Unfortunately, choice and competition are mutually exclusive in the long run. If your local hospital isn’t “chosen” by lots of patients, it will lose income and close down (in the unlikely event of politicians allowing these reforms to reach their logical conclusion). It follows that you will no longer be able to “choose” that hospital, any more than you can choose to watch Premiership football live on the BBC. I’m afraid capitalism tends to monopoly, except this time it’ll be a less regulated private monopoly solely interested in profit rather than patients and public service.

    • Aileen Abbott says:

      I agree there needs to be more providers in the system. Patient numbers are increasing quickly, transport and parking (including costs)are getting forever harder for patients. New providers are a great oppurtunity to move services closer to the patient, not further away.
      I don’t believe it’s helpful that they are private companies legally obliged to make a profit out of the tax payers health system. Why can’t there be simply more ‘newer NHS providers’. Within my domain which is hearing, a provider that values hearing/ long term detriorating sensory conditions/services for older people, and recognises the service as a key part of its portfolio would make a lot more sense thatn trying to compete in a large Trust arena geared up to providing A&E, Heart Disease and Cancer Care.
      With more NHS providers comes competition between the NHS providers since some patients will always choose to travel if they’re not getting the service they want. That is as long as they can genuinely choose, CHOOSE AND BOOK despite its name has never really genuinely allowed this to happen.

    • Dr Daniel Knibb says:

      Competition is an entirely inapplicable model for quite a lot of what the NHS does, as there is only one group of people who have the skills to provide a particular service in a particular area. An example is my area of work: dentistry for people with special needs. The important thing is that professionals are allowed to get on with treating the people they serve, without overcomplicating the system by introducing unnecessary illusions of ‘choice’. The way to make these services more efficient is by good-quality epidemiological studies and joint working with service user groups to ensure services are targeted appropriately and reduce access problems.

    • karen almond says:

      I agree and would like to add that each hospital should be held accountable for the successes and failures of their operations and treatments.
      For example my local hospital has a bad reputation for failed treatments and patient complaints regarding sustaining physical harm when having routine procedures, and routine surgeries going so wrong that reasonably healthy people are not surviving routine surgery. Who is looking into safe practices, and reviewing what is going wrong.

    • David Robinson says:

      @Dr Julian Sims seems to have an axe to grind about the operational efficiency of the NHS, which I don’t want to get into. He does however raise a good point about the Peter Principle in the clinical workforce. Good clinicians don’t necessarily make good managers. Unfortunately the NHS, like most of the world, falls into the trap of thinking that managers are more valuable, or “better” than the people who report to them.

      We need to see a sea change in the way we assess the value of leadership. Granted, managers have responsibilities, but it is the workers who add value to the business. Why not have the most gifted employees on a higher wage than the managers to whom they report? If you really think about what each job entails, there is no reason at all.

      So let clinicians do what they do best, and reward them accordingly. Don’t make them think they have to become a manager in order to be promoted.

      Anyway, all this is digression: it really belongs on the Advice and Leadership page (I’ll go and add this to that one shortly), but I wanted to respond here to Dr Julian Sims, and thank him for raising the Peter Principle.

    • Lisa Corcoran says:

      I feel there should be more emphasis placed on dental treatment in hospitals, particularly for those people who have extreme dental phobia. This is becoming more and more widespread, with people suffering agony for years rather than go to the dentist and receive proper treatment. Add to that the heinous costs involved and also the difficulty in finding an NHS dentist, and we have a severe hardship on our hands, particularly in the current financial climate. I do feel that dental services should be more affordable to encourage people to take charge of their dental health and thus avoid future problems. Making this service so difficult to access and expensive (unaffordable for me and most people I know) is surely not the most practical solution? I personally feel that some dentists (not all) surely take advantage of the situation by carrying out unnecessary work; I am sure malpracticing dental surgeons exist as surely as malpracticing doctors! I just feel that something needs to be done as lack of dental hygieine can lead to othre health problems, and the public need to be educated about this in an environment in which they feel safe. A cold, clinical dental surgery with a brusque and unsympathetic dentist (yes, I have had my share of these) is not the place and it is precisely this kind of attitude practiced by the dentist which leads many people to hold dental phobias in the first place. I just feel that our hospitals need to provide an element of education, preventative action and restorative care, whilst raising the profile for the Trust and at the same time not breaking the bank.

    • Roger Hart says:

      I don’t want choice. i want a good hospital within reasonable distance from my home. Nationally, hospitals sharing best practice rather than competing with each other.

    • Justine Schneider says:

      Competition comes at a price. Economists call this transaction costs: the resources taken from the health care budget to undertake the tendering, negotiation, monitoring and re-tendering involved in competition. In the US, transaction costs absorb about 30% of expenditure on health. In England they have risen from 5% to 14% with the opening up of the market to independent providers in the past decade. Do we want to increase transaction costs still further at a time when we are required to make massive cuts? They can only come from two places: the NHS budget or patients’ pockets.

    • I have locumed in a NHS-hospital where there have been serious quality problems in the past. The hospital had faced the problems, revewaled the truth, and found the way to improve and be back to highest standards.

      Not because of any concurrence, but because the motivation was ethic, commitment to the patients best and the will to reestablish a workplace where everybody can be proud to be a member of the team.

      I have seen different health systems in the world and I think NHS is the best construction at a moderate cost and it should be kept as it is, it lives and is able to improve.

      Privatization will increase costs, replace ethical standards by profitmaking gradually and focus healthcare on the needs of the worried healthy.

    • Joe King says:

      The moment that the NHS is privatized patient care will surely begin to suffer. Competition for profit between health providers will result in cost-cutting measures that won’t reflect the interests of the general public. I find it worrying that the government is even contemplating these measures.

    • Catherine Lander says:

      In the past expertise has been shared, we have coperated with our colleagues in other areas. Now we will be in competition. I spent time on the phone to a colleague in another area; I am a speech and language therapist with a specialism and my colleague is in a location where there is no specialist support available so she contacted me. In the future I would have to charge for the service or a service level agreement would have to be drawn up with monies flowing accordingly. Meanwhile the client would be left waiting.
      I am also concerned that only ‘informed’ patients would be able to access and fight for services. Many long term disabled and chronicly ill have little energy left while coping with their illness or disabilty, and may not have the capacity to fight ,they will be left without services they need.

    • Frieda Rimmer says:

      I agree with Ruth about the treat of competition protects against complacency and drive standards up however unbridled and poorly regulated competition can and will lead to cherry picking of the easy to deliver and profitable aspects of health care leaving the complex cases for a destabilised NHS to mop up. I see nothing in the current White Paper thats leads me to believe that the coalition understand this and will protect against this. The paper is clearly about opening up the so called NHS Market. All the areas that require addressing can be done without the need for this white paper.

    • Kate Patience says:

      Competition should indeed raise the standards of services as we would expect GP consortia to refer patients to the best and most effective services so it would be in the provider’s interest to raise the standards. However, it cannot be ignored that the cost of the service is going to play a huge factor. For example, a patient needed follow up after a stroke, and the options are a first class service with highly specialist therapy staff that is very expensive but effective, or a less experienced but cheaper rehabilitation team that would produce less favourable outcomes – who would you choose if you were a) the patient or b) paying for the service?
      Though we have been told in the NHS that we must work collaboratively across such boundaries and help with training etc, why would we do this when it would risk us losing our patients and therefore our income?

    • Dr No says:

      I believe that some competition is healthy but in terms of making choices it has to be balanced against the fact that most patients do not want to travel too far for their services.

      A competition driven service will have the effect of fragmenting the NHS and making larger more lucrative trusts driven to advertise and provide services whilst smaller hospitals are going to lose their services.

      I agree with the points made about so-called ‘patient choice’ which in fact is only really going to be used by the better informed and articulate patients as it is currently.

      In terms of GP commissioners, this will have a variable success as most doctors are clinically trained but have very little management experience. The changes must be done with proper consultation with secondary care as the NHS is still the best provider of these services rather than private companies.

    • JEH says:

      I don’t really want choice or competition. I just want my local GP and hospital to offer a good service. I don’t want to have to make choices about where to go and who should provide the treatment, I just want somewhere close to home that ofers everything I need without having to travel too far. I want to be able to build a realtionship of trust with my health providers so that I can go to the same people for lots of different reasons and get to know them and trust them, rather than simply going somewhere different each time.

    • Mr Eric Morris says:

      I understand that some level of competion can help improve stanards, but if the NHS is opened up to private companie there is a risk they will just cherry-pick the most profitable proceures. Thus leaving the NHS to pick-up the most costly annd least attractive end of the health care. I do not see how lining the pockets of private company share holders is going to improve the NHS or patient care?

    • mary mcdonald says:

      I agree entirely with Roger Hart who said

      I don’t want choice. i want a good hospital within reasonable distance from my home. Nationally, hospitals sharing best practice rather than competing with each other.

    • Alison T says:

      I don’t believe the basic proposition that competition promotes quality or choice. The notion comes from a market place where choice may be promoted because someone spots a gap where her/his idea for a new product can be sold. But healthcare is not a series of separate products: what we need is integration, not a scattergun of competing providers. If we think that the present NHS is offering poor quality (and overall it’s clear it offers good quality) then that’s a failure of management; it seems to me that the government’s claim amounts to something like this: ‘the NHS is too unwieldy for us to manage it effectively’. Dividing it up will shift responsibility from the government to GPs and other, often private, organisations, but I see no reason why that should improve either efficiency or quality. The NHS is clearly expensive, but I don’t believe it’s more expensive than the sum of public, private and insurance money in a GP-managed system, supposing that system maintained the present quality of service. What increases costs is our own ageing and the development of new treatments and tests; a more rational solution would be to increase general taxation, an obvious course which none of the mainstream parties seems willing to consider.

    • Kate says:

      The question “How can we best ensure that competition and patient choice drives NHS improvement?” has a massive ideological bias! A better question is “How can we best maximise the quality of care in the NHS while maintaining affordability?” Choice and competition do not feature in my answer (and I guess, many people’s answers) since they are pretty much inimical to a good quality comprehensive service (http://www.unison.org.uk/acrobat/14564.pdf).

      How about democratising the running of the NHS, empowering staff (and patient forums) to shape and develop services to respond changing circumstances. For instance.

      Or what about increasing staff, decreasing hours and improving the wages for the lowest-paid NHS staff. Funded by a more progressive income tax.

      Or simply de-politicising the running of the NHS – developing a cross-party commitment to a comprehensive nationalised health care system (the NHS) forever. Full stop. That might inject some confidence into the poor NHS workers.

      To repeat: choice and competition cannot feature in improving the NHS. Making profits from the sick and broken is simply immoral. Government policy should reflect this. People demand it.

      Let’s pay people well whose work is to heal and care. Let’s not allow public money to be siphoned off to people who already have money to spare and happen to invest their money in a hedge fund that happens to have bought a derivative that happens to contain a smidgeon of a share in a global multinational with a poor human rights record, a subsidiary of which has won contracts for cleaning services in a few NHS hospitals and recruits low paid and undervalued cleaners. Give the money straight to the cleaners, whose work should be an integral and valued part of the hospital’s work.

    • tim says:

      profit profit profit……
      my nan needs a cataract op she has had one eye done they say now she can see tv one eye is good enough
      how will this change with the competition /profit motive involved

      save our nhs or is it already a done deal …the kaiser principle
      see you in a and e david and george on no may not see you at harley strret
      pp pip old bean

    • andrew john christian says:

      The danger is that powerful companies that are uncomfortably close to Government Ministers will cream off the easy, profitable operations. The motive should be overall efficientcy and increased care not concern to fill the pockets of the encircling wolves!

    • Alison says:

      If we are forced down the privatization route the ordinary citizens will not be able to afford good health care.
      When I lived in America from 1994 to 2003 I had dreadfully expensive health care until I could no loger get insurance.

      On my return to the UK I found that the Labour Goverment was making sure that the NHS was modern, efficient and far superior to that of the American system. For your information my cousin who is a world expert in Myasthenia Gravis (MG) had to become a US citizen after working in America since the 1960′s because he could not get health care when he retired.

      Do not force my doctor to spend time working out the cost of my treatment let the doctors spend finding better ways of keeping me healthy and curing me when I am ill.
      Stop the Conservatives from destroying our NHS.
      A worried patient

    • Amanda Evans says:

      I am extremely worried about the proposed reforms to the NHS. I think Andrew Lansley is not acting in the best interests of the public and his plans will destroy the NHS. I don’t feel the need for choice, all that is required is a good standard of practice nationally throughout all hospitals. I had major surgery in 2009 and the level of care from the nurses was excellent. I also had to have a blood transfusion. I am very grateful for the kind people who freely donate their blood to save peoples lives and I hope that the blood service does not become privitised. If this is truly a listening exercise then you will hear enough voices telling you to leave the NHS alone and you will drop the Health and Social Care Bill and leave the doctors and nurses to save lives!

    • TB says:

      I don’t want choice. When I get ill, I want to be treated and get better. The NHS does this for me very well. Thank you.

    • Wendy Patterson says:

      I agree, ‘Choice’ and ‘competition’ are two of the concepts that have served to damage the NHS and delude the electorate. Everyone, including politicians, knows that the vast majority of people want equal access to a good service locally – just the same as education, social services and the rest of the welfare state. For the majority of people, in the most cases ‘choice’ is a myth. The main difference is between the rich and the relatively wealthy who choose private health and the rest who cannot afford to do this. Competition within the NHS may drive down costs for a temporary period but in the long term costs more and delivers a poorer service – ask any NHS manager or politician to be honest about this.

    • Cathy Holden says:

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

      Competition will not drive improvement. Competition means that the cheapest service provider will be chosen, and that will not necessarily be the best for the patient.

      ‘Patient choice’ is a fiction. How do I as a non-medically-trained person have a clue who is the ‘best’ service provider? I just want the nearest one. And what does ‘best’ mean? If I have a broken leg I want it to mend. How can one service provider make it better more quickly than another?

      ■Which are the types of services where choice of provider is most likely to improve quality?

      See above.

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

      Meaningless question. This is not a game of football – people’s lives are at stake.

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

      Listen to the thousands of doctors and health professionals and members of the publice who say we don’t want a competitive health service. No-one should be allowed to make a profit from sick and vulnerable people. Multi-national companies should not be able to cherry-pick the least difficult procedures. Co-operation between the different agencies involved is much better for patients. Keep private companies out of the NHS.

    • Jess Adshead says:

      I think the principles underlying a desire to increase competition make people anxious – understandably so given the outcome for the many industries in this country that are now in ruins following privatisation.

    • B. Smith says:

      I disagree with Dr. Julian Smith, I have experienced health care under both the US & NHS systems, my feeling there is nothing second rate about care under the NHS system. I feel the NHS system provides better care, in most circumstances, than the US system and the NHS system does not discourage people from seeking care due to cost.

      If someone where to ask me how would I change the NHS? I would say, cut senior management pay, make senior mangers more accountable for their decisions, keep private companies out of the NHS, regulate / license health care professions, and establish “targets” for patient care. For me, I believe the Health & Social Care Bill should be pulled, rewritten, and submitted to MPs for scrutiny before the bill is approved.

    • MJH says:

      I think it is misconceived that competition and choice produce a better service. Like JEH I don’t want to have to make choices about where to go and who should provide the treatment. I just want somewhere close to home that ofers everything I need without having to travel too far. I want to be able to trust health providers to supply a consistently high level of service. Private suppliers will first and foremost be thinking about their own margins, not what might be the best outcome for patients.

  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

    • Oliver Hawksley says:

      Emergency Care is expensive, relatively unpredictable and requires a lot of resources to be available just in case. No private bidder is going to want to take on a service and have it “standing by” and not generating money from tariffs for operations. Whether this is for simple broken bones or major polytrauma it takes a lot of resources which get in the way of more profitable elective/planned work.

      Add to this further dispersal of specialties to any willing provider and offering a true major trauma centre or unit will become increasingly difficult without having the elective contracts/operations to pay for enough neuro /ortho/ cardiothroacic / plastic / general surgeons and all the support teams with enough experience to man an on-call rota.

    • Clare Moloney says:

      In response to A Roberts, I am amused that you think nationalised services monopolize the sector and private services do not. Hello, Virgin Trains anyone? The idea of privatisation generating more choice and better services to the customer is a cheap myth. So called ‘choice’ has nothing to do with patient care or the rights of consumers, private companies are going to be focused on their bottom line and that means delivering the service as cheaply and as efficiently as possible. How is that going to improve patient care?

      By the way, I thought this listening exercise also involved Andrew Lansley et al meeting members of the public and listening to their feedback face to face – when and where is this happening. It all seems very cloak and dagger to me!

    • FreshEyes says:

      Cherry picking challenges institutions that habitually cross-subsidize services (or products). Such cross-subsidies distort the communication mechanism on which the market relies: there is no clear signal what things really cost and hence no competition or innovation will be forthcoming to drive costs down and quality up.

      In the NHS, and public sector services generally, we see lots and lots of managers, but we still don’t know what anything costs. We have lots and lots of “performance management”, reporting on any number of targets, but the targets are brain-dead stupid: failing to measure value added and easily faked. (And faked, especially, where penalties or rewards are linked to targets.)

      So, cross-subsidies mean we won’t know what anything costs and performance management tells us nothing but lies about how we perform. And you’re telling me we should keep it that way?

  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?

    • Edward Jones says:

      Regarding Ambulances I see that private firms will be able to ‘bid’ for 999 jobs in the near future. I have recently had the oppertunity to meet a private crew. Between them they had the collective training of 12 weeks. GPs, MPs private firms, please be aware of this if your thinking of taking the emergency service away from the NHS. You are risking lives.

    • Roger Frankland says:

      Choice is all very well provided it is informed. When it is an emergency all hospitals should be of a standard to provide a high quality of care. If it is elective treatment then one of the things to bear in mind is distance. My wife had excellent care for her kidney stones in a hospital 35 miles away. I drove nearly 400 miles that week to visit her and take her to out patient appointments. The NHS is one of the best Health Services in the world and free at the point of contact BUT the relatives have to pay – Petrol , Car Park fees and bumped up phone charges.- never mind the grapes and the flowers.

    • Jean Lymath says:

      As a patient I have always wanted a local hospital to provide quick help when required and I have always been extremely happy with the service provided in the time of emergency. As a member of staff I have seen challenges when the patient needs to be discharged from the care, trying to get the patient home when they are eligible for patient transport is not cost effective and often disorganised, reflecting poorly on the organisation and the great care they may have already received. I strongly feel that the focus of change should be within the structure of the NHS, the follow up after care and not about choice.

    • Martin Price says:

      Choice & Competition is a means to having services provided by third parties. Leading to Privatisation with massive cost increases as British Rail.
      More effort should be given to retaining NHS as a public run non-private/non-mutual/non-partnership organisation run by NHS emloyees not “carpet baggers”.
      The “listening forums” are ill advertised and as meetings appear to be closed private clubs.

      Thank you

  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.

    • S Jones (BSc Hons Biochemistry) says:

      Exactly, the reforms will mean that the private sector can “cherry pick”, their way through routine treatment to bigger profits, whilst the NHS will be left to pick up more expensive and complex treatment, leading to frontline service cuts and compromised care.

      Take heed David/Nicholas, the Brown legacy of super schools and academies has done little to improve education.

    • Robert Traquair says:

      I totally agree with Mike Griffin and most of the comments left on here, having worked in the public sector whose duties were taken over by private companies, initially everything in the garden was rosy,at the first tendering stage to reduce their cost and increase their profits staffing levels had to be reduced to a bare minimum,at the second tendering stage the quality of the materials used were reduced, once again to maintain their profit margins.We have examples of this throughout the country where cleaning contracts have been awarded to private companies and there has been a massive upsurge in hospital aquired illnes e.g. MRSA,CDIFF.Patients, myself included are now frightened to be admitted to hospital. Admittedly there are things wrong in the NHS but adopting Mrs Thatchers and the conservatives mindset of selling everything to the highest bidder does not work. Keep the NHS out of greedy private hands

    • Estelle says:

      I agree, with your points and would like to make another. If a patient has complications during surgery, at a private hospital, that patient will then need to be admitted to an NHS hospital for treatment. Private hospitals are sometimes not equipped to deal with an emergency, so when things go wrong it will be left to an NHS hospital, to incur extra costs clearing up the mess. I have not done enough reading into this subject as I am a first year podiatry student, but I would hope the NHS charges these costs on to the private hospital.

    • Kate Patience says:

      As a therapist with 10 years service to the NHS I totally agree with your comments about follow up. When the government speaks of healthcare it is often the doctors and nurses mentioned with little regard to the rest of the Allied Health Professional workforce that are involved in patient care. The NHS has robust care pathways that take into account the rehabilitation required after periods of illness or injury (including surgery) with well trained therapy teams that often rotate through different areas to gain more training and experience. This gives a more holistic approach to patient care and follow up as we appreciate the after effects of hospital care and how this can impact on daily life. Often I get referred patients from the private sector who have had their quota of therapy input and now are seeking NHS input to fix the problem as private companies do not have the experience of the complexity of cases seen on the NHS.
      To keep costs low, I foresee companies using lower graded staff/unqualified staff to keep the costs down which will have a potentially huge impact on patient outcomes and quality of life. While in some cases this may be appropriate use of staff, there is also the potential for a lower standard of patient care. Given the ‘choice’ I would rather have experience over cost.

  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.

    • Andy Hadley says:

      I want a service that is integrated for the benefit of the patient, and I have already seen where clincial teams are unwilling to share the detail ‘because it may help people bid against us for running clinical services’. And the worst offenders seem to be GPs.

      Private companies cut corners, increase costs, and generally are not, as most NHS front line clincians, putting patient benefit before profit.

      I don’t think you can have a competitive market which properly joins up the healthcare system. Yes there are innovations and changes we need to make, but many of these are from idiotic waves of system change that are forced on the NHS, and partially unpicked by the next wave of changes before they get a chance to bed in.

  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.

    • Andy Hadley says:

      I strongly agree with this. GP practices are small private companies. Giving them such huge public funds to direct breaks all ideas of probity and separation of provider and commissioner, as has painfully been achieved for NHS employed staff. Under GP fundholding, services were not always brought “in-house” for purely clinical benefit.

      We do though need more care delivered outside hospital settings (which addresses some of the cost issues if done well), and this can better be achieved through an integrated collaboration between health services, not competition.

    • Peter Chambers says:

      How are GPs to be viable commissioners? Dealing with business savvy providers, with serious bid-teams who know how to work the system will take commercial expertise and management strength. This can only come from large organisations with critical mass. Such commisisoners must also have the resources to assess bidders fully and face down the shameless under-performers. This means continuity and monitoring, as well as the ability to write a meaningful service level agreement and manage all its changes.

    • mary mcdonald says:

      I do not want choices of provider, I just want my local service to be delivered by the NHS and to be accountable to keep it to a high standard.
      As for GPs, it is difficult enough to get an appointment with one now, when they do not have the time-consuming full responsibility of administering and managing budgets. With this legislation they would have to employ administrators to help them manage, so there would be no saving from the present system, it may cost more as they would lose economies of scale.

  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.

    • David Robinson says:

      There is no way to forbid private providers from cherry-picking services. Why? Because a profit-making organisation will deliberately perform loss-making functions so badly that the good ol’ NHS has to bail them out. Pragmatic? Yes. Sensible? Probably. Ethical? Well, this is business, you understand!

      The biggest two problems I have with the concept of competition in healthcare are

      (1) there is no free market in which to operate. Patients do not really have money that they hand over, and sky-high tariffs for the most complex work aren’t allowed (yet).

      (2) competition is based on the concept of winners and losers. In business, when a company runs out of money it is allowed to fail and disappear (except banks it seems). But we can’t afford to lose a major community hospital!

      Like most people posting to this chatroom, personally I don’t want patient choice – I just want sound medical decisionmaking on my behalf by the experts, and preferably the most convenience possible.

  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.

    • Janet Edmonds says:

      ‘Patient choice’ is a govt sales slogan, used for all the sell offs of the nationals to the private but it doesn’t apply to the real situation. I can say I want to go to St X hospital, but the doctor should send me to where he/she thinks is correct.

      The PO was split, cherry picked and is now even more unviable than ever. Likewise railways, Virgin Trains gets the ticket fares, but the state still has to mend the rails, via Retwork rail which costs millions but has not help from the ticket office money.

      The same will happen with the NHS. Private clinics will make the NHS too expensive to run by taking money for the easy jobs. Those clinics have to be cheaper and give a profit – two slices off of money that should have been for patient care.

      When the NHS hospitals are left half full, the private sector will step into the void the government has planned for it, to ‘save the NHS’.

  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.

    • Jen Williams says:

      Choice of place and time does not work. We have had that three times in the 18 months we have lived in Durham.
      When we go on the site to choose which hospital, there has only ever been one hospital with any appointments available, and that was never at the hospital we would want to choose, which would have been the local Durham University Hospital.

    • pete says:

      Lets cut to the chase.. The government for purley ideological reasons wants to carve up the NHS, bringing in private companies, who, will be duty bound by european competition laws to make a profit.
      GPs will bring in third party private administrative/accountancy companies to administer the £80 billion budget. This married with the £20 billion savings that are expected of the NHS over 4 years will leave patients with limited treatments. So the choice will be made NOT by your GP or not by the patient it will be made by an accountant, deciding whether your treatment is affordable or not.

  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 .

    • Jen Williams says:

      My mother trained to be a nurse before there was such a thing as the NHS. She thought it was a brilliant idea as she knew first hand the difficulties of people not being able to get health care when they needed it.
      She also worked in isolation wards, and would have been sacked if she had transferred any disease to another patient.
      In 2006, before she died, she was in hospital and contracted MRSA. We saw nurses not wash their hands after she had been seen to.
      Competition will only make this worse. Contracting out the cleaning has made wards dirty. Making nursing an all-graduate profession has led to too many nurses not wanting to nurse.

  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.

    • wendy says:

      Whilst I agree with a lot that has been said here, let’s all live in the ‘real world’ this is back door privatisaion of our wonderful NHS – there is no real patient choice unless you are the worried well who have the money and are articulate enough to get what they want. Why do sucessive governments insist there way is best? the Tories introduced ‘GP Fundholding’ which was a disaster and in a few cases lead to fraud being comitted and waiting times went through the roof – competition in the NHS is a non-starter and management needs to be reduced and more ‘worker bees’ in service at the end of the day the NHS is a NON PROFIT MAKING organisation NOT Corporate based!

  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.

    • Anita says:

      I agree with the Professor, and what is more annoying the USA pays more for its publicly funded health care than the UK does, pays as much again or more from private funding and still many people do not have any health insurance and overall the USA has worse health outcomes. We want more co-operation and integration, not false choices.

  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

    • Andy Hadley says:

      Agree completely. Dismantle the Internal Market, and get managers to support/enable clinicians to innovate and deliver more care closer to home. The barriers between health organisations, and between health and social care cause all sorts of inefficiencies and faults to good communication.

      Look to Scandanavia, where integrated health and social care works well (and yes, they face similar financial stricture). And to Torbay and others in the UK who have found ways to integrate despite the Department of Illness

    • Siobhan says:

      Well said!
      The internal market has caused huge increase in ‘backroom’ expenditure since it’s inception. It should be dismantled forthwith. Clinicians and others working ‘at the coalface’ to provide the best health care we can should be acknowledged and encouraged to get on with the job…not ceaselessly undermined by politicians and others using spurious statistics to compare and contrast different ‘service providers’. We need collaborative healthcare…NOT competition through the ‘free market’. Of course we need some regulation and maintainance of standards but the ‘market’ will only uncover the underperformers when things go horribly wrong. There will be no desire to openly admit problems and look intelligently at ways to resolve them…as you might lose your contract!!

  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!

    • Jen Williams says:

      Choose and Book has never worked for us. We live near Durham and have used Choose and Book 3 times in 18 months. There has only ever been one of the three choices with any availability, and each time at the hospital furthest away.
      My husband has cerebellar ataxia. When it was diagnosed we lived in York, and he was supervised by the neurological unit at York Hospital. Even speech therapy was situated in the unit.
      Since moving to Durham, he has been as far South as James Cook hospital, Middlesborough, West to Shotley Bridge, East to Sunderland North to RVI Newcastle and and various places in between. We live six miles from University Hospital, Durham which has a neurological unit, but he has never been there, although he goes there for the diabetic clinic.
      That would be the hospital of his choice, but he never gets there.
      The idea of choice and competition in the NHS is anathema to most people, apart from those who stand to make money out of it.

  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.

    • Michael Swarbrick says:

      : Choice and Competition. There is an assumption here that competition will provide more choice. This is not necessarily the case with the NHS as a whole. It may be true in large urban areas such as London with high concentrations of GP practices and hospitals. However for most of the country competition will merely reduce the range of services that can be afforded with the limited resources available.

  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?

    • Deborah Milburn says:

      You may not be nameless but an awful lot of you are called ‘nhs manager’ on this website! Hardly surprising if people regard you as faceless bureaucrats as a result.

    • Clementine says:

      I too am an ‘NHS Manager’ (in commissioning) but i’m also a nurse & Health Visitor & use this experience to ensure quality & patient safety is integral to what my PCT commissions. I could use my ‘official title’ but just for ease I use NHS Manager – stupid really as being a ‘NHS Manager’ seems to give folk the green light to think you’re a waste of time & space & according to Mr Clegg we shuffle papers around …

      I am proud to be an NHS Manager, proud of what I do, know I make a difference to patients e.g. help to keep them safe. For these reasons I sleep soundly at night & dont have any doubt that I am worth what i’m paid. When others dismiss NHS Managers its this that stops me getting down or mad !

    • Christopher says:

      I am a GP. My view is that managers are essential, but the issue is what they should be managing.

      Health care is unusual compared to most businesses in that the managers are less highly qualified than those they manage and understand less about the front line service provided. (Thought experiment: if managers and clinicians all swapped places tomorrow, what would happen?)

      Despite this our experience as GPs is that we are being managed in increasingly onerous detail; we are given more and more detailed guidelines to follow and are asked to count more and more things. This perhaps allows our PCT managers, or indeed our PCT managers’ managers a sense of control but I can tell you it adds nothing to care of patients ‘at the coalface’. As qualified professionals, why can we not be trusted to do the work we understand? On the other hand, there are a lot of tasks that need to be done, that are not directly clinical, which we could do ourselves if there were enough hours in the day, but which we are glad to pass on to the managers we ourselves employ. I argue that is the place of managers in the NHS – to work alongside clinicians to achieve clinically-led objectives.

      One of the craziest things about the latest round of ‘reforms’ is the idea of disbanding PCTs completely. What is needed is a change of emphasis. Instead of being tasked to control us, it would be great if our PCT managers who already have the necessary knowledge, skills and experience in commissioning could work alongside us. This would surely be cheaper, better and less disruptive than what our political leaders are currently planning for the NHS and still achieve the objective of allowing doctors to lead.

      As penultimate note, most doctors don’t want to be managers. There will always be a few who do, and more who reluctantly go along with the latest NHS ‘reforms’ because experience shows that once announced they are inevitable. (Our political leaders only hear what they choose to.) A final note, it is our political leaders who decide – with every change of Government – that the NHS is broken. It is a testament to all its staff that the NHS has continued to function despite repeated ‘re-formations’.

  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?

    • Clementine says:

      Exactly. As GPs are already private (by their being independent of the NHS) they will be commissioning & supported by other non NHS staff. So for this huge part of the process of commissioning & provision, the NHS does not feature … So for half of the process (the commissioning) the ‘NHS’ will not feature. All we need is to increase the number of private providers to support the choice & competition agenda & there will be no NHS left. Strange when Cameron says he believes in the NHS …

  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.

    • B Jones says:

      Completely agree. Also GP’s are not trained to commission or manage but to be a first port of call and access point into more specialist care. Why waste all of their highly specialist training to put them in a managerial job that they have little to no training for when there are specialist managers in the endangered PCTs who could do the job?

      Leave the jobs to the specialists so that they can improve and keep going at what they are good at. This will improve standards so ‘choice’ isn’t an issue… evryone is happy with their local service. (or is that cloud cuckoo land)

  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.

    • mary mcdonald says:

      I agree totally with Laura

  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?

    • web editor says:

      Hi Baze – thanks for your question. The comments appear in chronological order as we think this makes it easier for people to follow conversations and to see what others have previously said.

      Annelise@DH

    • David Robinson says:

      I agree with both of you, so would ask for an additional option in this page, or a copy of this page, that will order comments as Baze suggests.

    • George C.A. Talbot says:

      Rather late for this but I search each page with the current date then one day earlier.

  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.

    • Concerned commentator says:

      I agree with you. Speaking as a part of the NHS management that has burgeoned since 1991, the creation of an internal market has: a. identified the prices of services (good), b. led to the employment of thousands of management and admin staff charged with protecting the financial position of providers and purchasers, c. without any discernible quality benefit (in my opinion, and d. but with a bias towards investment in acute hospitals at the expense of mental health, LD and community services (because acute hospitals have been able to generate extar income as a result of the PBR system).

      All of the quality benefits have come from top-down directives as to priorities, and not from choice, which has been around since 1991. Even though there was an internal market, some of the problem areas (MRSA, C-diff, poor care of the elderly) got worse.

  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.

  181. Elaine Kemp says:

    Dividing commissioning of services into ever smaller packages with hundreds of consortia will return us to the good old days of declining procedures becuase the purse is empty. How on earth will there be equity of access for patients when each little patch will decide what it wants and more importantly can afford to pay for?

  182. AndrewPratt says:

    I think choice is meaningless. People want healthcare not choice. It’s irrelevant. And all the is sompeteition so called free market workship. Its rubbish. Health should be public services not provided to make profit for shareholdersetc.

    The govt reforms miss the point anyway. The only good idea is to locate public health with local authorities but until they say how much budget will be protected for public health it’s just rhetoric.

    The issue is using our public resources holistically to promote health. Now far far too much is sucked up by hospitals and hi-tech costsly treatments when we need to invest more in health promotion etc. What we need to debate is how to achieve this. I think it means giving more power and resources to Directors of PH and having democratic representation via the health and wellbeing boards that are being set up.

  183. Anon says:

    Patients do not want choice of different health providers. They want good quality services that are all of the same good quality whereever they are accessed. They may want choice over where they access those services and at what time to fit in with their personal commitments. They want services to remain free (within the NHS). I agree that services should offer value for money but how can making a load of staff redundant in one organisation and then re-employing them in a new organisation to do a similar job be offering good value for money which is what appears to be happening at the moment. Patients do not want a privitised health service.

  184. Bristol GP says:

    I desparately hope that these messages do penetrate to the “great & good” who are in the driving seat of the planned changes. I am in complete agreement with the comments which emphasise that the NHS is not for profit and should not be in the business of creating profit for other organisaitons.
    However, I fear that we may all be deluded into believing that these views will truly influence the decision makers and this listening exercise is simply a diversion!

  185. fay says:

    What if there are no types of services where choice of provider is most likely to improve quality?

    Choice can only be in planned NHS care, by creating too much choice we risk those who are unable to choose missing out, a two teir service. In an emergency who can choose, if choice is there and there’s no time to in an emergency situation, how are patients going to feel if where they go is not where some would choose to? A see a vicous circle promoting some options by seeing others delcine. Why not drive up standards another way? patient satisfaction surveys, open reporting, audits etc

  186. Andy McAllister says:

    The reforms will mean significantly increased privatisation of the Health Service and the commissioning of services being subject to EU competition law. This will in turn mean vastly increased costs for the taxpayer due to legal challenges, and the closing of hospitals as activity is siphoned off to private providers to promote competition at the expense of quality and cost-effectiveness. In the long-term there is a good chance that it will mean the ‘dismembering and dismantling’ of the NHS and its core principles. If this website asked the public whether they wanted this then im sure the answer would be a resounding no. However, the level of misinformation coming out of Downing Street on this issue is astonishing.

    There is no evidence whatsoever that increasing competition within health will improve quality or save money, and in fact the evidence from other privatised public services is a decrease in quality, and more cost for the taxpayer and the consumer (e.g. social care, electricity and gas, water, etc.). Im all for positive reform of the NHS, but why does it always have to be the same blinkered nonsense about markets and competition?

  187. Michael Wilkinson says:

    My main concern is one of management.
    Just because a doctor is excellent at their job does not make him/her a manager.
    Managing a budget whilst caring for people is a skill few possess and I suggest that a medical centre manager with responsibility for finance will be the key to success.
    There must be no hesitation in replacing managers who are unable to provide the service expected of them and any regular audits carried out to prevent bribes etc being accepted or even offered.

  188. M J says:

    I disagree with the contention that competition or choice can provide improvements to patient care on the following grounds:
    1) there is little evidence to support this from healthcare systems that have employed such a market approach (USA)
    2) Patient choice caters better to elective non-urgent services – providing a second class of patients requiring acute services – these will typically be the poorer, elderly, less articulate end of society.
    3) Healthcare workers have little interest in making money , but are interested in providing caring care. It is “big business” who are interested in market values – conversely they are not interested in providing care, but rather making profit for their shareholders.
    4) Health services cannot be sufficiently controlled through market regulation because the complexity and unpredictability of treatment makes it impossible to set out all eventualities in contract.

  189. Debbie moody says:

    How can you have competition in an environment where women are accessing services that are equipped to safely deliver their baby. Women and babies are not commodoties with a market value that will generate an income. They are human beings that require a service that supports them through pregnancy and childbirth. Both are extremely unpredictable and serious problems can occur. Our service is already stretched, midwives work long hours, 0ften without breaks to provide this service, they are demoralised and often disatisfied with the level of care they are able to give. If competition increases the amount of women booking then the service and the midwives will be further stressed and unable to cope. I really don’t think that competition will help us to deliver the standard of care we all strive for. I see these reforms as yet another of the conservatives efforts to privatise our health service, to the detrement of those who are poor and vulnerable. Everyone is able to access health care when they need it and this is how it should stay.

  190. Richard Wallace says:

    Wheelchair Services:
    The forgotten part of the NHS.
    Under funded
    Under staffed.
    Under rescourced.
    Therefore under performing, (from the patients point of view)

  191. Andrea Franks says:

    As many others have said, there is no evidence at all that bringing in the private sector will improve care or lower costs. There is plenty of evidence that such policies will increase costs, because of higher administrative costs, shareholder profits and so on. Quality of care is very likely to suffer, particularly when there is competition by price. Integration and co-ordination of care are essential but will be far more difficult with multiple providers which are in competition with each other.

    The Bill is a real disaster, is hugely unpopular, and must be thrown out completely. Any party which supports it will not be forgiven by the electorate for a very long time.

  192. Frank says:

    As a patient, I want choice. I don’t want competition.

    When I go to my GP and (s)he thinks I need elective surgery or to have an outpatient appointment, I want to choose where and when to have it, much as I would choose a hotel or flight by looking at the options on the internet and making an informed decision. I should be looking for when they could fit me in, how far the provider is, etc. and listening to my GP’s recommendations.

    Obviously all providers should be meeting the minimum agreed standards for care but some may be more specialised in certain areas and some doctors may be better at some aspects within their specialism, so quality of care should be visible when I’m making this decision with my GP.

    The least concern to me, as a patient, is the cost because all care on the NHS should be free at the point of need.

    • Frank says:

      As an addendum to my note above, what I don’t want is my informed choice to be overridden by a well-meaning organisation, whether it’s a PCT, GP Consortium or the NHS CB, who think they know better than myself and my GP, and for my referral to be switched without my consent.

    • Anna says:

      We are unable to afford a system where cost is disregarded. Everything will only be free at the point of need if we are wise with the money we have. If we all say we are not concerned with the cost then the NHS will collapse.

      We do however need to look carefully at services and ensure that they deliver acceptable outcomes and it is vital that value and not just cost is looked at.

      Choice of provider will only work if there are restraints on expensive services, particularly where there are cheaper alternatives that deliver quality outcomes. We simply cannot sustain patient choice without cost being part of the decision. Any qualified provider could be a disaster.

      If you were looking for a hotel you would certainly include cost in your decision. Don’t you think it is unreasonable to ignore it just because someone else is paying?

  193. Andrew Graham says:

    It seems fairly clear that as far as patient choice is concerned the public has aleady chosen. When it comes to deciding between a privatised health care system and a public service funded by taxes we want the NHS to remain a public organisation. Any other questions of choice are quite secondary to this.

  194. Brian Kirk says:

    False Choice!
    The only choices regarding illness are (1)Treatment or no Treatment
    (2)effective treatment or inneffective treatment(3)universal access or pay as you go.
    The NHS used to be centrally planned with resources provided to meet known and anticipated need – this has been long lost due to clinicians being forced to “compete”with other clinicians with whom they used to collaborate.
    Competetion is usefull in business but since when did pain and suffering become a commodity to be traded and profitised?

  195. Ian Lawrence says:

    The internal market was brought into the NHS in the 1980′s & at that time had a big impact in shaking up what had become a complacent & wasteful beaurocracy.
    The NHS has moved on. Almost everybody in the NHS now realises that money is limited & value for money is key, everybody I work with is desperate to improve efficiency and patient care.
    There are 2 main things that keep getting in the way, the first is that every time we start making some headway everybody gets diverted into a big reorganisation & all the improvement plans that were half done get forgotten & we have to start again.
    Secondly, the internal market focuses all the managers efforts onto budgets, tarrifs & contracts when they should be focussing on supporting the clinicians to look after patients.
    The internal market, whilst a helpful tool initially is now hugely wasteful & past its usefullness.

  196. Kate Young says:

    people need very good information in order to make informed choice. Who is making the choice the patient or the GP or another professional? The question is not clearly defined. For therapies neither GP nor patient will necessarily have the knowlege to make an informed choice. Choice will therefore depend on the ability of providers to build a good website with good links, advertising, or word of mouth, as it does with private sector services. Stat sector services should already be providing clear info on what they provide. Think the whole choice question is not the right one to ask- think the right question is how can you ensure good quality local services in all areas. Getting a good GP and dentist in the first place are the major challenge for us in London, let alone getting referral on to secondary tier services.

    • Dr J Martin says:

      I completely agree with what Kate has said. Real choice can only happen when patients and clinicians have access to accurate, clear and unbiased information on outcomes or quality. And we know that healthcare quality is incredibly difficult to measure. It’s simpler for one-off elective surgeries (hip, eye, etc) but nigh on impossible for people with complex and long-term conditions or for co-morbidities.

      Providers will have to provide information (aka marketing material) and who will be ensuring the accuracy of this? (and paying for it…?)

      And this marketing will also cost money – driving up costs for providers.

      Healthcare is a team effort, we drive up outcomes by collaborating with our colleagues across the NHS. We tell people about or best practice and seek advice and second opinions when we need to.

      We do not compete with them!

  197. Real choice will eventually cost more money no matter what competition is generated! Choice in the current NHS set up is just a farce, titivating around which treatment centre one would wish to go to – this isn’t real choice! Let’s stop all this choice nonsense – what we need to be realistic about is if the NHS needs to stay afloat with good quality health/ill care then the fundamental focus should be that NHS care should only be provided as an essential need, not one of choice or luxury! Why would I care if I get treatment at Hospital A, B or C – as long as Hospital A is safe and near to my home, why would I want to bother with Hospitals B or C? And if Hospital A is not safe to provide treatment, why should this Hospital remain in business? The costs of operating what the NHS terms as choice currently is a pure waste of money!

  198. John Robert Cash says:

    Outside the NHS. We have retirement homes, Care homes and Nursing homes. Over a number of years there has been and it continues media criticism of the interfaces between patients when they are admitted. Nurses are now much better educated and highly trained almost to degree level. Therefore there must be a fundamental change in the way patients and dealt with. That is to say the NHS should seriously consider splitting the “Care” side from nursing and introduce two new grades. The first grade would be responsible or ward cleanliness including toilets and bathrooms and also the provision of beverages etc.including the provision of water outside meal times.
    The second grade would be responsible for the Care side involving personal hygiene, combing hair, serving meals and helping with feeding and dealing with continence issues. There could be career progression through to nursing. This could be cost effective and free up nurses to do the job they are trained to do

  199. Rob says:

    I have needed expensive cardiac care for the last 20 years. There is really no choice as to where it is provided as it has to be a regional heart hospital. I cannot see how competition could possibly change this and am really afraid that the government will wreck a perfectly good service.

    I live in dread of the day I go to my GP and am told the cheapest option is 300 miles away or, worst still, there is no money. That is the reality of the proposals.

    Doctors I have spoken to say they are alarmed by what will be expected of them. One GP said that doctors were being setup to fail as they could not possibly cope when they private providers will be brought in. What choice will there be then? How will the private sector make a profit out of the chronically sick?

    The NHS has served me and my family well for a long time but I feel future treatment will be compromised by an ideologically motivated government that knows little about the experiences of ordinary people. We do not have a choice now and will not have a choice under the new system. The message I get is that my treatment will be too expensive so the alternative, or is it the choice, is to go away and die quietly.

  200. Edmund Dunstan says:

    The question implies that competition will improve quality: is this fact or just ideology? The consultation should presuppose answers if it to be anything but phoney.
    A level playng field is best assured by requiring common standards, a common tarriff and no opportunities for picking the easy and profitable – i.e. no repeat of the ISTC fiasco.
    The keys to make patient choice a reality are ensuring good information is available about teh things that matter, and restoring to GPs the right to refer to wherever they wished which they had until the “purchaser-provider split” and other market based systems were imposed on the NHS.

  201. Martin Quinn says:

    What a dreadful leading question!!
    ‘How can we best ensure that competition and patient choice drives NHS improvement?’
    Anyone with the minimum level of expertise in genuine consultation methods will know this is an entirely bogus way to invites views.
    Why not substitute ‘co-operation’ for competition? All the academic evidence I have seem demonstrates that health systems based on co-operation deliver better patient care for the level of investment than those prioritising competition. The truth is the entire health bill is just a cover to privatise the NHS.

  202. Diane Hibbert says:

    I believe Cooperation is the key to a top-flight health service. Those who think competition is the answer are wrong. You cannot run a health service as if it were a greengrocers,with cut prices and special offers. The supermarket model is not the answer (unless it is the Co-op – have you studied their principles?)
    I want a good quality, local hospital, well funded and well staffed, with suitable patient input where necessary.
    Why do men always go for competition?

    • Kathy Allen says:

      I agree one of the key attributes of the NHS is the co-operation to be found in all parts of the service. The emphasis on competition will be the downfall of it. Personally I don’t want an NHS where competition is the sole management driver. My own health problems would not be attractive to a private provider.
      David Owen has produced a small pamphlet on the NHS bill and highlights some of the problems associated with introducing the form of competition proposed in the bill and especially the role of Monitor. I think all Dept of Health civil servants and MPs should read it. It seems to me totally inappropriate and unacceptable that EU competition law would be applicable to the services of the
      NHS . As a previous comment highlighted, this is a very loaded question from the Dept of Health, aimed at getting the answer it wants. I did expect better of our civil servants

  203. Lisa Silver says:

    The reforms are asking GPs to undertake a task that is broadly going to be impossible to achieve. We as GPs are being asked to slow/stop the upstream traffic from our surgeries into the secondary care sector. However the front door into our surgeries is wide open and there are no brakes on anyone consulting us for anything they so desire. Although we can bat away many of these requests ( this week I had someone asking for suntan lotion as he thought that it was too expensive from a chemist), this open door to general practice creates unlimited demand and does lead to activity up the chain. Politically incorrect this will sound unless there is some mechanism either insurance or a charge to enter the NHS, we are never ever going to be able to curb demand.

  204. Matthew Norris says:

    It is ethically and morally wrong to restrict healthcare to the rich and refuse healthcare to the poor, simply because they can’t afford it. That’s what happens in the US, where practically all of their healthcare is privately run. Letting health insurance companies into the game will drive us towards this disgustingly unfair system.

  205. C Williams says:

    Health is not a commodity and should not be subject to market forces. The new bill places far too much emphasis on promoting and increasing competition and this could ultimately be detrimental to the NHS, opening the way for full-scale privatisation. I am glad to see that the Royal College of GPs have come out against this.

    An element of choice already exists within the NHS but we are suddenly being told we need even more. I don’t think we, as patients, are actually asking for this. I think when it comes down to it, most people are happy to rely on the experts to guide them in the right direction. More choice and private providers do not necessarily equal better care. The White Paper on the NHS reforms mentions that these reforms borrow elements from the utilities, rail and telecoms sector. That’s all we need – a bewildering array of choice but not very good service.

  206. Deborah White says:

    The writers of these questions just don’t get it. Health (and illness) isn’t an industry with commodities to be bought and sold. Health is deeply personal and interwoven with every other aspect of our lives, and illness is often unpredictable and unfair.

    As a GP, I’m privileged to be able to try to help people with their health and illnesses, and I’m pretty sure what the vast majority want is the best quality services possible, as close to home as possible, and as soon as possible. Choice confuses patients – why would they want a choice of hospitals when they only live on a bus route to one? In my experience, most people choose the nearest local acute hospital; a few want to go to the next nearest acute hospital as they have had a bad experience at the nearest hospital. When a hospital about 10 miles / a 20 minute drive away is suggested because it has the shortest waiting time (according to Choose and Book), the response from patients is usually along the lines of “that’s a long way”, or “I don’t know where it is”.

    I am also a patient, and have had my life saved by the NHS. I’ve no idea how much I cost, but acute,
    life-threatening illnesses when everything is thrown at you despite your doctors thinking you likely to die don’t come cheap. And aren’t the kind of illness there is likely to be much competition to treat – which is what terrifies me about the proposed NHS reforms.

    Competition for pile ‘em high and sell ‘em cheap elective treatments (from private sector organisations using staff trained in and techniques developed in the NHS) will leave existing acute hospitals with the expensive illnesses in the risky patients, and they will collapse financially.

    Competition by “Any Qualified Provider” governed by competition law will not only generate massive process costs in an era of enormous cuts; it will be the end of the NHS.

    Competition will not drive NHS improvement; it will leave piecemeal services for patients who cannot choose when, where or how they get ill. Yes, the NHS can improve to give the choice almost everyone wants – high quality care near to home as soon as possible – but competition is not the vehicle for driving this.

    • Alison Forrester says:

      I agree with Deborah White. I’ve worked in the NHS for 30 years, both clinically and in public health medicine, and see these proposals as destructive, without electoral mandate. Health is not a marketable commodity. Choice is important but also expensive and what most people want are high quality, accessible services. This might mean some national agreement on what is provided within the NHS. The competition that is being proposed will drive down quality and rapidly bring privatisation. It is perverse to reorganise when we need to save large sums of money. The proposals make me very angry and willing (for the first time in my life) to go on protest marches, even riot!

  207. NHS veteran says:

    Totally loaded questions.
    To ensure a level playing field, don’t give the Private sector cherry-picking contracts, and factor in the costs of training for NHS providers.
    Why is patient choice of provider deemed to be so desirable ? I don’t want choice of provider, I want good quality care locally. But what I do want is to have my illness fully explained, and a choice of treatment options.

  208. Ben Ellis says:

    Choice is something you do when you go shopping. Health care is NOT the same – If I am injured, unwell or unable to get to a different location- choice is not a factor. The current system of choice is also a non-sense I recntly got asked would you like your mole to be checked out at Warwick or Northampton? I have no idea about the dermatology departments at either hospital let alone the competency of their staff or teh results- I picked Warwick because I wanted to go shopping after!? Is this really worth the expense?
    I think we have to stop thinking in financial terms when it comes to the economics of health and accept that value and cost are not measured in pounds when it comes to health and wellbeing. Choice will increase competitiveness but will not lead to better services as it is inherently prohibited by geogrphic location and the fact everyone needs care etc etc.
    Instead of choice the NHS should be more “Local” with more accountability local people should be able to see on their payslips how much money they are paying to the local health service. Everyone who pays becomes a share holder and the top tier management as well as other chages should be subject to “share holders meetings”.

  209. M Bennett says:

    Patients with back pain should have the option to choose to see a chiropractor. GPs should be able to refer under the NHS. It is good for choice and competition. Waiting times are usually a few days rather than weeks by which time symptoms are becoming chronic. Research for manipulation is favourable and NICE recommend it from chiropractors, osteopaths and specially trained physios.

  210. penny moon says:

    There is no doubt that there needed to be much reform and a shaking up of the status quo in many aspects of the NHS.
    However wholesale slaughter was not required and the deep feeling that this will destroy our NHS through privatisation is not unfounded and an ideology which was not specified when cons came into power and I wonder whose friends are going to benefit in the private sector…lets have no doubt about that!

  211. Senior Citizen says:

    I am concerend at the proposed involvement of the private sector.

    Throughout my life I have been able to consult my NHS GP in the secure knowledge that s/he has no pecuniary interest in the diagnosis being given.

    That cannot be said of the private sector. You only have to look on the internet to see hundreds of so-called qualified practitioners offering dubious remedies at high cost, and I have friends who have fallen victim to these and lost a lot of money. If, under these proposals, I am referred by my GP to a private consultant, how will I know the advice I receive from the private sector is not motivated by money?

  212. Alan Pucill says:

    The question is loaded: “How can we best ensure that competition and patient choice drives NHS improvement?” I think we need an NHS that is driven by care for patients and professionalism from staff. Competition is unlikely to deliver either of these. Staff are overstretched and feel undervalued and this leads to poor service for patients. Our county hospital is not replacing staff who leave because it doesn’t have the finances. We must not let the NHS be destroyed by those who are following a political dogma and who, at the end of the day, will be able to rely on private healthcare. If it costs us a bit more in tax to run it properly, so be it.

  213. Peter Gaskin says:

    I do not believe or want to have market competition within the NHS as it will lead to a two tier system. Already I cannot afford dental care and have not been to a dentist for over ten years. Although I work full-time I have not got the disposible income to find money for perscriptions and hence I have not used local health care. Please let’s have a health system that if free ,provided when people reallly need it and preventative.

  214. Michael Bannon says:

    There isn’t any evidence that competition will improve healthcare outcomes.

    Ben Goldacre is much more eloquent than me on this one:

    http://www.badscience.net/2011/02/andrew-lansley-and-his-imaginary-evidence/

  215. Orthopod says:

    It strikes me that one of the great issues in this choice and competition debate is the enormous potential for conflicts of interest. Many members of a large local ‘pathfinder’ GP Consortium are also shareholders in a Ltd Company, which also happens to provide healthcare. We are in a position where these GPs are diverting patients to their own healthcare provision company and therefore acting as both commissioners and providers. Every time we have asked for transparency on this, we are given evasive answers and I fear the public need to be made aware of the fact that GPs can in some cases reap personal financial rewards from these reforms.

  216. Alasdair Beckett-King says:

    Like many of the respondents, I question of the emphasis on patient choice, and the implicit assumption that free-market competition benefits the many rather than the few. Competition is no panacea, and the piecemeal privatisation of the NHS would be a tragedy.

    I urge the government to scrap these ideologically-motivated proposals.

    Please listen.

  217. robert hailwood says:

    The key to good quality general practice is consultation with the doctor.
    The time allowed, the setting and the state of mind of the people involved are most important elements. Much caring takes place below a cognitive level. We are not fixing broken parts on a conveyor belt, though at times it can seem to like that. Will increase in competition enhance this aspect of the consultation or detract from it by defaulting to the lowest common denominator of cost competition?

  218. Steve Elliott says:

    Why don’t you just ask us “which private company should run the NHS”. It would be a more honest question.

  219. Peter and Pauline kemp says:

    We have experience of the UK health system and the French health service for many years. The French system is far superier and has been assesed by the UN as the best in the world for over 20 years.

    Instead of having this consultation why not just copy the best?

  220. Sean Thompson says:

    The way this question is framed shows yet again what a fraud this ‘listening exercise’ is. We are not invited to challenge the wholly specious claim that ‘competition’ – that is, handing over chunks of our health provision to profit seeking companie is unquestionably a good thing.
    Since the introduction of the internal market, administrative costs have gone up from 4% to 12% of the NHS budget. ‘Competition’ is an inappropriate way to run the NHS, it isn’t (or shouldn’t be) a market. When we need is co-operation and co-ordination between local GPs, Hospitals and other parts of what should be an integrated and seamless service that doesn’t spend all its time sending itself invoices.
    As far as choice is concerned, mine is that I want a GP within walking distance who has the time to see me promptly and when necessary I want a local hospital a short bus ride away that is properly resourced – including A&E, maternity and ICU. I don’t want to have to choose between several hospital that are all closing wards and dropping specialisms.

    • Joe Simpson says:

      I completely agree with this statement. The way these questions are framed assumes the changes have already taken place.

      We don’t want or need any NHS restructuring.

  221. J Gait says:

    I am a patient. I don’t want choice. I REALLY don’t. I just want everywhere to provide the same level of service, and for this level of service to be as high as practically possible.

    Your questions in this “listening exercise” are some of the most transparently leading questions I have ever read. They’re practically a textbook case of how not to ask questions, or how to force people to appear to agree with you even if they don’t. Having read these questions, I will have no confidence whatsoever in the results of this “exercise”.

    • Peter Holt says:

      I totally agree with these comments.

      When people are ill they want good quality care wherever they are and not to be faced with having to assess and decide on different options. This is difficult when you are well but even more difficult when you have health problems.

      The ‘listening exercise’ is shown to be a complete sham because the questions in this case assume that people want increased choice without asking if they want choice at all.

  222. Les Scaife says:

    I can remember the so called consultation at the launch of the green paper on “The Future of Social Care” we were given 3 options to choose from. But there was no consultation in arriving at those three options, they were decided on behind closed doors at the DoH.
    So government was simply asking us to endorse what they had already decided on.
    What sort of consultation was that?

  223. Dr. Matthew Robinson says:

    What a terrible question. How can it be a listening excersise when the question is:

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

    How about a question asking whether we want competition to drive the NHS?

    I don’t want it.

  224. J McKie says:

    I’d just like to echo the sentiments of some of the above posters regarding the blatantly leading questions of this ‘listening excercise’. The question above should be asking us whether we want ‘choice’ at all.

    Choice isn’t always a good thing – particularly not where health is concerned. What’s best for most is a universally sound service that people can have faith in when they are in need. All choice does is give many people the opportunity to make bad decisions – particularly those whose financial situation predetermines their ‘choices’ for them. This dressing up of free-market ideology as ‘choice’ is a joke.

    • Malcolm Parker says:

      From what I can see the “listening exercise” (so right it is inverted comments) is a paper exercise by the government to paper over the cracks in the NHS Bill. Why have we had a referendum on AV which nobody was concerned about, and we are sleepwalking towards a privatised NHS. The Con/Dem government did not feature any of these proposals in their manifestos, there is no desire for it yet we have no voice in the change.

      Perhaps the result of the 2015 Election (if Labour can get their act together) will send a clear message to governments that they ignore the will of the people at their peril.

  225. Jos Wace says:

    Enforced competition will only serve to destabilise high quality integrated health care. If it down to who shouts loudest and pays most the most vulnerable will be denied high quality care, because the vulnerable are often the most expensive to treat.

  226. S Reddaway says:

    One area where local choice should NOT apply is which treatments the NHS will support. Deciding the efficacy of medecines and treatments is highly specialised, which is why it should be determined by NICE. Making NICE only advisory, with actual decisions taken locally, means that (a) decisions will usually be less well-informed, (b) decisions will be open to influence by local pressure, often with heart-rending accounts about particular patients, (c) less-rigorous local decisions will lead to money being wasted that could be better spent on other patients, and (d) it leads to a post code lottery.

    The greatest concentration of scientific expertise is in NICE, which was set up for the purpose.

  227. Jenny says:

    A dreadful question. As a nurse in the NHS, I have heard that our service’s contract is up for tender and that the commissioners are ‘keen to welcome new entrants to the market’. This is happening aside from the Health Bill and under the radar. Patient care will get worse in my area if the proposed changes go ahead (yes, I can provide sources) and there will be deaths (ditto).

    Competition is NOT what is needed in the NHS: collaboration is, with a decent standard of all health services wherever you live, and no matter how unprofitable it may be for those who provide you with those services.

    Your government’s desperate love of free-market ideology, and your greed to speed this ideology into play as soon as possible is so transparent it would be laughable if it weren’t so tragic: at least now more and more people are becoming aware that you take money/perks from the private healthcare providers and other big business who want to eventually strip the NHS bare, so are really listening to them, not us.

  228. Dr Jacqueline Marshall says:

    This is what is really happening.patients are being admitted under a diagnosis.The hospital receives a tarif.When the money runs out,the patient is kicked out.The Gp is then asked to do the tests that the patient should have had in hospital (so they are not paing for them) and then refer the patient to the outpatients which will attract a further fee. Each step is very competative on price.Shame about the patient. Oh and so much for choice.If the patient chooses to go elsewhere the whole process has to start from scratch.

    • Rod Whiteley says:

      That’s a very good point. Many commentators here seem unaware of the competition you describe, which happens already throughout the NHS. The question is not whether it’s a good or a bad thing. It’s a fact of life. The question is how to put it to better use and make it drive improvement.

  229. joan sweeney says:

    i do not want choice, i want good care local to where i live. i do not want the NHS that i have gratefully grown up with irrevocably destroyed. Mr Lansley – leave the NHS alone. you do not have a mandate to destroy the jewel in our crown.

  230. Jonathan Norton says:

    Scrap the entire bill. No mandate for it, vast majority of health professionals aganist it, the public are against it.

    Lansley has the arrogance to think he knows better than all the experts ? He doesn’t realise that the GBP hold the National Health Service concept as precious and something this country is proud of.

  231. Jennifer Durandt says:

    Competition between private providers and NHS will cause fragmentation of services, reduce quality and prevent integrated working. It will also delay procurement, as we are seeing already with NHS London Pathfinder support, which has been severely delayed by procurement rules and is now having to spend scarce time and money on this problem

  232. Anita Curtis says:

    I agree with the other posters who have commented on your leading questions – this is a textbook example of how NOT to write a survey! I believe this survey to be biased and, as such, I have no confidence that you will make a balanced decision. Basically, we are being given a choice between privatisation and privatisation; an impartial survey would also have considered a ‘Do Nothing’ approach – this should always be the starting point when planning a new project.

    My answer is that I don’t want a choice. I’m not medically trained and I want to be able to trust that my GP will make an informed decision on my behalf, in which money is NOT the deciding factor.

    I find it laughable that the public is being offered a ‘choice’ regarding health care, yet the ‘Vote No’ campaign was based on the premise that we are all too thick to understand AV! Please make up your minds – do you think the electorate are intelligent or not?

  233. jeff warburton says:

    choice – i work in mental helath services – choice is important however sometimes the rapid access to services and the level of risk would mean choice is not an issue; access is needed quickly and crisis teams through local services work hard to maintain people in the community. people with mental helath problems often given the choice would not engage – how does that fit with the new proposals.

    access to IAPT services is where choice is peorhas needing to be available however quality and level playing fields are important.

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

    in mental helath services – competition should not be allowed to happen – private mental helath servcies would and do cream off the profitable and easy to operate services. they contribute little to the training of staff prior to taking them into private sectors and also appear not to have to operate to the same level of governence.

    there should be no clear competition as such otherwise we will return quickly ot the days of poor mental helath servcies and this will fly in the face of the governments mental helath servcies proposals.

  234. Pete Shulver says:

    The NHS cares for people who in most cases are not well. You cannot treat them in the same way you would treat products on a production line. the NHS is not perfect but it still has it’s heart in caring for people.All competion will do is harden the attitude towards already down trodden people.

  235. Pam says:

    This government seems to have its heart on destroying our NHS. We are the envy of the world with our health system.
    The Americans health system is in a deep hole and trying to claw its way to a better system for all its citizens, but our coalition government just can’t wait to jump in and join an American like-wise system, the haves and the have nots!
    Ask the older citizen’s in our society what health care was like before the NHS and how wonderful it was when it was born.
    This government is digraceful!

  236. Dr Kathryn Manning says:

    The amount of patient choice that was present in the NHS is sufficient: patient’s having a choice of GPs within a geographical location; having a choice of which A and E to attend for non-critical conditions; having a choice, informed by their GPs, of which local hospital and which consultant at that hospital to be referred to; having a choice, guided by their hospital consultant of which tertiary referral specialist to be referred to. Beyond allowing that, the government’s role in patient choice is to ensure everyone has timely access to reasonably located health services irrespective of postcode, which has more to do with improving quality and networks than improving ‘choice’ and competition.

    • Rod Whiteley says:

      True, there is quite a lot of patient choice already in the NHS. But that isn’t the question. The question is how to use that patient choice to drive improvement.

      One way would be to ensure that patients’ choices are better communicated. For example, if a patient chooses between hospitals, those hospitals, and commissioners too, need to know why the choice was made so that they can improve services. There have been cases of substandard services shunned for years by local people in the know, without anything being done about them until a story appears in the national media. Fixing that is the challenge.

  237. Scott Durairaj says:

    Choice and competition is good for the NHS with limitations. Poor NHS practice has been allowed to thrive with little governance or scrutiny such as Mid Staffs, however allowing private companies a wide range of oppertunities (local pay negotiations facilitate this) by making the ‘buisness more attractive’.

    The choice should be between good NHS Trusts and NHS Trusts who have partnered with Third sector orgs Not Private companies that have one eye on the patient and one eye on profit.

    The key to a good NHS is better governance and scrutiny rather that focusses on outcomes for all patients (including those facing persistant and worsening health inequalities).

    Once Private companies compete (being subsidised by other parts of the buisness) the NHS will diminish once reduced in capability what stops these private companies increasing cost as the NHS wont be in a position to compete.

  238. Carol Laidlaw says:

    Talking about “patient choice” is an utter nonsense. When I’m unwell, I haven’t got the mental focus to ‘choose’ medical treatment as though I was shopping for a new frock. All I want to know is that I can trust my GP’s recommendation for treatment and that I’ll get it at my nearest hospital. This is convenient for me to get to, and also for my friends and relatives to visit. And, it should all be provided from public funds. This will always be cheaper than using private providers.

  239. Sam Allen says:

    I don’t want choice I want a functional NHS. I’m not saying that the NHS is perfect at the moment but changing it on the misplaced ideological belief that the market knows best is not going to help anyone except the corporate fat cats who will undoubtedly profit from cherry picking the most profitable parts of the NHS, regardless of any measures put in place. History has shown many times that corporations move far quicker than governments, and that these measures are quickly circumvented if there is money to be made.

    I don’t like seeing the Conservatives using a GLOBAL economic downturn as an excuse to strip the most important and envied part of the welfare state.

  240. Steven young Min says:

    The NHS has for many years been organised around acheiving shorter surgical waiting lists and acheiving waiting time targets for treatment. The people however that use the NHS the most are those that have chronic disease and it is time that the NHS organised services accordingly. The current primary versus secondary care divide is artificial and distorts care with unhelpful and disruptive competition. Commissioning decisions should – as much as possible – be removed from those who might have a vested interest in favouring one part of the NHS from another. Those that make commissioning decisions should aim to minimise overall costs whilst providing optimal care and value for money to the patient. In many cases providing the best treatment even if slightly more expensive may be cheapest option in terms of overall health and social costs.

    Expensive operations and hospital admissions are likley to be more often required when there has been a failure of chronic disease management. Focussing on the optimal management of chronic conditions by designing pathways of care, championed by specialists in partnership with GPs has to be the best way forward.

  241. David Robinson says:

    If you really want to listen, then listen; NOBODY voted for this reform as it wasn’t in any of the parties manifesto’s. 42 GP’s and private medical companies aside, NOBODY wants this; not the doctors, not the management, not the surgeons, not the nurses, not the patients, not the the public, not Labour, not the Lib Dem conference, not even doctors on the Tory backbenches. I’m not sure which part of NOBODY you fail to understand but you say you want to listen, well this is what the people are saying

    • Sam Allen says:

      Couldn’t agree more but this isn’t a listening exercise it’s a cooling off period. The government are simply hoping those of us who object (i.e. the vast majority) get bored or distracted by other things so that they can implement these massive and damaging changes under the radar.

  242. Nicola says:

    Why don’t we expand the use of the NHS so that it is not centralised through GPs?
    If for example the patient knows they need to go to a physiotherapist, why can’t they go to a physiotherapist on the NHS without having to go through their GP.
    Sometimes the GP is not the best person to do the diagnosis considering they are jacks of all trades and experts of none. For example, I personally have been to A&E got 1 diagnosis after a period of time that they said to then go to GP, i went to a sports injury clinic & they diagnosed it differently & suggested I needed an MRI, after seeing 3 GPs (both in Scotland & England) only after the 3rd GP have I been put forward for an orthopedic review, which there is an apparent waiting list of 8 weeks.
    Had I been able to go to the private sports injury clinic and had they had the power to put me forward for an MRI, this would have been over months ago instead of a year after the injury not actually knowing what is actually wrong.

  243. Sue says:

    People want good, reliable services, as local as possible (allowing for specialisation). We want collaberation between care services and information to help us make decisions. For that to happen, we need clarity and accountability from those providing services. It is not clear how that will happen with the government’s proposals for change in the NHS. Where is the detail? We do not want another rail privatisation fiasco where tax-payers have now ended up paying far more so that private companies can choose how many trains they’ll run!

  244. David says:

    My MP says that choice is a priority and an overwhelming concern amongst many patients. I disagree. The majority or ordinary people want their GP to decide where best to treat a problem. The last thing we want is an internal market in the NHS. Or are you using the rail industry as a model?
    Don’t believe the management consultants. They are the people who audited the banks!

  245. An NHS professional says:

    Who wants fragmentation of the NHS, prevention of staff working collaboratively in multi-disciplinary teams and hampering of the delivery of integrated seamless pathways that deliver best outcome for patients?? Who wants a competitive environment in the NHS to make it harder to share good practice? Who wants private companies to cherry pick more profitable NHS services? Who wants the result of a competitive environment in the NHS to lead to a race to the bottom in employment terms and conditions, pay and pensions in order to cut costs? Certainly not me and I am not alone. It is all about money, money, money,cutting costs – not a thought for PATIENT CARE. “Listening Exercise ” this might be, but is anyone at the DOH actually going listen, PAY ATTENTION and act upon the huge responses from all the different health care professionals and their professional bodies???

  246. Terry Squire says:

    When I need medical assistance I want to be able to contact a health professional who is local to me, whether it be my GP or somebody at the hospital. I want this person to be able to recommend the best course of treatment that is going to resolve my ailment in the quickest possible time regardless of the cost. I do not want a cheaper alternative that is going to be less effective.
    How we achieve this I do not know, I would guess that the people at the sharp end (the GP’s and the Dr’s and nurses in hospitals) would be the best people to guide us on this. However this should be a national service free at the point of delivery, so that it is available to all regardless of their own financial circumstances. If we want a more efficient and quality service perhaps we should look at models in the not for profit and charity sectors who in the main deliver an excellent service on a shoestring as opposed to big businesses who provide a much lower standard of service to their customers and are more concerned with keeping their shareholders happy.

  247. Lynne says:

    I would be interested to learn how competitions rules apply in a service that has gatekeepers (GPs) and where gatekeepers are also providers.

  248. Bob Hudson says:

    Choice and competition are simply means to an end, not ends in themselves. Presumably the ‘end’ (as the SoS keeps telling us) is better patient outcomes. Neither choice nor competition are necessarily needed for better patient outcomes, so the focus upon them is misplaced.

    There may well be a role for competition in agreed and appropriate circumstances, but to spend tens of millions setting up Monitor to promote competition is ridiculous. And even where competition might deliver some cost-savings in specific areas it may have harmful effects on other related services especially in hospital settings.

    The main challenge facing the NHS is older people with long-term conditions – many of them complex. What is needed to address this is not competition but integration; not choice but confidence that someone is taking responsibility for designing and delivering a care pathway within which there will be choices. Maybe we do need a new Monitor – not to promote competition but to promote integration. What DH needs to do is ensure financial incentives promote an integrated health and wellbeing journey rather than fragmented episodes of care.

  249. JL says:

    Our NHS is a public service, not a market economy. Market forces have no place here so leave the private sector out of it!! We do NOT want to end up with a two-tier system as in the USA, with superior healthcare for those who can afford it.
    As for devolving healthcare completely to local GPs — it’s easy to see how standards would then depend on where one lives. An affluent area would enjoy great health facilities, while a more run-down place …
    Surely the aim of the NHS is equal treatment for all, irrespective of where a person lives, not a postcode lottery? We should be able to access the same standard of healthcare at the surgery/hospital/clinic nearest to us.

  250. Martin Hughes says:

    At a time when the U.S. is trying to move to wider health coverage, we want to smash ours into a thousand compeating shards. The GP’s will be both providers and commisioners of healthcare, surly a conflict of interest.
    How much does it cost to train a GP? We then want to turn these people into pen pushers, stuck planning and resource meeting all day. Eventually this role will be outsourced, then GP groups will join up to save administration costs and within 5 years and many billions of pounds we will have reinvented the primary care trusts, without the oversite we have now.

  251. KM says:

    I am horrified at the prospect that the private sector are ready to swoop on yet another public sector area. If the NHS is inefficient then get to work fixing it not selling it off so that the wealthy can again profit. As we have seen with most privatised industries and PFI schemes we the public get less service at inflated costs – far more than the cost of inefficieny. We are then help to ransom with little, no competition or choices that are a complete stitch up. You only need to look at our public transport, schools and utility companies to see this. Savings are also often made by employing staff on lower wages and worse terms and conditions, who benefits from this? certainly not society.
    Start to fix our health service and not dismantle it at the expense of all and the profit of few – you have no mandate to do this.

  252. Steve Harrison says:

    Patients want high quality local services not choice and competition. Perverse incentives and the conflicting budget priorities of GPs, commisioners and hospitals caused by the current financial flows do not help. These propsals will make this situation far worse. Introducing more private providers who cherry pick off profitable services whilst leaving the difficult and complex cases to what is left of the NHS is a sick joke that only an ‘i’m all right jack’ tory would believe is a good idea.
    In my experience the only winners in all of this will be the private firms, the consultants working in those practices and the wealthy.
    Empower local front line staff to improve thier own system, focus on quality, invest where change is needed (e.g. rapid support and social care for old people to keep them out of hospital) and we could have an NHS that is higher quality, patient centred and much much cheaper.

  253. JP says:

    I agree with Dr. Sims description of the NHS as a monolithic nationalised industry, the dream has died – new ideas are urgently needed.
    Considering the amount of Taxpayers money poured into the Health Service, and the army of specialist people it employs, one would expect that the health of the Nation would be excellent, or, at the very least, improving – sadly, this is far from the truth. The Health Service needs to rethink its blind faith in the greedy self interested pharmaceutical Industry, and give training to doctors in Natural Ways of Healing.

  254. dominic williams says:

    I think that competition is driven by cost, not quality. Cost is an easy measure, measuring quality is much more subjective. High quality healthcare should be available to everyone. This is not a commercial commodity Mr Lansley, this is peoples lives. Invest the money put aside for these changes into frontline services. Concentrate on reducing waste, and endless middle manages. Efficiency will result in better services, but competition will put services on the scrapheap. I joined the nhs 20 years ago as a nurse, to make people better. Now the nhs has lost its main aim, and this government will be remembered for getting it very, very wrong.

  255. Shirley Cole says:

    The bigger question and answer should not so much be choice and competition. How can you have improved choice with less cost? The system does not work… Patient choice is only at the point of regional service – what someone can choose (or is available) in one part of the country is totally different to choice for treatment and care in even a neighbouring town….. This is fundamentally wrong and is the greater issue that needs to be addressed. It was supposed to be addressed years ago but has got worse instead of better. We still have a system of huge postcode lottery despite people paying an equal percentage in relation to income via NI contributions. We don’t work in a REGIONAL Health Service. Lets actually make it a NATIONAL health service where treatment and choice for both patients and staff is equal throughout our Nation.

  256. Richard A says:

    The large majority of patients just want the guarantee of high quality care and an ideological obsession with choice is likely to lead to wasteful duplication of resources and increased costs.

    There is scant evidence that large-scale private involvement in true public services actually leads to reduced costs, particularly when the service requirements put strong constraints on the amount of competition that is really possible. For example, we have probably the most expensive railways in Europe, but they are little better than under British Rail and provide the worst service of any of the more affluent countries. Air travel performs much better on price but shows little inclination to provide a proper public service. In fact, one does not need to look beyond health care; the USA has notoriously expensive health services but recent evidence shows that the health of Americans is generally worse than that of UK citizens.

    Cherry-picking by private providers would be detrimental to the core NHS services where private providers will have no interest – specifically accident and emergency and most other areas where there is a real danger of patients dying. You have only to look at the state of the Royal Mail to see the future of the NHS core under the proposals. Yes, there are good commercial courier services but they have taken much of the more lucrative business from the Royal Mail with obvious consequences for the universal postal service and the Royal Mail itself.

    Opening the service to ‘any willing provider’ will be disastrous because it will result in competition law requiring tendering across the EU with increased bureaucracy, wholesale fragmentation of the service into many private providers, and an inevitable loss of control of the service by local management.

    Some services could be provided by private companies, as they are now, but only when local NHS management deems that to be appropriate on grounds of service quality. Simply give local NHS management the same sort of discretion as universities have and voluntarily exercise for example. There certainly should not be a general move to open up all services to ‘any willing provider’.

  257. Jessf says:

    I don’t believe that creating a purchaser provider split has helped health care. I don’t see how competition will drive up quality, in fact I believe there is more risk of driving down quality. It will merely increase the variance we have been trying so hard to eliminate.

  258. I am a little concerned about the focus of the debate from the Department of Health. It seems that there is a consensus that choice and competition are good. Unfortunately the evidence suggests that the benefits of choice and competition may be somewhat overblown.

    We currently use 14% of the NHS budget to support a choice agenda and the White Paper heralds an increase in choice. Over the next 5 years whilst the NHS struggles to cope with a £20Bn gap as a result of a freeze on funding we will be blowing £70Bn plus on choice.

    If I exercise choice it means that some less articulate (even than me) person will be left with a less good option. This cuts against the equality suggested in the title of the white paper.

    Most people want to have choice in their healthcare but only a tiny proportion exercises it. The effect of competition and choice on healthcare performance has been disappointing. We could really do with different penalties for the worst performers both in primary and secondary care and be prepared to close down those that are not able to reform.

    If I were unwell I would want to be managed by a local integrated system that focussed on keeping me well with evidence based care. Perhaps I should move to Torbay from my dotage so that I can experience a Kaiser Permanente system that works hard to keep me well and out-of-hospital.

    Suppose I don’t like the way the police operate in my neighbourhood – I’m not going to dial RentaCop – I want the local constabulary to respond to national and local democratic views and deliver accordingly. The same should be true of the NHS.

  259. Alistair Brown says:

    INVOLVING ALL CLINICIANS AND PATIENTS IN RATIONING

    Could there not be price & quality competition between NHS Trusts, e.g. we could commission a neurology team who were prepared to give strong reassurance rather than order a CT. Such tests could always be performed on a private basis. GPs are currently more comfortable in operating like this but I would suggest their needs to be a culture change. One quality measure would be the speed at which clinic letters were dictated. What we must avoid is taxpayers money being lost to shareholders and in red tape and contracts.

    I think we need to collaborate more in efforts to reduce costs and waiting lists for those who do urgently need specialist assessment. In Cambridge we are trialing email advice from Consultants or setting aside timed slots for Primary & Secondary care clinicians to speak on the phone. Then I think we can truly share care and responsibility. Surely some of the time currently spent seeing follow-up patients might be more profitably spent speaking directly to a GP who knows their patient inside-out?

    I wish Consultants would try to manage conditions slightly outside their area of expertise by having a chat in the coffee lounge rather than inconvience their patient’s by making an expensive cross-referral.

    Where there is dissent about the benefit of a certain treatment then I would propose this is brought to an exceptional case grant panel.
    I think a larger role could be played by patient representatives on these panels, and I wonder if county counsellors would be well practiced in this role. If we truly work with those we serve in deciding priorities / QALYs then GPs are less likely to be blamed if it all goes wrong. Most guidance should come from a national level and NICE have a role to play in this.

    If we are to maintain a free NHS then we have to have these difficult conversations with our patients. In my practice we bring all such decisions to an in-house panel and think we manage to maintain our relationship with our patients. I tell my patients that in the situation that they need urgent treatment, then I will go the extra step to ensure they are seen soon.

  260. Jeremy Hall says:

    Many NHS hospitals are saddled with PFI agreements that commit them to high fixed costs for many years to come. I would like to know what will happen to PFI contracts and costs in the scenario where a private provider of health care services is successful in winning contracts for patient care that leave an NHS hospital with depleted revenues. What is to prevent the extreme scenario of the tax payer ending up paying for health care services twice over, once for PFI payments on an empty hospital and secondly to the private health care provider?

  261. Deborah Colvin says:

    The role of choice and competition for improving quality: The NHS is a health service, not a commodity. It cannot give everyone real choice for two reasons. One is because very often patients are not in a position to make a truly informed choice. It takes a huge amount of time to give someone enough information to make truly informed choice. The NHS can function because there is trust from patients and integrity from doctors. This means not everyone has to go to medical school in order to make the right choice. Secondly there is limited money in the health service and sometimes that means people can’t have what they want because that might mean someone who is more ill going without. All the evidence collected from social researchers about this subject repeated finds out that patients want a single effective good quality service far more than they want choice.

    Competition: Competition when using financial rewards does not improve quality. Again this has been shown by researchers repeatedly. Quality is improved by integrated working, trust and openness. When general practices within one borough are showing how their colleagues are performing, this will drive them on to improve the quality of their own service and to try and find out how they could do it better. If money is the driver, people become secretive and they often lose their integrity. Money is a very powerful motivator and may override doing the right thing.

    How to ensure public accountability and patient involvement in the new system:
    Openness will ensure public accountability. Consortia should have to publish why they are driving a particular path forward and to justify it in terms of patient care. Patient involvement is difficult. Patients are not a homogenous group – they are all of us. We all have different motivations to be involved in health; these may be personal motivations and can result in destructive or constructive involvement. Some patients (people) are reasonable; some patients (people) are not. Clinicians must not have to jump to the whims of individuals or groups with a particular axe to grind or with a particular interest to put forward. I do think that service users can gain a particular insight in to the workings of the NHS that is very valuable though. So I think that people wishing to represent patient interests should be interviewed and selected for their ability to be objective and constructive.

    How new arrangements for education and training can support the modernisation process :
    Education and training seem to be very neglected in this white paper. I can only see the picking apart of the service having a negative effect on education. Education is not cheap. At present many of us support education even though it is a ‘lost leader’ because we think it is important. That is less likely to happen if profit becomes the sole motive for involvement in the NHS and if there are hundreds of local consortia across the country. Furthermore the NHS as an academic organisation leading in research will suffer because it will be far more difficult to collect research data.

    How advice from across a range of healthcare professions can improve patient care :
    Clearly this can be helpful. Again though there has to be reasoned careful thought about the value of services, evidence that they are effective or not and objectivity. If all services are struggling to make an income then clearly they will all insist that their way is right. This is why there has to be collective responsibility and why the ‘any willing provider’ model is so destructive.

  262. Deborah Colvin says:

    Which are the types of services where choice of provider is most likely to improve quality?

    Continuing from my previous comment, I think this question is a red herring. Rather than obsessing about choice improving quality, why don’t we find out what does improve quality and work on that? Choice is not the answer. Quality will improve if the service is properly funded in the first place (we know that driving down costs eventually destabilises services). It will improve if the people who provide the care are given the responsibility to improve quality (working with management support but not being told by managers how to do it). Harnessing the effects of the providers pride in the service will drive up quality (harnessing the human desire to be the best). Ensuring that users also have pride in the service, care about it and use it responsibly would help. Quality will also be increased by collaborative working. We know that people working collaboratively together are better than people fighting. So why not do it?

    The other real difficult with choice in an organisation that has to deal with surges and lulls in demand is that if you try to staff the service to deal with the public efficiently all of the time you have to overstaff. Sometimes we have to accept that in order to prevent a lot of money being wasted with staff not being fully employed all their working hours, there will be times when people have to wait for a service. If you have multiple services trying to offer a responsive service and they have to compete on response times as well as cost, either it becomes very expensive or costs and quality deteriorate.

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

    Well again, why do you want to do this? The more providers there are, the more money is dissipated in to running costs and transaction costs. In other words, choice is expensive. The government keeps telling us costs have got to be kept down and the NHS needs to be cost efficient. Multiple providers is hardly the way to do it. Governance arrangements become more expensive because there are more providers to visit and assess. Financial arrangements are more expensive, transaction costs increase. It is absurd. The NHS is one of the cheapest most effective health care systems in the world still (contrary to what the government wants to tell us). All the evidence is there. The NHS can do this because there are NOT multiple providers involved.

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

    Patient choice is not a reality and never can be. This is a chimera. So you could choose to go to one of two companies providing chiropody for example. They should be as good as each other and offer the same services, no problem if they want to do it differently but since surely the NHS would want to ensure they are of equal quality why would it want to pay to run two services where it could run one? I think that there should be a chiropody service in every borough and the improvement in quality should come from comparisons between them and as i have said, professional pride then driving up quality in each borough (and clearly having governance arrangements where that is not happening). That way quality improves without more money leaching from clinical care to other things.

  263. Robert Tyrrell says:

    It is possible that there may be in the foregoing jumble of suggestions, criticisms and prejudices some useful ideas to improve the NHS, but even if there are it is unlikely that anyone will read through them all to find them. Muddled thinking will prevail as usual, but let me make a few simple points, and hope that someone will consider them:

    Quality can be defined as goods or services which are fit for their purpose, free of defects, reliable, value for money. Do not confuse quality with grade, luxury or expense. A match that strikes and burns evenly then is thrown away has quality; a gold-plated lighter that fails to function does not. Japanese cars, cameras, tvs etc. have quality built in at competitive prices, so they dominated world markets.

    So. specify the needs and desires of the end user. Do it precisely, then take the cheapest price, holding the supplier to his promises.

    The same principles apply to services in the NHS. Any doctor or surgeon knows you must first diagnose the patient’s complaint, then plan the remedies. The most economical are obviously the best – so long as they do the job effectively and reliably.

    < There is no conflict between quality and cost. Defective goods and bad service are always more expensive. But your quality must be
    defined.

    Results must be recorded and analysed, so faults and failures can traced back to source – then eliminated. Prevention is better than cure.

    There are proven systems for achieving this, widely used in both manufacturing and service industries: the international standard ISO9000 series. Quallity, properly defined and measurable, is the basis. The techniques rely on precise specifications, accurate records, statistical analysis and preventive remedies.

    Plan, do, check, amend… Calculate the cost of faults and failures, then eliminate them so that in future that money is available for better purrposes; make everyone responsbile for the quality of his or her own work, give them the support and training that they need.

    This kind of quality control is not created by inspection and supervision; it must be led from the top by example and exercised at the lowest level feasible. All employees should understand that quality is their first duty. The job of management is to create the conditions in which employees can give of their best.

    Quality is not expensive; cheapness alone is. ISO9000 – it’s all there.

    Will anyone take any notice in the great ramshackle sacred cow of the NHS? Probably not. The fundamental ideas are simple, but applying them in practice means thinking, working, leadership and persistence.

    Thus spake the Prophet

    Managers are, in a sense, the servants of their staff.

  264. Steve jones says:

    No “competition” in Nhs please. Save nhs from competition. Please.

  265. James Knight says:

    It seems counter-intuitive to be striving for a system in which “patient choice [is] a reality”. This suggests that we are pushing towards a state of fundamental inequality of provision. I realize that not all providers can be equally resourced, but, rather than accentuating differences through the potentially damaging forces of competition, we should be increasing the efficient sharing of resources and of best practice.

    If I am afflicted with a serious health condition, I do not want to be faced with a choice between rival providers, but rather to be directed towards the most effective care through a co-operative and clearly communicating organization.

    By instilling the principles of competition in an organization like the NHS, you encourage an environment in which individual performance is valued over communicative and co-operative mutual benefit. It is fundamentally against the inclusive spirit which makes the NHS our greatest national asset.

  266. ELW says:

    “Patient Choice” is not the right terminology to describe what a majority of people want from their hospitals.

    I want to be able to trust the local healthcare provider to have my best interests at heart.

    I want to be able to trust that my local healthcare provider will give me sound advice and to keep me well-informed.

    I want my trust to be well-placed. But I also want to be able to trust that if my faith is broken that whoever is responsible for breaking that trust will be held to account so that lessons can be learnt and mistakes avoided in the future.

    We should be voting for “Patient Trust” not “Patient Choice”

  267. Rachel Atkinson Speech and Language Therapist says:

    Patients want information and choice over specific care management decisions e.g. drug therapies suggested by their GP not who provides that care. Increasing “choice” by farming out services to the private sector who will make a profit out of them is a false economy. the market system has already cost the tax payer millions in contracts, billing, legal fees administration and transaction costs and is only set to cost more. If I was asked to choose I would choose a single local high quality health care provider which is not trying to make a profit, who’s sole duty it to me as a patient and not shareholders and which is free at the point of access. That’s the NHS as it should be and I choose to support it. The health and social care bill is destroying it.

  268. David Veale says:

    The first step on the choice agenda is for the NHS to stop discriminating against mental health services. The NHS constitution gives a right to choose the organization that provides their treatment when they are referred for their first outpatient appointment with a consultant-led team. The Department of Health now appears to discriminate against people who are disabled by their mental disorder, and needing elective care, as “mental health services” are specifically excluded from the legal right for choice of referral. It is true that many referrals for mental health services are emergency, but a significant number are not. This includes patients who perhaps fail therapy within Increasing Access to Psychological Therapies (IAPT) service or secondary care and should be according to various NICE guidelines be stepped up to a specialist service. This is often not done and patients are denied access to effective services within the NHS. An example of this is in OCD or BDD, a condition which, because of the sufferer’s obsessional doubts, fears, and compulsions, can over many years lead to severe disability such as the inability to work or study, becoming housebound or being dependent on carers. I have had communications with many people with OCD or BDD (or their families) who are severely disabled, and who want to be referred to our service at the South London and Maudsley Trust because of our reputation and results. Our patients often seek to travel to our unit when local care has failed. They may be seeking an assessment for out-patient treatment or for admission to a residential unit. However because they may not be able to obtain a referral, it means individuals with mental health disorder are unable to obtain elective care at a hospital of their choice. Choice is important to some people as they have not made progress locally and more specialist input or intensive therapy is required.

  269. Paul Schofield says:

    I worked in the private sector for 40 years. The aim of every company is to maximise its profit. Corners are severely cut, ridiculous risks are taken, morality is forgotten, all to maximise the bottom line.

    The aim of trying to privatise the NHS is to make money out of it.

  270. James Robinson says:

    My MP, Sarah Newton, has failed to reply to my questions e-mailed to her on 25th April, which are repeated below:-

    Dear Mrs Newton,

    Thank you for your letter in reply to my e-mail routed through 38 degrees. I am not reassured.

    Firstly – you say “supporting NHS is my top priority …” – but Lansley says that too and his proposals would wreck it, in my view. So more attention to detail is needed, especially in relation to the two major concerns which I set out in my earlier e-mail.

    Firstly – the way in which competition is organised and encouraged. This needs to be in a way which does not endanger or slough off major parts of the NHS to private companies which in later years will be able to raise prices in a way which causes big problems and raises dangers of a two tier health service. (In passing, note how some of these practices have played out in USA with costs of health care per head double what they are here – with a worse health outcome – due substantially to private providers and insurance companies taking a cut).

    Secondly – the speed of change. The NHS is subjected to major change, imposed from the top, year after year and it diverts enormous energy from patient care. The complexity of managing the health service – human resources, technology, best practice, budget, and many more, means that hurrying the process will inevitably bring a worse long term result than one that has been carefully worked through. This requires systematic, (not token or politically driven), steering from grass roots – patients, clinicians of all disciplines, and health managers, and independently evaluated by a competent body such as the Kings Fund.

    Lansley’s statement to The House of Commons, (which you kindly enclosed), also is at a level of generality that glosses over the two points above which I am most concerned about. Turning to one piece of detail, he says “The coalition government is increasing NHS funding by £11.5 billion”. This is £11,500 million and pro rata should give Cornwall £115 million. Your quoted figure for Cornwall (£7.5 million) appears to show that this county is being very substantially short changed, again.

    I do support the joining up of adult social care with health services, and a shift from secondary to primary care – but to have an impact, far more money will be needed. To illustrate from my own recent experience: during extended hospital stays at RCHT it was apparent that many patients, who had genuine and sever health problems needing in patient treatment, also had social care needs especially by virtue of dementia. The level of staffing in nurses and auxiliary nurses was so low that I was constantly having to intervene by day or night as one or other confused patient started to remove their cloths, go to the toilet in an inappropriate place or to walk away from the bed while attached by pipes or wires to his bed. My intervention might be by ringing a bell, suggesting to my neighbour that a wait for the nurse might be a better idea or sometimes, going to hunt for a nurse. The point is that my life as a patient (with severe illness) was not improved by interrupted days and especially nights because the staff were fully committed elsewhere. So £7.8m on joining up services is deeply unimpressive in the face of substantial demographic change and existing unmet needs. When I spent 3 weeks in a (first class, NHS) tertiary centre, it was very clear that the poor levels of care at Treliske were by no means unique – in fact what I describe above is typical for secondary care.

    It is for these reasons that I hope you will support the NHS by seeking for the bill to be withdrawn altogether and rethought – from the bottom up. I am quite sure that the changes that result will be a great deal better than those which come from a Lansley down process.

    Yours sincerely,

    James Robinson

  271. Helen says:

    Having read through most of this thread it seems obvious that somewhat of a consensus is forming. I hope the powers that be are taking note. Fundamentally what we want is an NHS that provides the most appropriate, high quality services, as quickly as possible, locally, and free at the point of use. We aren’t interested in choice for the sake of it, just quality healthcare when we need it.

    The comments from healthcare practitioners seem to be in agreement that co-operation and sharing of knowledge and best practice are what raises standards and that competition between providers isn’t conducive to this. There also seems to be consensus that, particularly financially driven, competition isn’t appropriate in a healthcare setting where any kind sub-standard care is completely unacceptable and possibly dangerous. It would seem to me that there is already sufficient ‘competition’ to drive up professional standards in the sense of the prestige earned by for example being a pioneer of an effective new treatment or other such service motivated outcome.

    Communication between the practitioners and services required by a patient needs to be clear and efficient to avoid delays and important information being missed, and this is more effectively done when those services aren’t provided by different organisations with varying priorities. (It seems to be difficult enough already sometimes for the necessary communication to take place between departments in the same hospital let alone different organisations altogether…!)

    Regarding the issue of ‘choice’ I did though want to point out that there is one sense in which I don’t think anyone would want to relinquish the ability to choose. And that is were specialist services are concerned. To be an an expert in something requires experience and experience for medical practitioners working in a particular field means seeing patients with that particular problem. For less common conditions it may not be practical to expect there to be a specialist practitioner working in every local hospital as these individuals wouldn’t see enough cases to gain enough experience. So to have access to the highest quality care may mean choosing to be seen at a specialist centre, which may not be local. This of course already happens and if having some choice makes it easier for patients to see specialists when they need to all the better.

    I think what is really being said is that patients aren’t so concerned about being offered a personal choice between several general hospitals or A&E departments at the point at which they are acutely ill or seeking treatment for a relatively common condition, there should be a standard of care/service maintained accross the board. However, they expect to be able to rely on quality advice from their lcoal primary care practitioner to help them decide on a course of action and access the most appropriate care for their particular circumstance, and if that means seeing someone not based at their nearest hospital then that shouldn’t be a problem.

    Finally, a couple of people have alluded to those with chronic conditions. There are a couple of issues here.
    1. Sometimes individuals suffering chronic conditions may actually know as much or more about what’s best for them than a primary care practitioner and in this case their voice needs to be heard. The comment above about physiotherapy is a case in point where if you know you have e.g. sustained a muskuloskeletal injury (experienced tennis player say) or an old condition flares up that you know benefits from a particular treatment, would it not save time, appointments and paperwork to self-refer direct to the appropriate practitioner?
    2. The NHS is excellent at dealing with acute problems but does shy away from much follow up or preventative care, which while perhaps perceived as being an unjustifiable cost (the patient is not completely incapacitated) may actually help prevent future expense. E.g. someone complaining of back pain (how many hours of lost work due to that??) may feel better in the short term after taking painkillers (cheap) but actually might prevent future or worsening problems if they can see a muskuloskeletal specialist (expensive) quickly to investigate the cause and address that.

  272. Douglas Russell says:

    Choice is generally regarded as being about choice of hospital.
    I suggest that the first level of choice is about choice of GP practice, and within that, which individual GP I want to see. As the profession becomes more part-time, more multiple role (including now commissioning) excercising that choice (for continuity of care) is becoming more difficult. The recent Kings Fund report on imrpoving quality in general practice re-emphasised the importance of continuity of care as bein equal to that of access, and even more so for those millions of people with one or more long term conditions. (it is rare to have just one long term condiition)
    As to choosing a GP, there is insufficient innfromation available. Currently all GP data relates to a practice, not the individual even though in parts of London the GP population are nbow >50% not partners. Most of taht data says nothing about the core skills of a GP – consulting, diagnosing, communicating, empathy, compassion, diligence, teamworking. Indeed the instruments that were available that started to address some of those (GPAQ and IPQ) have now been discontinued in favour of the far less detailed (in terms of individual GPs) patient surevy.
    There is a prospect in future of not only being able to choose a GP practice, but also of choosing which commissioning consortium to belong to, with a further risk of erosion of equity. The commissioning board will have the power to “disband” a consortium and effectively with that theconstituent GP practices. How exactly will the patients of thoise practices be in volved in that decision?
    Registering with a GP practice remains a challenge in parfts of the country. Few rely on NHS Choices, with most people going by word of mouth recommendation.
    The idea of being able to register wherever you live with any practice is totally mad, driven by the perspective of MPs living in two places most of whom access private healthcare anyway. The old contract mechanisms of temporary residents, immediately necessary treatment and emergency treatment atill valid, still available and even more effective with the advent of on-line patient acces to their won records. All that is needed is to make patients more aware of this and to access them more, and also challenge those practices that have not yet implkemented it.
    Choice of hospital provision is only appropriate in my view for elective procedures. How realistic isit to suggest “hmmm I wonder which air ambulance helicopter to call, lets check out Trauma Advisor….”?
    More publicly available timely and accurate data are needed – not simple league tables please but something that shows confidence intervals or addresses the issue of comparing apples with pears.
    Long term conditions (whichy is where the really big money lies in terms of potential savings / gains) requires integrated multidisciplinary teams serving a long term population of educated and supported patients. My preferred model would be not “Any Willing Provider” with the fragmentation and duplication that would inevitable ensue; rather, “Contested Collaboration” – integration of locally based teams, but tested out for safety, value for money and effectivenes and patient experience.
    The whole excercise is looking at the NHS through the qwrong end of the telscope. We need integration not fragmentation, continuity not a discontinuous provider landscape, collaboration not competition, professionalism not profit (as the sole driver).

  273. michelle says:

    I work in the NHS and have seen a major shift away from partnership working because of the competition element. Local community services and hospital services are in competition with each other. Collaborative working has all but disappeared. GPs are also ‘clubbing’ together to provide certain services with the support of big drug companies and competing with local already established services. GPs are independent business men and not directly employed by the NHS. The end result is fragmentation.
    I think that our NHS can be more efficient and effective but introducing this level of market forces is destructive.

  274. Dr Mark Cowling says:

    The introduction of competition is superficially attractive in order to drive improvement in services. If done properly i.e. opeing up all services to competition this might work. However, the considerable down side to this is the loss of co-operation between organisations and the lack of strategic planning. In addition, the damage to education and training in healthcare is likely to be considerable, with employers choosing to poach staff from other organisations rather than invest in training themselves.
    Throughout my career I have found politicians to be wary of full competition and as a result we have endured various “fudges”, such as the internal market, which leave NHS providers with the more difficult, time consuming and generally loss making work, whilst independent providers are able to “cherry pick” the more lucrative work.
    Although I am naturally inclined towards competitionand personally would welcome the opporutnities that it would provide, I would also acknowledge its downside. If the people of our nation wish to have comprehensive, joined up and well thought out healthcare I would have to accept that this is probably best achieved with an overarching organisation such as the NHS. To make services better, however, their organisation should be devloved to local bodies with public and patient involvement, and those bodies should be invested with real power. PCTs could be evolved to do this, and in my view are better placed than GPs to take an overall strategic view. The DoH should be reduced in influence probably doing no more than providing a national service specification of the minimum level of services that the publich can expect. There is also no reason at all why such local bodies could not make use of independent providers if they wish to do so.

  275. Leanne says:

    If choice and competition worked then hospitals like Mid-Staffs would have no patients. But they do. For many choice isn’t option – many admissions are as emergencies, plenty of peope can’t or don’t want to travel (and frankly why should they?) and most people don;t have the knowledge to make an informed choice. Most of us just want a decent local hospital and accept we might have to travel around our region for specialist care.

    Private healthcare companies exist to make a profit. They exist for no other reason – why would they want to provide care that makes them no money? Many services in the NHS (some specialist cancer care for example) operate at a loss – the NHS needs the routine work to pay for this.

    It’s already been said that private companies will make a killing (in more ways than one) if these reforms go ahead. Patient satisfaction with the NHS is higher than ever – why are we risking our best ever achievement to put more money into the grubby hands of the super-rich?

    Who is going to look after the patients that won’t make a profit?

    Stop these reforms now, before it’s too late and we realise how good we had it. Save our NHS.

  276. Nicola says:

    I think the questions asked in this listening exercise are completely bogus. They start from the assumption that choice and competition are definitely a good thing. I am far from convinced of this. I genuinely think what most people want is a good local GP, a good local hospital and the ability to be referred to world class specialist services if they need them. The NHS is not perfect but the ‘evidence’ the government uses to convince us wholesale reform is based on incorrect interpretations of the literature. The claim that 5000 deaths from cancer could be prevented if we had outcomes as good as Europe for example – the research this is based on actually says 7000 deaths could have been prevented if we’d had European mean cancer survival rates in the 80s and 90s it does not apply to 2011. Cancer survival has improved year on year in the UK since 1995. One of the areas that really does need improvement is care of the elderly. What is needed for this is societal change in attitudes to older people and an improvement in the status and work conditions in this area so experienced dedicated staff want to work in it.

  277. Dominic Houghton says:

    Is there anyone who would honestly choose a health care provider that prioritises profits over one that prioritises the best outcome for the greatest number of patients? I don’t think so.
    Private health care can provide a better service than the NHS for very specific sets of patients, but only because they can select their patients very carefully. If you want to be ensure a good health service for everyone, you need the NHS – and let’s not forget that the NHS is one of the best health services in the world.

  278. David Wells says:

    Bringing competition into the NHS will in theory remove complacency and drive up quality in the NHS itself but runs the risk of cherry picking of services unless every provider tenders on the same basis. To create a level playing field in competitive tendering either a factor for training costs has to be removed from NHS costs or an appropriate contribution to NHS training costs has to be included in any tender from a private company not contributing directly to NHS training. In addition the private sector must meet the full cost of all treatments it chooses to take on and if not provided by the original service provider the NHS must be able to recharge for all care provided as a result of complications of that treatment especially high cost critical care. Only then can we be sure we have a true competitive market and I suspect we will find reduced interest from profit making organisations if they have to carry high cost risks as the NHS already does for much private health care.

  279. Sarah Woolman says:

    Reading through these posts, the overwhelming majority from well informed (many directly involved) people is coming out against this proposal.
    As a number of health professionals have pointed out competition naturally makes loss making ventures harder to justify and as by its nature most health care is loss making, expensive and to some extent inexhaustable, simply hiving off cheaper operations to be carried out by private (profit making) companies is not going to help. It simply creates profit for private companies.
    On the question of choice, many mothers don’t have the choice of natural home child birth or water birth because there are not the midwives or expertise in their area. So will these proposals really benefit patients to have ‘better’ choice or ‘more’ choice, because actually isn’t it a question of ‘any’ choice for some right now?

    The government did listen to the public over forests, again regarding the reforms to the NHS they are being told TO STOP THIS BILL. I very much hope they will listen and act with reasonable sense rather than costing us a lot of money creating havoc with a system that is working well. Rather than rushing into these massive changes from on high, they could consult with GPS, nurses and those working in health care and groups of patients/citizens with a real need first, to make the changes that will benefit all.

  280. Sarah-Jane Speech and Language Therapist says:

    It seems to me that patients most want to be seen by effective and caring professionals at locations they can reach with relative ease. That’s what I want as a patient!!

    We in Speech and Language Therapy are constantly reflecting on ways to address patient access and making service adjustments because we recognise that equality of access is a very real issue and one that our NHS with its roots in social justice values has asked us to look at – this is a value we readily identify with and it leads to real changes and choice for patients because it is based on clinical understanding and consultation with patients. For example, people who stammer can use email and text to contact the specialist therapist as phones are often a barrier. We offer evening appointments and evening groups because many people who stammer are at work or in education which keeps them busy during the day.

    Companies that have shareholders to whom they are ultimately accountable do not have the right values to be able to design and deliver truly patient-centred care.

    Also, as others have said, private companies will cherry-pick the straightforward conditions, and ones that can be ‘cured’ in very easily measured ways, as the target for their provision. Who is going to care for those people – who are many – who have complex and/or enduring needs, to put in the time and effort required to work as a team? Certainly not private companies.

    The Matrix report from the Royal College of Speech and Language Therapists shows the cost benefits to the taxpayer overall of providing speech and language therapy for children and adults with communication difficulties. Private companies won’t care about that. Why would they?

    I think too that fragmentation of services, and the constant changes that one provider winning a contract and then in a short time another winning it that will inevitably result from endless tendering out of services, seriously threatens the development of consistent and co-ordinated healthcare.

    When things go wrong for individuals in the area of health and social care it is nearly always a breakdown in communication that is found to be a major contributing factor in the failure of the services to meet the person’s needs. If we are constantly changing providers the scope for poor communication is manifestly going to increase and so more people are going to have more frustrating experiences and inadequate care.

  281. Briony Ladbury says:

    I work in a Strategic Health Authority and also provide consultancy on health matters to Barnardos . It is becoming increasingly difficult for the very skilled practitioners in the third sector to influence the NHS modernisation agenda for transitional arrangements or to inform the planning phase going forward with regards to establishing GP Consortia and the other structures in the reforms. One of the reasons being given by NHS Consortia Development Teams which results in excluding the major charities leading to them being absent from the table is that there is a ‘conflict of interest’ and an ‘unfair advantage’ if the charities are included in discussions. This is nonsense and does not acknowledge the amount of work that the charities undertake directly with children that is directly linked to improved health outcomes. It shows scant regard for the knowledge skills and experience of the voluntary sector workforce in providing very complex services to children and their families. Strategic planning and service design is (and should be) entirely different and seperate from the tendering and procurement phase which happens much further down the line and on a level playing field. It is the childrens charities like Barnardos that are best placed to advise on ‘patient participation’ for the large populations of children that form a GP patient base. It is disgraceful that children do not seem to have a focus in conversations about the reforms – they are conspicuous by their absence in the planning documents.
    How then do we give children the choice? How can children evaluate what they are receiving? The medical (and nursing) professions are not seen as being hugely skilled in working with children and this becomes even more noticable with hard to reach children living in vulnerable families. Please listen to the Charities such as Barnardos to get it right for children and to give them a voice. I would suggest Consortia (and Clusters) need well informed advice from the Charities on how to achieve children’s engagement and advocacy from primary and preventive care through to specialist provision. I would suggest that choice for children will depend on advocacy through skilled engagement. Representation for children by children is important on several levels, for example for the HWB to produce a good JSNA (for children), for service redesign and evaluation, for public health campaigns and to secure a voice for children as part of Health Watch. Please make sure the third sector is properly invloved.

  282. Andrew Munro says:

    Competition on price, such has been proposed by Andrew Lansley’s bill can never be a good thing for a national health service. Inevitably it will lead to private firms taking the “profitable” areas of care – elective surgery in the young and fit for example – and leaving the NHS providers to fill in the gaps. Why is this a bad thing? Well quite simply because providing the “profitable” care provides surpluses which the NHS uses to subsidises the care commisioner (ultimately the government)’s tariff for the loss-making care; typically care for the elderly, chronically ill and those with complex interactions of multiple conditions. As such by creating a market where the private firms can leach capital from the NHS into their shareholder’s pockets, NHS service provides trying to complete the services for their populations will be left running a deficit. Furthermore it seems to be the intention that should a service be left running a deficit they will be allowed to fail! What then for the unprofitable swathes of healthcare? Will the private firms magnanimously step in to take up the slack? Why would they? It’s only going to hurt their bottom line – at the end of the day they answer to their shareholders not the patients.
    But I guess that’s alright seeing as the duty of the Minister for Health (oh wait is that Lansley?) to provide a Universal Health Service is being quietly chopped at the same time.
    Whatever the NHS’s failings (chronic underfunding being a major cause of these but that’s another matter) this proposed stealth privatisation is most certainly not the answer to create a truly world leading health service! Healthcare can never be a place for profits – look at America if you need any evidence for why this isn’t a road we want to go down.
    So my constructive criticism would be quality is where it counts. Address areas such as hospital food, staff morale, cutting the bureaucracy which stifles innovation, see the value of prevention and quality rather than cost (a little more money spent now can save patient suffering AND tax payer’s money down the line – the ceravix vs gardasil choice is a prime example of how this has been got seriously wrong in the past!).

  283. Dr Dickon Bevington says:

    I work as a consultant in child and adolescent psychiatry in the NHS in Andrew Lansley’s constituency, specialising in work with multi-problem, high risk youth who have serious substance misuse problems, alongside psychiatric comorbidities, offending, educational failure and frequently histories of past or present neglect or abuse as well as frequent exploitation. This patient group represents some of the most vulnerable youth in the UK, and long term studies demonstrate that their lifetime prognoses (across domains of health, employment, offending and relationships) are desperate, and very expensive.

    Firstly I am concerned in relation to clinical care and risk management: One of the key problems that services for my patient group face is the fragmentation of care, with multiple workers from a wide range of agencies (youth work, health, mental health, social care, youth justice, Connexions, etc.) approaching these “hard-to-reach” young people to deliver more or less specialised interventions. As frequent inquiries over many years have shown, poor inter-agency collaboration is a particular problem for these youth; one that is associated with poor, even fatal, outcomes.

    Whilst there are many difficulties implicit in communicating effectively about these young people under the best of circumstances, I have had direct experience (and very frequent feedback from professionals I have trained in many settings) that suggests that when the several agencies involved do not have an explicitly and exclusively collaborative relationship the risk of miscommunication is dramatically increased. Introducing or increasing competition between the care-giving agencies that are required to knit together an integrated multimodal package is a recipe for poorer, less integrated care, with increased risk to these young people, and potentially the general public. I have myself had direct experience of working for two organisations which were pitted against each other in forthcoming tender bids, and I have no doubt about the impact of this upon effective patient care.

    Secondly, I have real concern about the deleterious effect on innovative and sustainable local service developments if they are to be placed on an ever-revolving ‘wheel’ of tendering contest after tendering contest. I have direct experience of the importance of staff retention in small innovative services that rely heavily on networks of human knowledge (of allied services and personnel) and relationships across a geographical area, as well as (conversely) the toxic effect of uncertainty upon staff retention in the anxiety-provoking year leading up to a new commissioning tender. Quite apart from this, the amount of hours that a small team is required to put into putting together a tender bid is extraordinarily burdensome on top of day to day clinical commitments. Under these circumstances really innovative practice, and practice that is focussed on long term goals (as opposed to short term commissioner-led targets) is increasingly hard to sustain.

    Thirdly, as has often been stated already, there are very real concerns about the capacity of a largely decentralised and de-regulated system such as I see proposed to provide the robust commitments to provide clinical experience and training for new clinical staff (doctors and other health professionals.) This is potentially devastating to the longer term development and sustenance of healthcare provision in the UK.

    Fourthly , I should now be old enough not to be surprised when the political rhetoric about avoiding muscular change-for-the-sake-of-change in the NHS fails to materialise. I am most disappointed that this massive reorganisation was in no way put to the vote in the General Election.

    Finally, as a ‘coda’ to these points I want to attest to the fact that, contrary to much of the rhetoric that would have it cast as, at worst, an example of centralised paternalism, in many senses the NHS is in fact more representative of many of the most desirable features of the “Big Society” that this government seeks to promote than almost any other setting on the UK. It is mainly driven by an unsung army of low paid workers whose motivation is evidently not financial but instead is simply to “make stuff that works better”; many NHS clinics and innovative services run just because an individual or small group of individuals has a passion to fix something.

    I have long argued that what most predicts a patient’s or client’s sense of value in a service is the gratuitous – that which is freely given; the staying behind to explain something again, the making of a cup of tea, etc. For my patient group, who traditionally have been seen as ‘failing’ to attend appointments, or being “hard to reach” by conventional services, this kind of attention to “treatment” in the widest sense of the word is particularly important. This is hard to legislate for, I warrant, but I think that, without wishing to idealise the organisation, the NHS is the place where it happens more than most.

    I would also argue strongly that the NHS (and this is undoubtedly so within my own specialist field of work) has a far stronger record of innovation in health care technology and delivery than the private sector has.

    So this is the baby that risks being thrown out by your bathwater change; one that introduces (or at least dramatically increases and cements) competition as the principal driving force for change in the NHS. I strongly reject the notion that competition in this arena is a purging force for good; surely it is the extent to which the government can help to set the conditions whereby purposeful collaboration can take place (rather than competition) that will determine success?

  284. amanda says:

    Patients do not need lots of choice they need goof quality cost effective care. They need the service that meets their needs not anything they want

  285. Jean says:

    Which are the types of services where choice of provider is most likely to improve quality?

    This is what is known as a leading question. It makes the assumption that private providers will inevitable improve quality. I would like the evidence for this assertion? To date having read extensively on this subject and as a British trained GP who has worked for 6 years in the system, I failed to be convinced. In fact many private providers, which have now been commissioned to provide simple operations have in fact been subsidised by the British Tax payer. Ironic but true. This is because they are guaranteed a minimum income and often did not generate this income by undertaking enough operations. Therefore they were paid for “Under utilisation” of their service. That appears to my eyes to be very inefficient. Secondly there is no after care? When operations are unsuccessful or have troublesome sequelea these centres do not provide any review service. Thirdly they do not train doctors and make no contribution to the cost of doing so. Fourthly they will only do the simplest of procedures, so where do we send the more complicated patients? As if the proliferation of private providers continues unchecked, and “see everyone clinics” in hospital are down graded there will be a proportion of patients that who the private providers deem unsuitable who no one will see. Perhaps it maybe easier to use a case to illustrate this point. A lot of hernias can be done by laproscopic surgery which is cheaper as it often requires less recovery time for the patient. However a number of hernias are unsuitable for this type of procedure , however now we have a private provider who only does laproscopic repairs. The hospital no longer sees hernias as they all dealt with by private providers…… where do you send the patient? If your in your 70′s you don’t want to travel to a hospital 200 miles away which provides some specialist services. So in reality the cherry picking of private providers not only provides a chance for private companies to profit
    but will ultimately result in a reduction of available services.
    I have never understood why the duplication of administrative services and and services in general leads to efficiency .

  286. Jean GP says:

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

    Patient choice has been held up as the most important tenet of health care? Is this really how most patients feel?
    Very often when I have explained various options for ongoing treatment. Often at great pains to educate and empower people allow people to make a valid choice, they ask if you were in my situation what would you do? What most people want out of the health service is the best care that can be provided, they do not want 100 different types of hip operation , they want the one that works. Fragmenting a system which has been set up to provide a high standard of care, into lots of different services all basically aiming to provide the same thing, seems that it avoids the economy of scale that come from a unified service. Secondly it makes it very hard for the clinicians performing the service to gain enough skill to excel in their jobs. I also wonder who is going to inspect all these private providers and ensure they provide the same high standard of care that the NHS does?

  287. S Grange says:

    A lot of work has gone into setting up the Deaneries in their present format. The Deaneries are work well and have trained staff to support the recruitment and training of junior doctors. Where is the sense in dismantling something that is working! This is not just about staff it’s about disruption to doctors education and training processes as a whole.

  288. Dr Penelope Jarrett says:

    As a GP, I am obliged to offer choice to my patients when I refer them to hospital. The vast majority want to go to the nearest hospital. Other factors are public transport routes, parking and whether they have already been seen at that hospital. This bears out much research that if offered “choice”, most people will not say no, but when they have to rank it against other things that they want (eg. good service, local etc) then it comes low down in the priorities.

    Choice is only advantageous to those who have the financial means to travel. We have seen in education that it is now schools who choose pupils, not parents who choose schools. Private healthcare providers and insurers are only interested in low risk patients. I recently saw a middle aged patient refused insurance because of her moderate hypertension. Private patients are transferred to NHS hospitals as soon as things go wrong: it is too expensive to provide the ITU back-up and expertise. One of the reasons the NHS can provide such high quality care at a reasonable price is risk pooling – the risk and cost are spread over a large population. The fragmentation which the Bill proposes will limit this, and hence increase costs.

    Academic health economists have shown that competition and choice in healthcare do not improve standards and do not lower costs. Quality, insofar as it can be measured, is driven down to keep prices low, but overall costs go up because of the transaction costs (e.g. monitoring and managing contracts and tendering processes). Hence healthcare in the USA, the most marketised system in the world, is 2-3 times the per capita cost of the NHS, with worse overall outcomes. Informaticians tell us that competition only works for discrete and identical units, eg baked beans. I resent me or my family as patients, or me as a doctor being treated as baked beans! The care I give and the care I want to receive is individualised!

    One of the reasons disadvantaged groups find to difficult to access primary care is that PCTs, following central diktat, conduct “list cleansing” exercises, where they send letters to registered patients. If they do not reply, they are deemed not to exist, and deregistered. How are the homeless, travellers, migrants etc meant to see a GP? And this occurs under a system where PCTs have a responsibility to their populations; how much worse it will be if the Bill is passed and consortia only have responsibility for their registered populations? I cannot see how any profit driven organisation will have any interest in taking on these expensive patients, nor any mechanism in the proposed structures which could ensure such groups are offered appropriate services. Abolishing practice boundaries will also risk further increasing health inequalities – see the RCGP submission.

    Lack of information remains a significant problem, not only for those patients who do wish to exercise choice, but for mangers trying to evaluate services or clinicians who want to look at their own performance. All the IT effort seems to have been spent on the largely pointless and unwanted “spine” for sharing patient records, instead of useful things like improving data collection, or local links between GPs and hospitals. Quality in healthcare is hugely difficult to measure, and subject to so many confounding variables that it is difficult to interpret. But even those things which are measured are not fed back to clinicians, services are mostly unevaluated, and huge changes such as those proposed here are not even piloted!. It is very frustrating for clinicians trying to practice evidence-based care to have politicians imposing assertion-based policies upon us.

    But is measuring quality is so difficult, perhaps we could just ask patients? Overall satisfaction with the NHS is at an all-time high of 64%, and satisfaction with General Practice routinely runs at over 90%. How many politicians have such ratings? Perhaps they are jealous? It certainly does not seem a good basis for embarking upon the fundamental changes envisaged in the Bill.

    Other possible reasons for the changes are the supposedly poor outcomes of the NHS (this was well and truly exposed as false by John Appleby, Chief Economist at The Kings Fund), and the Nicholson Challenge. The latter is undoubtedly a problem: better drugs and technologies mean healthcare is ever more expensive, and as there are more older people, there are more people requiring that care. However, as has been shown repeatedly, more choice and competition can only reduce cost by driving down quality. Most people do not want this.

    As the psychiatrist, Dr Dickon Bevington, explained so eloquently in his post yesterday, healthcare works best when it is integrated and collaborative. It is a win-win situation, as such care is also the most cost efficient. But is no good just mentioning integration in press releases when the whole Bill works against collaboration. The vast majority of those who work in the health service do so not only for their salary but also because they believe it is an important job, and should be done to the best of our ability. In a truly national, tax funded, system, we all have a stake in making things work. Philosophers have argued that the very existence of the NHS makes us better people. The Health and Social Care Bill should be withdrawn and David Cameron should get the drafters to start again to produce a bill with collaboration at its heart.

    I fear however this may be yet another sop of a consultation, with the submissions largely ignored (as last summer) and all the time and effort we have put into it wasted, when we could have been learning he new NICE guidelines or even seeing patients….

  289. Tom Sparks says:

    I am deeply concerned about the focus on price. I for one am not particularly concerned about the cost of the NHS – I regard good general health of the nation as being worth paying for. In the NHS there can be no substitute for a comprehensive and quality service – price simply shouldn’t be a factor. When you introduce profit making organisations the bottom line will inherently be a consideration – we need regulation not competition. I don’t want to be able to choose between different local service providers, I want there to be a single, well funded, efficient and responsive service. Already privatisation in the NHS (in cleaning and catering services and in grounds management) has led to a significant reduction in standards of patient care and (some studies suggest) the rise of the hospital superbug. We need to roll back, not roll out, competition in the NHS.

  290. E Bloch says:

    I do not think we should ever consider Health and its provision as a business. Human beings are not commodities. Choices are for those that can make them and there are plenty of people who cannot! By providing choices we will alienate a great part of society and as usual the poor and less fortunate will suffer! Are we really going to become a country where you need private insurance, like the USA, to ensure that we get the treatments that should be available to all?

  291. Janet says:

    I have experience of working for many years in both the public and private sectors (not healthcare). I know from experience that the idea that the private sector runs things better and more efficiently is pure myth (I have worked for large, global companies). The NHS will not be better / more efficiently / more cheaply run by private providers. They will, in any case, cherry pick – have you ever heard of a private ICU?? Instead of wasting money on contracts, monitoring contracts, picking up the pieces when the contracts go wrong, why not just look at the layers of management in the NHS and redistribute resources so that we have less chiefs and a lot more indians?

  292. Roger Hart says:

    I don’t want choice. I want a good hospital within reasonable distance of my home. Nationally I would like hospitals to share best practice rather than compete.

  293. Alan Bailey says:

    As far as is possible, I want health care from people who want to take good care of me, not people focussed on turning me round and pushing me out a.s.a.p.

  294. Tony Keeling says:

    Choice and Competition is what was promised for the privatised railway.
    What have we got. Any choice? No. Any competition? No.
    Biggest cost in the history of our railways? Yes!
    Don’t ruin the NHS with this silly ill thought out plan like you did the railways.
    It won’t work and everyone knows it.
    The doctors don’t want it, the nurses don’t want it, but most important – the users of the the NHS don’t want it!

  295. Ruth Manning says:

    I find trying to discuss the proposed NHS reforms difficult in the 4 catagories set out. They all interlink and one has an affect on another.

    For example one of my concerns regarding the notion of “any willing provider” is that with all the extra choice of service hosts, WHO chooses which provider is best for the local population and HOW is that decision made. It has been mentioned by Dr Julian Sims that poor management can occur as a result of promotion of good clinicians to managerial positions “which they are ill equiped to serve”. Is this not what the government are pusing GP’s to do? They maybe excellent clinicians who can make all the right decisions about their individual patients’ care, but what experience and training have they when it comes to commissioning the best services for a large population and how to budget 80% of the NHS finances. With increased competition and more providers for GP’s to choose from – will the promise of the best possible rates be looked at first and the quality of care second? In order to be competitive, all providers will slash their rates to make themselves more attractive for the new commissioning bodies – and will the cheapest option the best one?

    Competition makes you work harder – yes, but it is only fair if everyone is on an equal playing field. However, the NHS is already on the back foot. The only way acute trusts can make money inorder to make improvements is by winning commissioning contracts and treating increasing numbers of patients. With increased competition, patients will go elsewhere, less will be treated in the local hospitals and with less demand for services – services will stop! The difficulty is that the acute hospitals have no other way of making money – even fund raising is highly policed. For example, a physiotherapy out patient dept might be able to fund raise for equipment, but if they raise more than their equipment costs, that surplus cannot go towards anything else, eg: staff training, uniforms, computer equipment, payment for extended services etc, their hands are tied. Trusts are being cornered into cutting their prices in order to maintain their competitive edge and patient appointments that would normally be paid at £40 per hour are being paid at £10 per hour. Yes this undercuts the private sector – but how long can you run a service like that and how much does it devalue the work of the excellent clinicains providing that service!
    The NHS is THE PLACE to learn if you are a health care professional. Where does the government think that the Dr’s, nurses, physiotherapists, pharmacists and social workers got their experience? Have they thought about who the people are that provide private services at present – NHS consultants are normally the leaders in their field and predominantely work in the NHS, but they would most certainly have trained in the NHS. They are ones who take the private clinics and run the private theatre lists along side their normal NHS jobs. It is a common occurrance that if you have a private Physiotherapy appointment, your physiotherapist will probably also work in the NHS, and if not they would have trained there.

    If as a result of the proposed changes to the NHS the acute trusts disappear, where will the training happen? How will the training of our future health care clinicians be regulated and where will they be able to get the fundemental experience in practice if these precious resources go? what is your plan there Mr Cameron?

    I second the views of many people who have commented before me and state that in a democratic society – let the people choose – we chose you to govern us, now you do the descent thing and let us chose how we should be cared for, stop assuming you’re doing the right thing for everyone and ask us instead! A referendum about how many boxes to tick on a piece of paper seems greatly insignificant in comparison, yet the nation were asked to vote about that! The information you are getting from these message and e mails are important, but you cannot for one minute think that it is a fiar representation of the population as a whole – we need a referendum about, we should be able to tell you what we think and KNOW that it counts!

    thanks you.

  296. The government should stop worshipping the false god of ‘patient choice’.
    No patient I have met who is ill wants a choice. They all want, and need, a top rate, local hospital which works in close collaboration with primary care, investigative services and social services. Competition and choice risks fragmenting these services, reducing collaboration and integration while only giving the individual patient the luxury and an illusion that they are having some ‘choice’ over their care
    There is no real evidence that choice and competition improves services or reduces costs. The NHS is one of the most efficient health care systems in the world. In this world of evidence-based practice the only changes that should even be considered are ones that are proven to improve outcomes, not ones that promote choice and competition simply because they are part of the ideology of the government who happens to be in power at the time.

  297. Tom says:

    Our Communities need local services and value best thathas served them effectively over the years. This is “Choice” at its best and allows for interaction and onward improvement. The “Level Playingfield” must not be so over-regulated by the “System” that it destroys this “baby” yet again. The cycle of “Change” in the NHS is beginning to look more and more like a downward spiral at this time and great care is needed so that “more for less” does not squeeze the last living breath out of an efficient locally based health care provider. This will definitely give our Community less for less and it will be the fault of the “System” and seen as such. The emerging GP Consortia must be able to show that they have consulted in a full range of forums to support the best that can be achieved in each of our local health care areas. Too much change can be very confusing and no one wants to waste their time if they foresee that they will be going round in circles. These “Changes” must be seen to be meaningful and solid enough to be built upon and influenced by politics as little as possible.

  298. Kevin Orme (RN) says:

    I feel that the introduction of private companies into a competitive framework will shift the emphasis from delivery of best patient care to profit. I think that the previous and deplorable example of private companies being paid for surgical procedures not done is a disgrace and could happen on a greater scale if private companies with a profit motive become a part of the NHS per se. have no objection to a greater role for for Not – For – Profit organisations and charities becoming involved more in the care delivery process as they bring to the system an altruistic and not fiscal motivation. Intrinsically I feel that the patient’s identified and expressed need should drive the process of commissioning.

  299. patient choice is not necessarily linked to the marketised competition between services and such competition may in fact lead to less choice, particularly for the most vulnerable in need of care. Having a range of small and local providers is the best way to improve choice in delivering healthcare.

    Recommendations:
    • To increase choice women’s organisations, who provide specialist services, or women-only provision should be available in existing services to ensure that women’s needs are met.
    • Special licence conditions should include support for existing women’s services.
    • The ‘mandatory services’ obligations should include women-only services and specialist services to marginalised women.
    • Women’s organisations that provide health services should be commissioned or given funding if they are working with the health sector.
    • Where communities facing discrimination make up a very small proportion of a local population local authorities or the NHS Commissioning Board could commission specialist borough-wide, regional or national services for them to address accessibility or cultural issues.
    • There should be a condition in the licence for providers to ensure that antichoice providers refer women on to other local services and do not create barriers to services.
    • There must be a focus on long-term and preventative strategies as these will lead to future savings.
    • Clear guidance is needed from Government on how to commission health and social care services from the non-statutory sector.
    • Commissioning processes must involve women’s organisations and women to ensure that gender-appropriate services are part of the landscape of providers.
    • GP consortia must have sustained and meaningful engagement with the women’s voluntary sector to ensure that the services it commissions accurately meet local needs.
    • The voluntary and community sector should be supported by Government and commissioners to fully engage with GP consortia and commissioning processes.

  300. Jon Hassler-Hurst says:

    Competition in the private sector seems to mean undercut on price. As we all know cheaper is not always better. Robust governance will be required to prevent substandard care being delivered as a result of profit driven efficiencies with private provision.

    Choice is fine but must come with a contract that if you make a choice you will be fined if you do not attend your appointment / admission / day surgery.

  301. Richard Walker says:

    Competition in healthcare is a distraction from the provision of services focused on safety and quality towards those that place efficiency above all else.
    There is room for substantial improvement to be made within our state healthcare system and I would support change, but not change that undermines the hard won gains that have been made predicated on safety and quality.

  302. john says:

    In the debate on choice, it seems to have largely gone unremarked that the doctors that staff the private sector are mainly the same ones who staff the NHS, (with the partial exception of one or two big cities). Financial rewards are better, of course, working privately. Expanding choice by expanding private provision threatens motivation towards providing the best NHS care as incomes become more reliant on the private sector for some staff. Nobody is going to be enthusiastic to go the ‘extra mile’ if a longer waiting list will guarantee a bigger income in the private rival. Choice for some compromises standards for others.

  303. Ainsley Robinson says:

    In my experience private providers main concern will be profits,so will put in low tenders to try and ensure they get the contract and then worry about how they will deliver it,I know of providers (for outreach services)who cannot ‘support people’ as they have not included in their tender, enough money to take into account travel costs,thereby people in rural areas do not get seen as often as they may require, if at all.

  304. Dr Karl Brennan says:

    I am concerned that increased choice refers only to choice of provider. The NHS is currently able to offer patient-specific choices within a healthcare episode. I’m worried that with the implementation of so-called ‘best practice bundles’ – & who has determined this is not clear to me – what we actually may offer patients is one package of care, take it or leave it. Whilst this may demonstrate better outcomes to a population, it does not necessarily allow variation for patients to optimise the patient experience.

  305. Helen W says:

    Whilst I feel that patients should be able to choose, many would just prefer to use local services – and they should be able to get the same service in whichever area they choose.
    Do patients really understand what it is that they are choosing between?
    I am concerned that the choice for patients would not be equal across the country effectively leading to pockets where patients cannot access services they need.
    Patients will get the best service when they receive an organised service from a company not operating for profit.

    Patients are most likely to choose hospital or in-patient settings rather than community based services.

  306. Jane says:

    Women in the area I live have the choice of many hospitals to have their baby. At the moment one hospital is very busy as women are choosing to give birth there and the staff under real pressure with the sheer volume. While the other has many empty beds but is still providing sub standard care. Over a number of years the hospital with spare capacity has not had a good reputation in the community but has done nothing to address their problems in a way that filters down to the care of mums when they have their baby. I’m not sure choice has served anyone very well. Effective management, transparency and meaningful user feedback that is acted on may help. The real issue for maternity care is to tackle the bullying in the work place and for staff teams to have the time and the training to care for mothers in a kind and professional way.

  307. Celina Mbwiria says:

    when people talk about patient choice, I often wonder what they really mean. how many people out there can actually say theyknow enough to make the appropriate choices in what they require about their health. I consider myself as a knowlegeable person in the area of health. however, the experience i had recently with my health, i realised how little i knew about what choices i was able to make. my GP needed to refer me to a rheumatologist and he did. but had he asked me to make a choice, i would never have known whom to choose. i wonder if those less knowlegeable of health issues than i am would have faired better. to have a choice is a good thing but only if the service users understand what choices there are.

  308. chris murphy says:

    I think that insurance companies have no place in the national health service. The american model is disasterous unless youre rich. We need to move away from that model not towards it.

  309. Elaine Summerfield says:

    I am an allied health professional working in a hospital setting providing rehabilitation to patients. I work as part of a group of professionals including Occupational Therapists, Physiotherapists, Speech and Language Therapists, Nurses and Doctors to provide specialist treatment in order to promote independence to patients and enable them to return to live in the community. It is vital that I liaise closely with social services and housing associations in order to ensure all aspects of the patients needs will be addressed. In the last couple of months I have seen a dramatic change in my working practice taking me away from my clinical role and further towards that of a case manager.

    Because of the dramatic cuts in funding for local authorities the number of Social Workers has markedly decreased which has led to the Occupational Therapists having to carry out tasks social and other local authority workers would have previously completed, for example form filling on behalf of patients and chasing up with regards benefits and housing. As a result this leaves less time for the therapists to provide patients with the treatments that they are trained to do.

    The reduction in funding has also led to the closure of numerous community groups which provide ongoing support for patients with long term conditions and are often a life-line to reduce the impacts of social isolation and possible further ill health. Loss of such services would be detrimental to public health and lead to further costs to the NHS and the state through admissions to hospital, increased care needs and the reduced likelihood of the individual returning to work.

    As such services do not necessarily provide immediate, measureable results, I am concerned that they will not be considered as important by the commissioning bodies and therefore are at risk of further cuts. As a result of this, existing clinical services will be at risk of being judged as poorer quality in the outcome measures because of the increase in time taken to discharge a patient because a lack of available community services. Already health professionals find it difficult to source funding to enable individuals to access community resources and the proposed changes to funding community services would make this even more difficult and even more time consuming. Most importantly this limits patient choice and their right to a better quality of life.

  310. Stephen Hewitt says:

    If we believe in devolving power and decentralising decision-making then why is the coalition government proposing that primary family health services (eg GPs, dentists, opticians and pharmacists) are commissioned nationally rather than locally.

    There has been a lot of public debate about the commissioning of hospital services by GP consortia, which to my mind has over-shadowed the question of who commissions the GP consortia.

    Currently GPs, dentists, opticians and pharmacists are commissioned locally by the primary care trust, who will have the local knowledge about gaps in services, poor provision etc and take action to deal with them and have a degree of local accountability.

    With the proposed abolition of the primary care trusts, why has this been centralised. How will the NHS Commissioning Board in Leeds know what services we need in Bristol (where I live)?

    Just as responsibility for public health is being transferred to local councils with a ring-fenced budget, why not transfer responsibility for commissioning GPs, dentists, opticians and pharmacists to local councils as well. There seem to me to be very strong arguments for this:

    1. Integration with public health

    2. Integration with adult and children social services and health services already provided by the local councils

    3. Councils have has experience of commissioning services – health and social care, children and young people, drug services – which could be developed with expertise from the PCT.

    4. Less disruption as the relevant staff and expertise could be transferred from the primary care trust (as with and along with public health).

    5. In the longer term there are opportunities for better co-ordination with other local services that are based in the community such as housing, community safety and parks and sports services (eg prescribing physical activity instead of drugs)

    6. Local knowledge meaning better targeted services, more appropriate services. greater sensitivity to the needs of local communities and greater local accountability

    I have six monthly dental check-ups, see my optician every year or so and, being generally in good health, perhaps see my GP once or twice a year on average. I rarely have to go to hospital (well at least not yet). So it seems bizarre to me that it is only the expensive hospital treatments (that fortunately only a few of us need at anyone time) that will be decided locally by GP consortium – while in future the primary health services that everybody uses every year will be decided hundreds of miles away by some national quango rather than locally. Where is the patient choice in that?

  311. Alan Spicer says:

    Choice in itself, is not a bad thing but benefits and drawbacks to the NHS need to be carefully considered to ensure the whole is not compromised by the part. There are very few issues with choice between NHS providers, as this should drive up standards within the NHS as each hospital/clinic/service strive to offer something different over their rivals. This should definitely continue under Choose & Book. The issue that is continually mentioned is cherry picking the easier procedures by private providers that rarely cause complications or indeed litigation. This maybe could be addressed by licensing private providers only if they carry out all procedures within a particular speciality. For example, I imagine (I’m no clinician) that ingrowing toenails is a quite straightforward procedure but if all chiropody issues were included in that private providers service to qualify for NHS funding, with appropriate ratios of easy to hard, this could perhaps mitigate the issue.
    e.g. Hard/Very Hard 20:100 ; Standard 20:100 Easy/Very Easy 60:100
    If this is palatable or difficult to police what about just having choice between rival NHS providers with private providers being included in NHS funding only when the NHS providers cannot reach a certain standard whether that is timescale and/or outcome? Patient choice is still present, it gives the NHS first call but, crucially, if they cannot achieve a certain benchmark, private providers are invited to pitch. Standards are driven up, the NHS has some protection but the safety net for continued quality is available.

  312. Peter Holt says:

    These reforms are misguided and driven by ideology.

    The well known Conservative mantra is that everything must be private. It seems that the Government intend to give control of the money to the part of the NHS which is private i.e. the GPs. This is ideology.

    We need an NHS which is free at the point of need, works efficiently and provides the best possible care within the constraints of the resources available (i.e. the cost the taxpayers are prepared to pay), but I am far from convinced that these proposals will provide this. Instead the service will become fragmented which will increase costs and result in a more unequal service. The suggestion that patient choice will automatically improve things is an illusion because most people do not have the knowledge to make an informed decision. There will be the suspicion at least that the G.P. is basing his advice on the greatest benefit to his practice rather than the best interests of the patient. Even though more information may be provided most people are not in a position to assess this. In addition, with more private companies involved we will see increasing amounts of advertising designed to persuade (i.e. mislead) patients into choosing a particular provider.

    While I can understand that involving clinicians in the design of services could lead to improvements, wholesale change such as this are unnecessary. People love the NHS and levels of satisfaction have been very high – lets keep it that way!

  313. Chris Linacre says:

    Choice (of provider) has proved illusive for a number of reasons, many of which are described above. In addition to those comments it is beyond doubt that choice requires an excess of capacity over demand to enable sufficient providers to stay in the market at levels of utilisation below what is assumed in the national tariiffs. If the price (tariff) does not include a margin for excess unused capacity those providers will shrink and eventually close thereby defeating the objective. Add to this the requirement to provide care with limited access times the balance between capacity and variable demand implied by choice becomes almost impossible without redundant capacity that has to be paid for.
    An extension of this argument also applies to the scope of choice. There is little evidence that the independent sector has been allowed to/ is willing to enter the provision market for unscheduled care or for the higher specialised services that often require infrastructure support way beyond what an independent provider would be able to provide unless they entered the complete provision world. If this artefact, undisclosed separation persists, the acquisiton of marginal elective activity by new entrants to the provider market will remove the financial contribution made by this activity to the infrastructure required to support the other essential services of the current NHS providers. This is being played out in micro with the desired rebalancing of activity between hospital and community where the infrastructure cost coverage becomes a real and difficult constraint, but manageable. If there is a further range of threats created by alternative elective provision with no transitional funding to bridge the time taken to reduce infrastructure reduction one of two things will happen, NHS providers will become non-viable and close or they will cease to offer those services that depend on available infrastructure (high cost imaging, critical care, Consultant expertise, laboratories, education and training) leaving the population who need these critical services with no choice.

    The business with Southern Cross also should provide a lesson. The consequencs of that organisation folding or exiting the UK market or demanding a significant price increase are unthunkable but now harsh reality. There is a failure regime of sorts for NHS providers but none (in terms of continuity) for the independent sector. What wouild happen to supply continuity if significant services which have become an accepted and necessary part of NHS provision decide that operating margins reduced by successive imposed effieicency gains (price reductions) that have no evidence base are sufficient cause to exit the provision market or use the threat to force prices up?

    I wonder if any of these consequences have been thought through? In simple terms there is nothing wrong with choice made available by competition so long as the market is fair, the impact is considered and managed and there is no excess costs associated with making it possible for what the vast majority of users seem to be saying is not an issue.

  314. Mark Bradley says:

    Working as a nurse, with vulnerable groups in my locality who lack capacity to make informed choices. There appears to be a potentially increased health inequality developing here. The NHS perhaps working better for those who have greater capacity to understand it?
    I can’t help but feel it is crucially important to have local health services, thoroughly scrutinised to ensure they perform as they should for all. Local NHS commissioners should be included in this scrutiny to ensure that the needs of all groups within any given community are appropriately assessed and on this basis, local services should be designed and developed.
    Shifting expertise out of area and creating market forces that are driven by those who shout loudest is in my view, in danger of segregating communities and potentially overlooking the most vulnerable groups in our society.
    Re-organise the NHS based on more thorough needs assessment of entire populations using services, not on what appears to be the opinions of a few relatively small stakeholders and consultations. That’s a mistake.

  315. Ernest says:

    The difficulty I have with choice and competition is that it admits that some parts of the health service are better or worse than others. I cannot believe that we have allowed the situation to get so bad that we need choice and competition to drive up performance or to ensure that funding is made available due to a higher demand for services in one trust over another.

    I agree as a current patient in the NHS System, that choice has worked for me, and has allowed both I and my spouse to receive treatment at the hospital located closer to our residence, rather than being obliged to travel longer distances to hospitals, where such services have been centralised.

    The ethos from the foundation of the Health Service was to provide an appropriate level of care, at a local level to where people reside. This approach has long since been abandoned and services have been removed or relocated obliging people to travel further for Accident and Emergency services in my own area and for Maternity Services further afield.

    Another issue of choice and competition is the post-code lottery approach now adopted by Health Trusts to providing treatment on the basis of cost, rather then its efficacy for the patient. Aided and abetted by NICE, whose charter seems to be to withhold new medicines on the basis of affordability, rather then their life enhancing or even life prolonging efficacy. No longer is saving life or providing the best treatment the mantra, it seems to be save money at all costs so we can employ more managers.

    I appreciate that money is always short and that someone has to decide on priorities, but the inhumanity and lack of compassion involved in these decisions, which in the main, ignore Clinical Opinion, just seem to me to fall into the category of murder by withholding resources.

  316. Dr Fiona Hayes, GP says:

    Young Diabetics disadvantaged by QUOF payments
    The current prevalence calculations have financially disadvantaged our population of young Type 1 diabetics this financial year. We run an in house specialist shared care clinic for out population of 42 type 1 diabetics within our University Student Health Service. We achieved more QUOF points (81/100) than last year (76/100) and yet our QUOF payments have dropped from £ 21,706 in 2010 to £1,724 in 2011. This means that we can no longer afford to continue providing the level of care within the practice and will now refer all the patients back to hospital for their consultant care which has to be a retrograde step.The reason for the altered prevalence figures may be related to our very low number of Type 2 diabetics ( currently 2 patients) which makes us very different from the average general practice. Surely Type 1 and Type 2 QUOF payments could be considered separately in order that the funding is equitable to the amount of work done, and to allow clinically excellent care to continue in a community setting?.

  317. Patricia Woodcock says:

    I do not believe that either competition or choice can “drive NHS improvement”. Nor am I reassured by the Prime Minister’s claims that there will be no cherry picking by private providers. With “any willing provider” how is this to be avoided? Private health companies exist to provide profits for their shareholders, so are bound to take the most profitable services, leaving the NHS to deal with the more complex and expensive – and to step in when one of their patients proves more complicated. I strongly object to private profit being made from health and care. As for choice, how can any patient, especially a seriously ill one, make an informed decision about where to find the best care for his/her particular needs?

    Dr Richard Taylor, formally an Independent MP and Health Select Committee member, has written:-

    “The most important battles the NHS should be concentrating on now are:
    Improving efficiency and value for money while cutting the NHS deficit,
    Improving safety and quality of care across the NHS,
    Improving patient and public participation in decisions about NHS services nationally,
    Strengthening commissioning, especially for quality of service provided, and as part of this improving communication and co-operation between primary care and hospital doctors.

    These apparently conflicting aims, when successfully addressed will all lead to improved health outcomes and can be effectively implemented by strengthening existing NHS organisations and initiatives rather than creating new ones.”

  318. Christopher Linthwaite says:

    My views on choice is that there is not really a choice when you are constrained by travelling distance, unless we are going to waste serious amounts of money funding it.

    Otherwise we are going to ensure a two tier health service where those who can afford it can procure the best in the health service whilst those who cannot have to accept what they are given. Or even within existing departments in local hospitals you may end up with popular consultants overwhelmed by a huge workload whilst his colleagues are sat around twiddling their thumbs, hardly the best use of resources in either scenerio

    Another constraint for choice is the cost of scanners etc, these cannot be placed in every single health facility they are simply to expensive, and where is the sense of having one standing idle whilst the other is being used 24/7

    So then we come to competition. You cannot have a free market using public money within the NHS it will not work unles you privatise health provision something I am vehemently against unless providers do not take over existing equipment paid for by the public, particularly if it is to be used for profit, but they provide their own equipment thus increasing competition and choice. Otherwise the whole exercise is pointless. Then people can make an informed choice whether to use the publically owned NHS or opt for private companies

    Companies bidding to provide services cannot cherry pick, if they are going to set up a general surgical hospital then they must undertake to perform all procedures currently done by a District General Hospital, or a regional speciality Unit. In short they provide services in parallel with current services, thus truly increasing choice and competition.

  319. Gini says:

    Competition will narrow choice because healthcare will be about cutting costs in order to be competitive, and this will mean that quality of care will suffer. We know that privatisation doesnt work for the people of this country. It only works for business. If these plans go ahead, the gulf between rich and poor will widen, and this will have devastating consequences on society. Wales and England have rejected these plans at government level. These plans have been rejected by the English citizens, and our citizens in Wales and Scotland are helping us with this fight. The Condem government will not win this one. This is our NHS and the government has no right to destroy it.

  320. Robert Tyrrell says:

    There is NO conflict between quality and cost, so long as the quality required is accurately and precisely defined and measurable.
    Goods and services must fulfil the needs and expectations of the end user by being
    < fit for their purpose
    < free of defects
    < reliable
    < value for money.

    Do not confuse quality with grade. An earthenware cup must have the
    above qualities just as much bone china. It is idiotic to use a gold-plated lighter in the kitchen when a cheap throwaway might serve just as well for less money. Total user costs must be known and measured.
    Do not buy something cheap if it costs too much to run and maintain.
    Quality must be defined precisely by the buyer, guaranteed by the supplier,and delivered reliably. The only question then is – price.

    All faults and failures must be recorded, costed and traced back to source (defective materials, faulty procedures, lack of training, wrong definitions or measurements?); the faults must be rectified at source. Systematic prevention is better than cure.

    This kind of quality management pays for itself, and shows a profit because the savings go directly to the bottom line.

    There are systems for achieving it, namely ISO9000 series (based on BS5750). All suppliers must be certified to this as a minimum requirement. The improvement of quality must be constant and measured.

    Many goods and services companies practise this kind of quality management. It was advocated by the Government many years ago, but never thoroughly practised.

    Start doing it NOW.

  321. claire Smith says:

    Most patients will coose local services above anything else, and in my experiece service users are usually happy with the service provided. Most services that patients have direct contact with are run very well and patient satisfaction is high, despite being under huge financial pressure. Money spent in the NHS continues to be wasted in many areas by constantly re-inventing the wheel, the competition brought about by this change will dilute quality as people strive to provide the same service but at less cost. In the long run this will result in more money being spent on new people being trained to do a job that a team was already very competent at.

  322. susanne griffin says:

    As a Consultant Child and Adolescent Psychiatrist working in East London with children, young people and families where a child has learning disability and/or autism, I am witnessing the dispersal of a long fought for and recently formed small specialist CAMH service. There will be no specialist service for this population group to reduce the risk of serious mental health problems developing and worsening, never mind a decent choice. The idea of promoting competition and choice where there is no money to develop even one decent and properly integrated service to meet complex health, social care, education and additional needs for children born with a complicated mix of developmental disability/illness seems a particularly cruel joke. The children I now see (many of whom I believe I will in future have to turn away until their mental health difficulties become massive and acute) have complex needs and disabilities which usually span multiple different ‘care pathways’. Unfortunately parents are usually ground down and exhausted by the challenging circumstances they face and the 24/7 care they have to provide, so campaigning to meet their complicated package of needs is difficult. As a result little ‘noise’ is made and little interest taken by the public media domain, until tragedy strikes, as for example when a parent sets themselves and their child on fire, as happened not so long ago in Leicester. My question is this “Forget competition and choice, just show sufficient compassion to prevent unnecessary suffering. Please fund and provide just one baseline decent provision, to work across and integrate care pathways and achieve the best possible physical, emotional, family, social, educational and quality of life outcome for every child born with complex disabilities.”

  323. D Reilly says:

    Payment by results for psychological therapy is an exercise completely ignorant of the complexities of mental health services, the problems service users bring, and the diversity of service user groups that services need to be available to. Psychology waiting lists are currently untenable and putting increased pressure on services will result in those most vulnerable and therefore less able to access services being marginalised from NHS services.

    Measuring mental health is impossible as what will be a huge leap forward for one individual may only be the first step for another. Each user of psychological services requires specific individualised treatment. Reducing therapies to a common ‘currency’ is disempowering and implies that mental health professionals need ‘incentives’ to put their patients first.

  324. robert galloway says:

    have worked as a doctor for ten years and feel passionate about the
    NHS. I have just been appointed as a consultant in emergency medicine.

    There are two things I would like to see develop in the white paper.

    Stopping evidence free expensive ways of reducing emergency A&E
    attendances which do not work, but instead integrating GPs into A&E, so that
    inappropriate attenders get seen by GPs. I would also like to see an
    expansion of A&E consultnats. This would reduce admissions and length
    of stay as the patients would get expert help on arrival to hospital. Often the sickest patients are seen by the most junior doctors especially out of hours and at weekends.

    The role of monitor in encouraging competition and not co-operation. I
    fear this will destabalise hospitals and risk the future of hospitals
    emeregcncy department. The risk in going forward [with the bill] as
    it is, is It would lead to some
    hospitals not being able to continue as they are. If you were to say
    ‘we’re going to go out to competition for vascular surgery services’
    and my hospital lost the contract to a private company, we wouldn’t
    be able to run our own
    trauma centre, for example, because you wouldn’t have the staff and
    the skills on site to do things and the volume of procedures needed to
    ensure clinical standards remain high.” A&E depend on the specalist behind us and if they no longer work for the NHS but for priavte companies doing routine ops, they are not there for us in an emergency. Monitor must ensure co-operaation and not competition.

    kind regards

    Dr. Rob Galloway MBBS BSc MRCP FCEM PGcMEdED MAcMedED

    P.s. I would really appreciate an actual response as opposed to a
    computer generated yer yer yer Mr . Landsley is listening. I would be
    delighted to meet him please can you publish when and where we can meet.

  325. Chris Bird says:

    This proposal is not about choice. It’s about profit. The concept of choice is just a smokescreen.

  326. Bill (NHS Consultant) says:

    Some of the comments from fellow NHS professionals beggar belief. Have they actually experienced other healthcare systems? Most in Europe are dreadful. To suggest healthcare is better in France or Germany is drivel. The NHS is extremely effective, of a very high standard and in my humble opinion, cost effective in many areas. Introduction of competition will fragment healthcare and increase “managerialisation”. Market forces just do not work in healthcare; yes, they create wealth for many “cherry picking” providers (I suspect some of the posted comments originate from these opportunists) at the expense of the central government and population most at need, proven time and time again in the States for instance. If there really were a better system out there it would’ve been noticed! Furthermore, very few patients want “choice” of provider, but prefer guidance as to whom it is best to see and where, largely from their GP. Quality is always more important than cost, surely. Competition will erode quality and result in a multi-tiered multiply-managed and ultimately more expensive system that will take years to evolve. Ignore the sharks….they want to line their pockets. I am in a position to make a lot of money from these reforms yet am strongly opposed to nearly all of them. I want to preserve our NHS, which can be improved I’m sure, and we should strive to do this through other reforms after consultation, not blind instinct. DOH, wake up and smell the coffee!

  327. Lawrence W. Hampton says:

    This government like previous governments say competion will bring greater choice, value for money and better services. One only has to look at the privatised Utilities to see that this does not and will not be a valid argument, I refer to the Thatcher era. Change for change sake is not valid, this is being done to FORCE people into going private, to make some ex MP a vast amount of money, shoot the lot of them the quicker the better, I will do it for free.

  328. S T Naidu says:

    The NHS is a free government run service which has been running along fairly nicely. Trying to make it look like a private medical care facility is to ask for the impossible. GP run primary care and consultant led secondary care are poles apart….GP training and qualifications, consultant training and qualifications are also poles apart. Asking one group to control another is a bullying approach. Already the Government has caused the training system to deteriorate badly from a first class one to the second rate one where nurse and junior doctor training is concerned: the cornerstone of respect for consultant authority is currently replaced by that for managerial authority: this does not augur well and trainees will not find themselves beholden to such authority and training already suffers producing mediocrities in place of excellent trained finished products as existed. All the time new and often silly plans are hatched by managerial staff to justify their existence and expand their authority and consultant bullying: the question lies in whether anyone of these measures led to improvement is patient care: the answer is no. The costs on admin bureaucracy is spiralling while keyline recruitments as nurses and doctors, are sidelined. To say that the Government is unaware is absurd but its time the rot was halted. Patients are happy with good medical care that existed before and it was reasonably priced compared to constant tales that are fed to show how wonderfully well managers have improved NHS!! At what cost? Where did the money come from? How did it really improve choice and what is competition and is there a need for it amonst government run organisations? Is there a need for so many targets? Just cut the bunkum and get on with the job!! Secondary care can be easily improved by giving senior nurses and sisters the teeth to keep their wards clean: there was no MRSA until the sister’s were sidelined and managers came!! Likewise the biggest risk is that doctors training is suffering and once this country allows medicrity to take the place of excellence this country will be doomed, thanks to the unbridled power of managers and not professionals. Often choices are imposed down the patient’s throats , they are made to travel huge distances whilst some dam’nd lie of a statistic is produced to show how efficient managers are whereas in reality its a load of bulls!!

  329. Dermot Ryan says:

    In the current context, the concept of introducing competition ( or choice) is rather like Sophie’s choice. Competition suggests that there is a overprovision of services from which a competitive exercise might ensure survival of the fittest. However, nothing is overprovided within the NHS.
    With the advent of cost savings and in particular the massive reduction in management cost, the procurement exercise in itself will consume virtually all the current resource.
    Although the rhetoric is all about quality, I have yet to see a quality proposal ever win againsts a qquantity proposal. On top of this, any outside provider, or at least most, are motivated by profit and will wish to see a margin on their investment from what is already an underinvested service. The concept does not stack up.
    The concept of Monitor forcing organisations into competition is riseable.

  330. Alex says:

    Choice and competition are nice words, but what we need is a public health service free at point of use. Not a state healthcare insurance provider. Privatising the NHS will mean worse care that is more costly than it is today. The NHS has its flaws, but it does tremendous good- and privatisation will ruin it- and give us the disgusting illness based bankruptcy that many in the US suffer from.

  331. Barry Hearth says:

    The NHS was brought in back in the 40′s mostly against the wishes of many in health at that time, has anything there changed?
    Ask any British man,woman or child and they will tell you that good health is more important than money and in this respect the NHS is of paramount importance, far too important to be left to the whims of andrew Lansley and David Cameron.
    Privatisation just means PROFIT.

  332. K Sidaway-Lee says:

    This whole choice in public services thing is completely daft. It has made a complicated mess of the school application system and it is likely to only cause problems for the NHS. I don’t want choice of services, nor does anyone else I know- I simply want the service I need that is geographically closest to me to be to be of a good standard. That’s it.

    I don’t think any kind of competition or privitisation is going to manage that because the focus of a private company always has to be on profit. Without that drive to cut corners a public service in the public sector is always going to be better.

    The only part of the NHS that would benefit from competition and choice is hospital food. That should also however include the choice for the patient to have their own food brought in and reheated if necessary.

    • Richard B says:

      I agree with K Sidaway-Lee in that I do not want choice. As a prostate cancer patient 4 years ago, I received first class treatment from my GP and the specialists I was referred to. If I had to choose, I do not believe I have the competence to do so and would finish up sticking a pin in a list! From my own experience the NHS in my area works well and does not need to change

  333. Tim says:

    This is just political ideology there are many ways to improve service. Everyone wants better and cheaper services. We can all work together as one big team and make a difference for the sake of improving peoples health. This all sounds remarkably top down. How about a real bottom up approach where feedback is sort from patients, nurses, doctors, all staff (no politicians!). Then during regular team meetings you have a quality section where the feedback is discussed and improvements made where appropriate.

  334. Pashley says:

    Purchaser/provider split is a waste of money. There is no evidence that it has improved health or saved money. Thousands of staff are involved in contracting; their salaries could provide more health care. “Competition” is a sham for dismantling NHS. “Choice” is meaningless when there is little spare capacity; choice is difficult to come by except in a major metropolis; most people don’t have the knowledge to exercise choice, which effectively is done for them by a doctor. So let’s return to the pre-Clarke NHS.

  335. Edmund Collins says:

    I have worked in the NHS over some 10 years, it is not choice or competion that is needed it is fewer managers with clipboards and more professionals to do the job they trained to do instead of endless paperwork and trying to meet targets, all of which do nothing to help the backlog of patients. And lets face it privatisation just means more costs so shareholders can get a return and even more paperwork.

  336. Florian Diaz Pesantes says:

    A patient or patients family will always seek for the best at any cost and not be willing to step back for the best of another patient with a higher need. As long as personal and financial resources are limited, this empowerment of patients must lead to a dislocation of rare ressources. The demanding smart patients will block the workforce of the very specialized most excellent doctors who should be spared for the most complex cases.

    Gatekeeping and vetting is essential to maintain an efficient healthcare and individual egoism must be balanced by independent decionmakers.

  337. Ruth StylesWilson says:

    For years doctors have warned of the dangers of increasing the use of private companies in healthcare provision. In other countries healthcare outcomes have worsened when the market is brought in to healthcare. Fragmentation of care occurs with many different providers involved in episodes of care. Costs increase when private companies move into the healthcare market – it isn’t cheaper or more cost effective – it costs the taxpayer more.

    Private providers have their eyes on the profitable, easy to perform aspects of healthcare. They don’t want to be involved in patients with many illnesses or those who may need extensive postoperative care or even intensive care – that is left for the NHS to sort out. The worry is that cherry picking these ‘straightforward’ aspects of care may destabilise local hospitals and also crucially diminish the opportunity for training our future GPs and consultants.

    The Government says they ‘never privatise the NHS’. This is a bold statement to make but it is misleading. The Health Bill may not lead to privatisation as we saw, for example, with the railways or water, gas and electricity companies in the 80s and 90s. What the bill does though is open the door to private healthcare providers and allow them massive opportunities to offer their wares under the banner of the NHS. The ability to use the ‘brand’ of the NHS is much sought after. Yes I understand the private providers offered services under the last government but this was on a much smaller scale and the NHS remained the ‘preferred provider’.
    By any other name this is a privatisation of the NHS in my opinion.
    Why break what does not need fixing? Patient satisfaction is very high with the NHS.

  338. Jane Birkby says:

    Competition is all very well, but it leads to a post code lottery for patients, because administrators play chess with provider outlets, playing the ‘my facility will be the best’ game, forcing patients to travel long distances for treatment to supposed ‘centres of excellence’.
    As an NHS patient I want good healthcare within 30 minutes travelling time from home, because I would be ill enough without makiing things worse for myself and/or any visitors and family members.
    I don’t want a myriad of private providers muscling in on what should be a vital service to the public, because with private providers comes inequality of access, and health for those who can pay the most.
    Unum health insurers can take a running jump, and keep out of British healthcare, we don’t want American style healthcare here, because it disadvantages the most needy and vulnerable – the chronically ill cost too much!
    It is all very well having patient choice, but it doesn’t always work in practice, and the general public are not likely to know much about the providers, to make a valued choice.
    All we want is good care everywhere at a point of delivery within 30 minutes travelling time of home.
    But of course that is too much to ask, isn’t it?

  339. David says:

    This is a sham!!

    A recent YouGov poll found that 95% of the public have no idea how to get involved with this “listening exercise”.

    How does the Government propose to engage with the elderly, frail or sick who do not have access to online forums?

    The reforms proposed to the NHS are heinous enough but to exclude the majority of NHS users who are unable or prevented from expressing their views is devious and underhand.

  340. luigina.palumbo says:

    As a GP involved in commissioning I fear that nhs contracts and nhs commissioners (managers and clinicians) lack the sophistication required to ensure that the private sector and their lawyers do not threaten integration and collaboration. I have witnessed the same service being interpreted quite differently by an established nhs provider versus another AWP, with the latter being far more costly. The result was the contract was pulled for both (to ensure fairness) and to in order to ensure that we do not trip up on any issues around competition in the future the service now has to be fully tendered. If the nhs is a public service let’s demand an open accounting system for both nhs and private providers and make certain that any legal fees are also fully disclosed. The no win no fee system has often resulted in more costs going to the lawyers than are won by the claimant. If we are required to achieve 20 billion in efficiency we cannot afford to divert precious resources to the legal system

  341. Sally says:

    Clinical professionals endeavour to practice to high standards underpinned by evidence based knowledge and skills in the best interests of individual patients before them, and appropriate referrals are ideally in the interests only of a better patient outcome and also based on evidence. Understanding scope of practice also defines a professional way of working as does having confidence in the abilities you have.

    Using every available pound for healthcare makes for financial efficiency and good clinically led management is about doing this.

    In the current system over the past 30 years gradually more and more healthcare resources are spent on other things, top slicing e.g. the predictably I’ll fated national IT project, transaction costs have risen, SHA,s and DH interfere in what should be locally and professionally determined. The legitimate function of private enterprise is to get best return on investments to make profits, the function of NHS is to provide most efficient and effective healthcare for the voted funds – they are different objectives.

    Abolish constant top down meddling, increase professions say in running NHS suported by fewer but directed managers and spend precious resources fully on quality health not for profits
    of independent sector or the bureaucracy to support a Market legitimised by notions of false choice.

    Change, but for the right reasons, not churn.

  342. Sally says:

    To continue, the inflencing moves towards marketisation relies on assertion over evidence, opinion presented as facts. A flourishing Market in amy case needs over supply, without it there is no real choice. In healthcare increasing marketisation means incentivising cheaper services and cheaper services in my experience means lower quality. Despite the pause SHA’s are still filming Carry On Regardless – the sequel – the worlds of the clinical professional and those that want to consign clinical services in the NHS to the same sorry fate as contracted out non clinical services collide.

  343. David Smith says:

    The NHS is supposed to be free at point of use and to meet needs whatever they are, irrespective of patient’s financial circumstances. In such a situation demand is potentially infinite. Increased patient choice, even where the patient can rationally choose does nothing to address this dilemma. Insofar as patient choice is appropriate it exists already.

  344. David Smith says:

    Of I am supposed to comment on competition. We have seen what a disaster this has been in the US – incredible waste of money and humiliation for patients. Leave it out! Introduce a Total Quality approach instead. This involves trust, and competition is the enemy of trust.

  345. Debbie Smith says:

    There is a lot to be proud of in our NHS so why do we need to dis-assemble it? Having worked in Social Services for many years I have seen first hand how the move from an in house home care service to tendering private companies has created a culture of profit above quality of service.

  346. E. Bennett says:

    I am highly concerned about the government’s plans to introduce more competition into the NHS. I believe that this will undermine every patient’s right to access a good health service. I also believe it will increase bureaucracy and cost in the long-term. As a trainee health psychologist I understand that the NHS is under financial strain from the increasing number of people requiring care for chronic illness, however I believe that a collaborative approach between patients, doctors and experts across the spectrum of health and social-care will provide the best solutions, and this forward looking approach is at odds with free-market thinking, which marginalizes and compartmentalizes patients, professionals and departments. Please rethink the reforms.

  347. David Blair says:

    Simply put I don’t want choice and competition in the health service, I simply want a good health service. And to be frank I really don’t see where patient choice can actually be of benefit to the patient. I had a tumour removed last year, it was found and dealt with promptly, which is how I think it should be. I was not an expert in any way on the medical details and fail to see how I could be expected to make informed choices on any aspect of my treatment. If for example I were given a choice of hospitals or surgeon for my operation on what basis should I be expected to choose between them? Would it be on the basis of statistics on success rates? If so, I don’t see how useful that would be, since no two operations of the same type are ever exactly the same and any statistics would be easily distorted since a hospital or surgeon who is perceived as being better would be oversubscribed and could cherry pick the easier operations.

  348. Sarah says:

    We engaged in a tender as a GP practice, this cost us 10,000. It is shocking to think that if this process occurred 250 times for Darzi Centres that a huge amount of money was wasted. If you are a GP in an area, then you are investing in your practice and doing a lot of work for notheing, also you are building up relationships with that community which have huge gains for healthcare. You cannot market this sort of phenoma, and there are not a pool of spare doctors and nurses. NHS organisations are value for money and often run on a shoe string. COmpetition can only push up the price and create a more mechanical service. This is not what we need with an aging population. Please drop competition and support professional culture.

  349. Sarah says:

    On the front line we hate choose and book. Choice is an informed choince about your health not necessarily a mechanical computer process. Not all commercial things fit well with health. In fact this has broken Dr networks by putting management in the middle. Please can we have healthcare with less red tape. What evidence is there that so much monitoring is at all efficient or motivating or better for the patient

  350. Justin Baker says:

    The question about which are the types of services where choice of provider is most likely to improve quality is a dishonestly leading question, because the question itself tries to trick people into thinking that “choice” of provider is itself “likely to improve quality” – it isn’t. The “any willing provider” aspects of Mr Lansley’s White Paper will actively undermine treatment quality, because willing providers are not necessarily the best qualified, and because the Bill’s provisions will compel providers to under-cut each other and compel GPs to award contracts to the cheapest providers.

    The question about how to ensure a level playing field between different kinds of provider is also a dishonestly leading question. The question NHS patients want answered is how to ensure quality of service, especially considering that the NHS is, considered in market terms, a health insurance scheme our families have been paying into for generations. The numerous forms of tax UK citizens pay have helped build-up the NHS over many decades, and this is a historic investment that we are entitled to draw upon when we are sick or injured. No-one wants “Free” healthcare. We want the health services we’ve already paid for.

    The question about making patient choice a reality is yet another dishonestly leading question. When patients visit their GP they prize an optimum quality service more than they prize the hassle of having to choose a rival service if the first is poor. The “choice” the “any willing provider” and lowest-price competition aspects of the NHS reforms are designed to encourage is the government’s hope that more patients will “choose” to pay extra (in addition to the tax they’ve already paid) and go private, because, as a direct result of their White Paper, NHS services will for many patients have become intolerably poor.

  351. Andy Hadley says:

    The idea that Cameron’s privatisation of services is in the interests of patients is complete rubbish. A report this week suggested the costs of administering the myriad companies now running the Railways is about 5 times the price it would have been under British Rail. The shareholders, lawyers and PR sharks are the main gainers. Passengers are an inconvenience except by paying spiralling fares.

    On railways, they have cut trains, cut out stations, inflated fares, and generally optimised to maximise income based on the very limited set of rules that are in their contracts. That is what private companies exist to do. The model was wrong and idealogically driven for the railways, it is wrong and immoral to use people’s illness as profit lines in this way, and with healthcare we will collectively pay for this waste.

    We know that the US insurance driven healthcare model is hugely inefficient and costly. But it seems that US Healthcare companies have been in on the design of the new NHS, will bring ‘expertise’ to GPs in exchange for a share of their profit, and we, taxpayers and patients, will be far poorer as a result.

    I have managed mostly to avoid the NHS as a patient so far, I will want efficient local and integrated care when i need it. As a taxpayer I want minimal money wasted and syphoned off, and as someone who has worked across all NHS health settings, I want the NHS frontline empowered, not just GPs who are often parochial and myopic when it comes to specialist or non medical clinical and support services. Oh, and with their hands in the till.

    The whole emphasis is wrong, it has been so under successive administrations, driven by the mandarins in Whitehall.

  352. Simon Bonsor says:

    Competition? The only competition seems to be bed managers who are not medically trained against nurses and doctors. Remove the bed managers, save the money.

    GPs already filter patients and restrict choices: further GP power will REDUCE the service delivered and remove patient trust.

    Creation of more internal markets will create more roles for staff who push money around rather than push and care for patients.

    How about finding some more funding for cleaning the hospitals?

    How about stopping the building of PFI buildings that we pay more for over the long term? There’s a nice MOD building in Bristol (Aztech Park) that is going to lose jobs – maybe convert that palace – which it is – for medical health needs?

  353. Sandra says:

    The main competition should be each hospital with itself, to improve its own services. As soon as competition between hospitals occurs, the focus shifts from the patient to the target, be it financial savings, “outdoing” the rivals etc..

    Choice should be part of a patient’s right, but in my experience most people want a service they can access easily – i.e. a local one. Psychological reassurance is often provided by swift action, especially in emergency situations; the patient feels safer because they’ve reached a hospital within 10 minutes rather than 30 and care can begin more quickly. Even if a transfer to a specialist unit is then required, at least the patient has had a better chance of being stabilised and reassured that something is being done for them.

  354. C R says:

    choice should provide the best care for patients.However private companies will put profit before patient welfare.This is not good.

  355. Barbara Arrandale says:

    Patients, nationwide, should have a level playing field of care…when ill, especially in an emergency situation we need the advice of the experts not to be asked ‘which hospital would you like to go to?’It is crazy to think that privatisation will produce a ‘better’ service more cheaply as any private company will be in the business of making a profit. We need to reassert the National in the National Health Service. Post code lottery care is absurd in this society.

  356. James Goodhew says:

    Competition:
    1. The costing of an individual procedure is arbitrary: complications can arise at any time, requiring supervision of a senior consultant; transfer to another department; etc. These costs cannot be accurately considered on a per-patient basis, and in the NHS the services are costed to cover these situations and so help to fund other activities within the hospital when things run smoothly.
    2. So, a private provider could use low-grade staff to provide a cheaper service short term, but when things go wrong they will require that senior member of staff, or that other ward to transfer the patient to. Of course, the money that in the NHS would have provided these additional services has gone into private profits. Also, the patient is not in a hospital, so the new system requires transport between providers in emergency situations. This amounts to a poor quality of care.
    3. With a lower patient throughput in hospitals, these lower value services could not be justified because economy of scale diminishes, and the money allocated to these tasks with the overheads of senior supervision becomes depleted also. So, funding for senior staff is diminished, junior staff do not have roles as these have been lost, and the hospital is no longer a viable healthcare provider at all. This is a slippery slope!!
    4. I do not believe competition is in the interest of patient care. The only driver we see behind competition in any market is profit. Utility companies underwent the same process of introducing competition. Safety has always been compromised, and illustrated by our recent oil disaster involving BP.

    Choice:
    1. There has been no survey to my knowledge asking patients whether they want to have to choose to which healthcare provider they go to, when they become ill. NHS doctors often wear a private doctor’s hat and take provide care for private patients within NHS hospitals anyway!
    2. Patients are not educated about healthcare.
    3. Doctors are.
    4. Doctors should be free to provide the best healthcare available to those patients who need it.
    5. Patient choice should be limited to whether to accept or refuse the treatment solution(s) offered to them by qualified doctors.

    • A patient says:

      I quite agree. The health service does not need competition which will drive destructive wedges between people where collaboration and co-operation would be far more efficient in cost and resources.

      As others have said, as a patient I want quality above choice, as locally as possible.

  357. Keith Bean says:

    It amazes me that the assumption appears to be that only competition can improve performance. Organisations in the private sector may be subject to competition but they do not deliberately seek competitors in order to have a reason to improve their processes. They look for ways to improve their processes in order to fight the competition that is there. Transferring funds to pay external providers will only weaken the NHS and make it more difficult to put the necessay effort into process improvement.

  358. magda says:

    I do not think that choice and competition will improve the NHS . What will improve the service will be good knowledge and interaction between NHS staff and the patient.
    Competition will not provide better Health Service as competition is about contest of resources.

  359. Elizabeth Jefferson says:

    I don’t want arbitrary choice. I would like a quality service for my individual health care needs, reasonably local. I would rather this was not provided by private companies whose main concern is profit. These companies tend to only provide care to those who are actually fit and well. If you are ill, or infirm, you will probably find the private companies don’t want to treat you, as it is too expensive for them. They take out all the “easy” jobs from the NHS, leave us to deal with the needs of everyone else and then when it comes out that a service more expensive in the NHS, they just assume it’s cos we don’t know how to be efficient like a private company does! We’re not treating like for like.

  360. Ruth says:

    ‘Choice’ means that the ‘alternative providers’ can cherry pick the straight forward cases at tariff rate, leaving the NHS to pick up the complex cases. Teaching hospitals need to have striaght forward cases in order to train future surgeons.

  361. Thinker says:

    Competition, by it’s very nature creates massive waste – it means multiplication of virtually identical services so that there is a fictional ‘choice’ between them. On top of this it requires money to be spent on promoting the benefits of one ‘choice’ over the other, money that could otherwise have been spent directly on patient care.

    The NHS should not be in the business of advertising and marketing, it should occupy itself with the provision of healthcare. The introduction of more and more profit-making organisations also means that the NHS is being parasitised, with money being extracted for shareholder profit, that should also have been returned as patient care.

    The phrase ‘different kinds of providers’ implies that more of these profit making companies will be making their way into the NHS, cherry picking the most profitable procedures, and leaving the real NHS to pick up the unpopular areas – the oldest people, the most complex cases, people from the least affluent backgrounds collected together to be given a second class service. Rather than thinking about how to make a ‘level playing field’ for providers, we should be making sure there is a ‘level playing field’ for patients, so that the oldest, sickest and poorest are not left behind.

    More important than ‘choice’ is QUALITY. We should be enabled to access the best quality healthcare. Also implicit in the notion of ‘choice’ and ‘competition’ is the idea that people with more money can access better services. This is inimical to the philosophy of the NHS.

    • Dr Yvonne Sougnez says:

      I read this after writing my response – you said it so much better than I did. Wish I could have that on the front page of every newspaper.

  362. Chris Easton says:

    Your questions are loaded toward the response you’re seeking: There is no evidence that competition in the NHS has ever driven improvement. If there were, I’m sure Andrew Lansley would have repeated it ad nauseum. In fact, there is much evidence that it does not. I have worked in the NHS for 21 years, and have been witness to many and varied attempts to bring the market into the health service. I and my colleagues are clear that, quite aside from this kind of organisational upheaval which costs millions, causes untold misery and disruption to staff, the introduction of ‘competition’ between say, hospitals, does nothing demonstrable to improve the service to the patient. We need less private involvement, not more.

    We are aware however, that there is very clear evidence that this government is keen to place our health service in the hands of their supporters in the private healthcare market. Care UK, KPMG, United Health, to name a few. Care UK – who already have control of all prison healthcare in England were contributors to Andrew Lansley’s election campiagn. This is the kind of issue which colours public perception of this government’s ‘initiatives’. Services owned and by shareholders, with the profits going to enrich them instead of back into the service of health provision can not possibly improve the service to the public. Only to the friends of the government.

    Choice of provider is not something that I have ever heard patients refer to as improving their perception of the service they receive. However, length of wait for an appointment, quality of care, and professional and kindly interaction with staff is something we hear lots about. Choice doesn’t come into it. People don’t want choice. They want a reliable, friendly, effective service at the closest point to where they live. Ask the patients. I haven’t seen a scrap of evidence that the government have asked the public anything before drafting this Bill.

    The widening of private sector involvement into the national health service ensures that it won’t survive as a national health service. There are many of us who see this move as an ideological project pursued by those who don’t use the service, to increase the revenues of their friends in private health companies – for example, McKinsey, who are well documented as pursuing their ‘right’ to have a slice of the lucrative health ‘business’ in this country, so that it ends up looking exactly like their US service. I could go on. The government seems to think that this information escapes the public. And the fact that Mr Cameron has hired McKinsey as part of his ‘forum’ is, to us watching this unfold, incredible, and demonstrates the lack of insight, and even common respect for the public, that this government is capable of. No wonder the nurses recently gave a vote of no confidence to the Health Minister, the BMA voted to oppose most of the Bill, Lord David Owen published his critique – ‘Fatally flawed’, and even Tories are asking awkward qeustions of the government.

  363. Patricia Stevens says:

    How have these 2 things become part of the NHS? Most patients want a reliable, reasonably efficient service which provides the care they need. Choice is only applicable in certain areas anyway and competition should be totally abandoned. Perhaps a return to the old principle of cooperation would serve as a better model.

  364. David Jones says:

    In my own recent experience in an NHS hospital the one area where standards fall far below the required level was the ward cleaning. This was in stark contrast to the scrupulous bed and furniture cleaning carried out by the nurses as part of their infection control regime. The cleaners were perfunctory and no furniture was moved or beds cleaned under, that I saw, during the week I was there. I believe this was a resource put out to private tender and I would suggest that in all probability the lowest bid was accepted. This would inevitably lead to the cleaning company having to pare costs down to the absolute minimum, paying their employees as little as possible in order to turn a profit and encouraging the cutting of corners. Opening up other areas of the NHS to competitive bidding is more than likely to lead to similar problems.
    Further to this a number of questions arise relative to the fitness of MPs to be involved in this bill. For example: How many have direct experience of NHS hospital care? How many MPs have connections and interests in private health care companies and /or rely on them for any serious medical care? What provision is being made to eliminate the possibility of contracts being awarded via the ‘Old Boy’ network?

  365. Simon Tulitt says:

    Whilst there are undoubtedly areas for improvement in all parts of the NHS, our NHS has undergone tremendous improvements over the past 15 years.

    My family and I have not had wait months for a referral, which was the case in 1996, for several of us.

    Surely it must be possible, at a time of falling real terms budgets, to transfer best practice form one place to another, without reverting to GP commissioning and changing the instutional structure so radically?

    Can’t the exisiting governance arrangements be relied upon for all Health institutions to stay within budget, whilst focusing on the outcomes necessary?

    It’s not broken, so why do we need politically-led changes that take us back to the bad old days, when the culture of partnership working in our best practice areas are there for all to see in service improvement?

    How much will these reforms cost and where is the evidence that such widespread instiutional change is necessary, or will actually deliver the improvements claimed?

    My personal view is that the Coalition have this badly wrong in even having a debate about the NHS. It’s fundamentally OK, and change can be made without making fundamental changes, for example in GP commissioning & competiton. Neither partner in the Coalition even got elected on a platform to radically change the NHS.

    I for one would hate for us to go back to the days when GP’s tried to guess because of the cost implications of referring for an X -ray or to a specialist. That would be to revert to the National Sickness Service we had then.

    Please don’t make the classic politicans’ mistake of thinking that changing the institutions will change the culture of the poor performers. It simply creates uncertainty in the best ones. For example, we already are seeing a flight of staff from PCT’s.

  366. shelley says:

    As I patient I find this to be a leading question in order the government can pull out part quotes and use them in their favour. So I will simply state the idea of competition in health care is unethical and goes against everything our NHS stands for. I overwhelmingly choose to go to an NHS hospital where all depts under one roof incase of complications (journeys from private clinics to HDU etc could decide whether you live or die), where staff are professional, properly trained and their to help you. Not a private provider where they may serve nice tea but they view you as a profit making commodity. Recently unbeknown to me was sent to private part of local hospital and was horrified. Not by their standards but by how the consultant spoke to me. I am not backward in coming forward to complain but this incident was so personal and awful I feel I can’t even report it. Yet had I been in the NHS part firstly I am sure it would never have happened and secondly their would have been a strong network of other health professionals about they would have picked up on it and complained on my behalf. The ideal level playing field in my eyes is boot all the private providers back to USA or emptying bins and stick with and build upon our NHS- Cameron did say prior to election the system works and we would be sticking with it and so we should.

  367. janeywilliams says:

    In response to the three questions:
    1) type of service most likely to improve quality – easy pickings e.g. minor and routine surgery – where risk is low.
    2) Level playing field: NHS organisations contribute to training and manage expensive high risk treatments e.g. ITU. To have a level playing field all organisations would have to be able to contribute to the costs and overheads and appropriate governance associated with these. They would also have to be a very large provider. To be fair to the taxpayer they would have to be not for profit and closely monitored, if not managed by government.
    3) Choice, equity and quality can be in direct conflict. Patients want quality rather than choice. A tax funded system has a duty on equality.

  368. Alex Brett says:

    I am terrified by the idea of competition: I don’t see how this can possibly help people with costly, minority, difficult-to-treat conditions that are already poorly understood and badly handled by existing systems. I am especially concerned about the impact competition will have on the treatment of trans* people, which is already woefully inadequate. And, as someone with chronic health conditions, I’m concerned about long-term support and decision-making: I’m currently on non-standard off-licence medication that is lots more expensive than the “standard” treatments but *actually works*.

    All of which boils down to: I am extremely concerned that quality of care (which is not easily measurable) will take a back seat to cost of care if the NHS (which is).

    (And I’m upset that the listening exercise is set up in such a way that I am feeling guilty and disenfranchised for simply not having the energy to read all other responses to this post before commenting!)

  369. Jeff Black says:

    Whenever I hear words like ‘choice and competition’ bandied about, alarm bells start ringing. Yes, on the face of it, they sound like a good idea – but really it’s the language of laissez-faire capitalism. What you actually end up with is the consumer (patient, in this case – which is even worse as it could be the difference between life or death) having to pay escalating costs for a worse service. For previous examples, look to energy supply and train travel. And how do you feel about going to the dentist if you’re not lucky enough to be on the books of an NHS one?

    The Tories have promised the NHS to the vultures that fund and support them. They know it offers rich pickings and hate the original socialist principles it represents. They have no mandate or right to take this action and must be stopped at all costs.

    . I don’t want to wake up in a country where I’m worried if I can afford to be ill. I suspect the few doctors who support these proposals will be those on the gravy train afterwards. LEAVE IT ALONE.

  370. Ian Busby says:

    Extracts from the paper New Health Horizons submitted to the Department. “We therefore suggest that the Department should explore the investment of more focused resource to develop a limited number of “Fast Track” Pathfinders that would develop a number of new models for wider Consortium adoption… This approach will help to surface issues that need to be addressed: for example, how best to ensure a balanced “trading relationship” between commissioners and providers such that desired gains can be achieved but without prejudicing the financial and clinical performance and viability of either side in the short term. …All parties will need to work together in a way that enables the Provider community to become more efficient without putting vulnerable yet essential Providers at risk of collapse…. The Fast Track Pathfinders should reflect the broad categories of different conditions that exist across the country…. At its most obvious level, a key difference will lie between largely rural areas and densely urbanised areas such as central Birmingham. http://www.newhealthhorizons.org

  371. Dr Yvonne Sougnez says:

    The fiction of choice: Emergency cases, rural dwellers, those without easy access to relevant data … will in effect have no choice. Choice is non-existent for many (most?) parents when they are seeking school places – is there any good reason to think health care provision would be different? I cannot see how.
    Competition: I fear this means competition to hold down costs whilst maximising profits rather than to provide high-quality health care efficiently and effectively.
    Managerialism is one of the biggest ‘drags’ on the system. Deal with that problem first. The NHS is a publicly funded body for the benefit of all and we have every right to expect government to sustain it until we have mandated you to do otherwise. Indeed there is more than enough data to show that we expect that.

  372. Michael says:

    I am against these proposals. Look at the mess “choice” of schools has caused in education – millions of unnecessary journeys and disruption for children to distant schools at a higher cost to families and the authorities – plus unnecessary extra road congestion and accidents (Having driven school buses I can vouch for my claims. I had one Mum in a hurry bury her car (with two small children in) in the Back of my stationary bus, 8’3″ wide, 11′ high and with it’s lights on!) In my day, we all went to our nearest schools and the overall standards were mostly superior to today’s schools, stricter disciplined, healthier, cleaner and no infantile political correctness wasting the budgets. (It is the latter that is eating public service budgets at an alarming rate)!

    Private contractors fail to provide quality services now! As witness huge costs of temporary agency staff and the awful quality of hospital food and extremely poor standards of cleaning and hygiene.. Walk around the back of a hospital, Ministers and poke around!) When I was a National Serviceman I dined in a mess feeding over 1,000 hungry people, three times a day, but the lady Flight Sargent in charge served up food of such quality on a tight budget that there was always a rush for “seconds”! If she could do it, why not hospital Kitchens?

    If the Government reformed NHS management, reducing all salaries to a maximum in special cases of what the Prime Minister is paid for leading the whole country, we might start to improve cost effectiveness. I am amazed at the huge sums paid for much lesser responsibilities than being PM and the huge obligatory pay off’s to such “higher Management” staff when they fail or are dismissed! The number of non essential jobs on good salaries being advertised in all public administration is truly alarming! Stop all this “celebrating diversity” and pandering to staff’s personal ideals, lifestyle choices and whims and get on with the core tasks.

    Some areas I have been to are very well and efficiently run, others are not. I have had what should have been clinical decisions about follow up appointments taken by unqualified staff on the grounds of “pressure” on resources. But if we cut the unnecessary administration, insist on quality and value for money from contractors seeking contracts – things can be improved and that “pressure” might be reduced.

    I see all this improving “choices” and “private contractors” as an admission that public services cannot be run effectively with existing well paid Managers. Surely this is not the general case? So I think what the coalition government it really trying to do is hoodwink us into agreeing to creating more opportunities for private companies to get their hands on more taxpayers money.

    I am all for reform, but without the privatisation angle. I would end private health care using NHS trained staff and facilities – without stiff leasing costs, that would level the playing field! After all, the NHS invests most in the training and takes back all the “difficult” cases, so why not charge more for it? If we are all really “in this together”, lets see everyone relying on the NHS and stop the wealthier in society from plain and simple queue jumping!!

  373. Paul says:

    In all honesty I am not looking for a greater choice of healthcare provider, I simply want my local health authority to be well funded and staffed. I am not living in some fantasy land though, where I am not a high earner but I would certainly be willing to pay more taxes to maintain standards at my local hospital.

    I have a couple of problems with the notion of increased patient choice as I’m not entirely sure what the supposed benefits of this choice are for the patient. Firstly, as somebody with no medical training, making a choice about which “provider” will best serve my medical needs, would be slightly ignorant, arrogant and possibly detrimental to my own well being. Medical experts are paid to make these recommendations as they have undergone the training required to do so. Secondly, I have no idea what health related misfortunes await me in the future. I imagine I’ll find out when they arrive. Maybe I will have time to spend reading up on my ailment and assessing which is the best available provider to use but chances are that I will not and in those circumsances I will want my local health authority to have at least a good chance of providing me with the care I need.

  374. Peter Rose says:

    This is supposed to be about choice and competition and I object to those being linked. We need co-operation not competition which may drive standards down.
    I already have a choice of NHS hospitals in the area where I live which is South of Manchester. I know which hospitals specialise in certain treatments and I can check their waiting times for less urgent conditions.The NHS hospitals provide a fantastic degree of specialisation, research and education. If we want to have private providers then lets compare like with like. I know of no private hospitals that do the research and training – in fact they clearly depend upon the NHS to train their consultants.
    It is an admitted fact that difficult cases are transferred from local hospitals to specialist hospitals and it is also therefore agreed that the recovery rates for these difficult cases is less than for the simpler cases that local DGH’s treat. I fear that private hospitals will cream off easy cases, not have the overheads of research and education and therefore their cost effectiveness will look very good when compared with NHS hospitals- better recovery rates at less cost.

  375. Michael Shackleton says:

    How about offering a referendum on these non requested and unauthorised by the majority of voters, radical changes to OUR NHS.

    This would be choice.

  376. Paul Walker says:

    I would like to see cooperation , not competition , to be the driver of the NHS
    1) Some patients will be discriminated against as private providers will inevitably seek to select patients that provide the best financial return and refuse to treat the more complex and risky cases
    2) Financial competition will force some hospitals to close – a decision which should be made strategically, not at the whim of the market. The bill enforces the logic of competition that only the fittest should survive. It reduces financial support and effectively allows hospitals to fail before steps are taken to save core services. The bill makes no provision for the loss of non-designated services
    3) A recent BMJ article backed the view that the bill is effectively a one-way door to privatisation, as it will force the NHS to follow EU competition rules. Private providers have publicly stated their intention to use the courts to reinforce their right to bid for any area of NHS work There is therefore no protection against the domination of the private sector in the supply of healthcare to the public. Many would call this privatisation, most would not support it, and there must be a change to the bill to prevent it
    4) Professional bodies have highlighted problems with the standard of care at some private clinics treating NHS patients.] However public scrutiny of these companies is shrouded behind commercial confidentiality. Privatisation of the out-of-hours GP service has produced several tragic incidents resulting in the deaths of patients. The regulation and safety of large-scale private sector provision for the NHS patients is at best unproven
    5) The costs of competition have been massively underestimated. International experience suggests the transaction costs will be substantial[10]. This burden will include not just the cost of the new competition regulator Monitor, but huge spending on lawyers for bids and contracting, as well as fees for accountants, management consultants and on marketing. NHS hospitals and GPs will be increasingly spending public funds on these unnecessary, non patient-related fees. Commissioning already consumes 14% of the English health budget, but expanding competition could force up transaction costs to 30% of all health expenditure – as in the US.
    The bill should protect the values of the NHS not undermine them. It places business motives at the heart of the NHS and passes control in to the hands of commercial companies that will be difficult and expensive to regulate. As the new budget holders, GPs will become “rationers” of care and will likely be compromised by their business interests. The relationship between doctor and patient will change and some trust lost. Services will be more difficult to plan around patients’ needs. Many medical conditions require considerable cooperation between agencies to achieve a high quality of care, but the bill will fragment provision between competing businesses. Quality, value and fairness will all be undermined. The values of the NHS will be eroded and eventually the public’s trust will fail too.

  377. Bryan Rhodes says:

    As a consultant surgeon working within the NHS I feel strongly that the plan to open up a free market in healthcare and ‘ show no mercy’ to the NHS i.e. not allow local NHS Hospitals to be a ‘preferred provider’ would be disastrous. This would ultimately lead to an American system which would be twice as expensive, encourage unnecessary treatments and ultimately leave some patients with little or no care. Bevan’s unified NHS Hospital network with Hospitals and clinicians collaborating ( not competing ) to get the best results for patients is a key feature of our fantastic NHS.

    The government does not have a mandate for allowing market forces to destroy our key NHS services and the process of allowing foreign profit hungry private companies to have lucrative ‘cherry-picking’ contracts whilst NHS Hospitals take on all the difficult cases and complications (and also deal with all the emergencies and training ) has to stop.

    When I see a patient I am only interested in getting the best result I can for the patient within the resources available. My decision is not swayed by financial considerations but is based on clinical merit only. Where necessary I should be able to refer the patient to another NHS consultant without having my decision vetoed by a panel of bureaucrats. GP’s and Consultants do not support the Governments proposals to marketise our Health service or sell it to private companies. Lets keep our NHS public. Mr Clegg has got this one right.

  378. Janet Dickinson says:

    Do we learn nothing? By choice and competition you mean privatisation. Is that because it worked so well with “outsourcing” the hospital cleaning contract? Oh no, actually it didn’t did it. Huge increases in hospital acquired infections because the cleaners are loyal to their employer and not to the hospitals. When they’re told to cut costs to ensure shareholders get their money, they cut corners.

    Ask any sick person who has had the misfortune to endure a Work Capability Assessment by a “healthcare practitioner” about how the private sector put money before anything else. They have to, they’re businesses – and if a business doesn’t make money it goes out of business fairly quickly. I can’t see what’s so difficult to understand about this. A private sector company only has one target and that’s quite simply ‘profit or bust’

    The private sector is the backbone of the country, they need to make money and on the whole they do it very well. But their place in the National Health service should be confined to providing goods and services at the going rate – not cherry-picking the most profitable of the services the NHS currently provides. Remember WE have paid for this service already through National Insurance and tax.

  379. Sara says:

    I do not want providers to compete for me – I just want to be given a decent service. The government has already been shown (by independent research it chose then to ignore) that allowing private providers to ‘compete’ for services which deal with the vulnerable (in that case it was with job seeking) doesn’t work. The private companies cherry pick the profitable cases and leave the hardest to deal with to the diminishing state services to pick up. If the NHS isn’t supported to provide a comprehensive service it will collapse – and then we will be left only with private companies providing for lucrative services, and the sort of costly ongoing services for the most vulnerable (poor, elderly, people living with longterm conditions and disabilities) will be left by the wayside.

    Considering we have all been paying into the NHS all of our working lives I find it incredible that Lansley has the audacity to even suggest what he has – and to press ahead with it when nurses and doctors have voted overwhelmingly against both him and his proposals is just arrogance beyond belief. To then pretend to have a real ‘listening’ period just twists the knife in further, when most of the ‘listening’ events go unadvertised and have taken place before anybody gets to hear about them, and staff in the NHS are being told to press ahead with implementing the changes.

    We criticise ‘leadership’ such as Gaddafi’s – but tell me please, when innocent people start dying because they can’t get treatment, precisely how does Lansley’s style of leadership differ?

    And one final question – how do we get proof that Lansley has actually listened to all of this? I will be certainly be awaiting answers to my questions before any of these reforms go further…

  380. Leigh says:

    Choice in the realm of competition is not an appropriate model to base the NHS on, full stop. Competition, I fear, would mean the result of holding down costs whilst maximising profits rather than providing high-quality health care efficiently and effectively.

    Many people end up losers under such a system, and like many doctors and nurses say, many in deprived or rural areas would have no choice anyway.

  381. Rajvinder says:

    Patient choice already exists and this has already led to services competing in some areas. Where patients are dissatisfied with a service they should be encouraged to excercise their choice as well as raising their concerns, this will drive improvements in services that need it. =no need for the reforms that are being forced through

  382. Rajvinder says:

    patient choice already exists. patients hould be encouraged to raise concerns when they are disatisfied with services and also to excercise their choice. this should provide sufficient ‘drive’ and competion to ensure services continue to improve.

  383. YS says:

    Competition will lead to cherry picking by Private Providers who pick off and provide those services that are more profitable. high demand and high cost services such as A&E will not be attractive for independent providers for obvious reasons.
    Developing a competitive market will only drive costs up – having tendered out health services in the recent few years in my role – transaction costs are high for e.g. tupe of existing staff to new providers is costly, time consuming.
    often patients dont want a choice of who provides their treatment they want high quality caring health services that they trust in. they want to be able to choose their appointment time and date and maybe which consultant sees them. you dont have to have competition to provide this choice.

  384. Andy Bruce says:

    As an accountant can I point out that the transaction costs associated with running the proposed convoluted and inefficient GP led commissioning system will end up being enormous and will far outweigh any ‘savings’ from shedding (albeit at huge expense and probably temporarily) the current staff in SHAs and PCTs.

    If, as I suspect, the real intention of the reforms is to fragment and ultimately privatise the NHS then this may well be a price the Coalition are willing to pay.

    We need to stop running huge unproven ideological experiments on a treasured and much envied public service and operate the NHS as the multi-billion pound business that it is.

    We need common objectives, set by the Public Health professionals, and clear targets that people understand and agree with. Let’s operate as one organisation rather than perpetuating the loose confederation of semi-autonomous self-serving organisations which the internal ‘market’ has produced to date and which will only get worse under these proposals. Healthcare should be more about co-operation than competition.

    We are in danger of producing a generation of leaders and managers who can only function in the chaos of continual re-organisation and who spend more time competing against their peers in other organisations than helping the NHS become more effective, economic and efficient.

    If we really want to save money, to pay for our ageing population and the increasing costs of drugs, follow the lead of the Scots and Welsh, and abolish the un-proven (even after 20 years) purchaser/provider split which I suspect adds little but cost to the mix.

    I would suggest we need to Simplify and Save rather than Complicate and Cost!

  385. Jenny Davies says:

    Patient satisfaction with the NHS is high, waiting lists are low, and massive sums of money are being saved by acute Trusts up and down the country. I am not a stupid woman, but cannot understand why we need yet more unnecessary, expensive, reformative turmoil, nor why these proposals were not outlined in the Conservative manifesto, nor why the LibDems are supporting them, nor why Labour aren’t voicing any meaningful opposition.

    After 30 years in the NHS I can honestly say that I have never seen morale so low. Even our GOLD-PLATED PUBLIC SECTOR PENSIONS are under attack – strange that nurses didn’t face this pension envy in the 80s and 90s, when we were always being told how marvellous we were for doing such a s*** job for so little reward.

  386. Jennifer Martin says:

    This listening exercise is based on ridiculously leading questions.

    “How can we best ensure that competition and patient choice drive NHS improvement?”

    This starts from a position that competition and patient choice will lead to improved outcomes – where is the evidence for this?

    The majority of the evidence I have seen suggests that competition leads to increased health inequality and reduced access.

    The mantra of ‘no decision about me without me’ is a great one. However, it should be remembered that when this phrase was coined in the late 1990′s it was all about ensuring that patients were involved in treatment decisions. It didn’t have anything to do with competition or choosing between different providers.

    There is a great deal of evidence of the benefits of shared decision making. The WHO has conducted and collated a lot of research in this area and has shown, for example, that shared decision making results in increased compliance with medication regimens and can also lead to improved patient satisfaction. Patients can only make truly informed choices if they believe that they and their clinician are working towards one clear goal – patient health. If patients believe that clinicians have vested interested in certain treatment or providers then this will ruin this relationship.

    As for competition, there is, as far as I am aware, no evidence that competition results in improved patient outcomes. As someone who has worked in health research for many years the idea of competition between providers is anathema to me. Healthcare is a team game – we improve by collaborating, sharing best practice with eachother and seeking second opinions when we need to. We do not compete – we work together.

    And as many others have already said: The NHS belongs to the British people. It is not yours to sell Mr Cameron.

  387. Celia Gardner says:

    I don’t want “competition” or “choice”, I just want competent doctors who can treat my mental illness without me having to go into massive debt about it. This is what most ill people want. Choice is for things like “do I want a blue jumper or a green one?” and competion is for sports and the like. Stop trying to make a profit out of society’s most vulnerable, you bunch of vultures.

  388. Gordon Morris says:

    Taking each question in turn:

    In many areas there is, in terms of hospital provision, only one choice, and often only one GP surgery. This is, therefore, a false – and leading – question. Most people I know are not concerned about choice (which, ineveitably, will bring with it bureacracy associated with contracts, prices etc.). They are concerned about having faith and confidence in local services and local practitioners. There is a need for transparency about the quality of these servcies, and the performance of practitioners, but arranging some sort of management consultant-led and designed “market” will not provide transparancy – quite the opposite.

    Again this question misses the point and does not address people’s concerns about, a) the proposed reforms, b) the need to improve certain aspects of the NHS, such as elderly care (to take this as an example, the need is for local discipline and management, not national reorganization and the organizational disruption which will surely follow from the proposed reorganization). Politicians of all hues appear to be wedded to the idea of large-scale – strategic – management change, rather than the less exotic but managerially logical apporach associated with incremental chaneg based on the assessment of needs within, eg, a particular discipline (eg oncology) /area (care of the elderly).

    Patients do not necessarily want choice. They do not appear to be asking for it. Where on earth is the evidence that this is what people want? Why this preoccupation with choice? Is it because the providers of choice will come from the private sector? Where is the evidence that the private sector is somehow best (we are, after all, living in the aftermath of private sector failure in the finacial sector, and the evidence from, eg, the US Commonwealth Fund, suggests that insurance-based healthcare is better than socialised healthcare.

    Please listen to the people you serve (and I don’t mean the private healthcare providers!). The SoS does not have a monopoly of wisdom or experience, and his party does not, in reality, have a majority or a mandate for these changes.

  389. L Duke says:

    Patient choice is important when they have been given all of the facts so they can make an informed choice, have the capacity to make that choice and have not been overly influenced while making the choice. But all too often no information is provided to patients about the options they have, they are given at a time when they have other more pressing issues to hand (keeping well) or have influencing factors which may not enable them to fully understand their choices. Which independent body will provide the information – correctly and accurately, giving up to date information on all of the services available to them and how can private companies be prevented from looking like the better choice through their slicker advertising and offering of unrealistic outcomes. In Neurological rehabilitation – one of the many forgotten parts of the NHS – patients have a wide range of private options already – but do they need it and have clear outcomes or just want it because its there? Evidence so far would suggest a lack of monitoring of this issue.

  390. Gordon Morris says:

    Taking each question in turn:

    In many areas there is, in terms of hospital provision, only one choice, and often only one GP surgery. This is, therefore, a false – and leading – question. Most people I know are not concerned about choice (which, ineveitably, will bring with it bureacracy associated with contracts, prices etc.). They are concerned about having faith and confidence in local services and local practitioners. There is a need for transparency about the quality of these servcies, and the performance of practitioners, but arranging some sort of management consultant-led and designed “market” will not provide transparancy – quite the opposite.

    Again this question misses the point and does not address people’s concerns about, a) the proposed reforms, b) the need to improve certain aspects of the NHS, such as elderly care (to take this as an example, the need is for local discipline and management, not national reorganization and the organizational disruption which will surely follow from the proposed reorganization). Politicians of all hues appear to be wedded to the idea of large-scale – strategic – management change, rather than the less exotic but managerially logical approach associated with incremental change based on assessments of needs within, eg, a particular discipline (eg oncology) /area (care of the elderly).

    Patients do not necessarily want choice. They do not appear to be asking for it. Where on earth is the evidence that this is what people want? Why this preoccupation with choice? Is it because the providers of choice will come from the private sector? Where is the evidence that the private sector is somehow best (we are, after all, living in the aftermath of private sector failure in the financial sector, and the evidence from, eg, the US Commonwealth Fund, suggests that insurance-based healthcare is better than socialised healthcare)?

    Please listen to the people you serve (and I don’t mean the private healthcare providers!). The SoS does not have a monopoly of wisdom or experience, and his party does not, in reality, have a majority or a mandate for these changes.

  391. Gordon Morris says:

    Taking each question in turn:

    In many areas there is, in terms of hospital provision, only one choice, and often only one GP surgery. This is, therefore, a false – and leading – question. Most people I know are not concerned about choice (which, inevitably, will bring with it bureaucracy associated with contracts, prices etc.). They are concerned about having faith and confidence in local services and local practitioners. There is a need for transparency about the quality of these services, and the performance of practitioners, but arranging some sort of management consultant-led and designed “market” will not provide transparency – quite the opposite.

    Again this question misses the point and does not address people’s concerns about, a) the proposed reforms, b) the need to improve certain aspects of the NHS, such as elderly care (to take this as an example, the need is for local discipline and management, not national reorganization and the organizational disruption which will surely follow from the proposed reorganization). Politicians of all hues appear to be wedded to the idea of large-scale – strategic – management change, rather than the less exotic but managerially logical approach associated with incremental change based on assessments of needs within, eg, a particular discipline (eg oncology) /area (care of the elderly).

    Patients do not necessarily want choice. They do not appear to be asking for it. Where on earth is the evidence that this is what people want? Why this preoccupation with choice? Is it because the providers of choice will come from the private sector? Where is the evidence that the private sector is somehow best (we are, after all, living in the aftermath of private sector failure in the financial sector, and the evidence from, eg, the US Commonwealth Fund, suggests that insurance-based healthcare is better than socialised healthcare)?

    Please listen to the people you serve (and I don’t mean the private healthcare providers!). The SoS does not have a monopoly of wisdom or experience, and his party does not, in reality, have a majority or a mandate for these changes.

    • Michael Burt says:

      Well Said Gordon Morris I wish I could put it as well as you and others Have This is realy about directing tax payers money into the pockets of the conservative party’s rich freinds and funders my experience of the health service has been good I would not be here without them and their dedication ,if BT had not been privatised we would have superfast Broadband, please do not let the same happen to our health service

  392. Claire says:

    Patient choice will depend on availability of providers and services between which to choose. Today the children’s minister said that the NHS is failing to support vulnerable young people – supply of speech therapy and basic equipment for children with special needs has become a postcode lottery. “A six-month wait for speech and language therapy can be critical; an 18-month wait can be really critical.”
    How will the commissioning support children with severe or multiple health and learning disabilities?
    How will local authorities and commissioning consortia work together to deliver the new single care plan covering schooling, health and social services from birth to the age of 25?

  393. HN Atkin says:

    Where is the evidence that competition in the provision of Health services will improve those services? I understand that transaction costs per procedure will increase from 10 to 20% of the NHS budget – one fifth of the whole budget going to administration of the competition laws (ensuring that no-one has an unfair advantage by being better at providing a service – rather than cheaper), filling the pockets of lawyers – what a waste of public funds. Such a shame, when there are dedicated people willing to collaborate – who willl be prevented from working co-operatively by the new ‘Monitor’ organisation, in case multinational companies are disadvantaged. How appalling – make improvements by all means, but don’t make health care about profit only..

  394. Hannah Walter says:

    I do not agree that choice of “provider” is necessary to enable patient choice.

    The NHS is already able to provide a choice of services and hospitals or treatment centres. I do not believe a further choice of providers is necessary or desirable.

    If different providers are introduced there must be parity of quality and cost for treatments. This should be regulated by an independent body e.g Monitor. It would also be vital that services and resources for staff (e.g. training) working for different providers, are the same across the board to ensure that providers do not attempt to cut costs in this area.

    Choice of Provider could actually lead to a reduction in patient choice as service providers are unable to forecast patient numbers and thus will have to operate with some spare capacity. Some excellent small service providers may find that this situation makes it impossible to operate (and go bust) as their income fluctuates in an unpredictable way. In addition it seems perverse that services will have to run with spare capacity at a time when the NHS is trying to reduce spending.

    Research which has already been submitted to this consultation and others on the NHS White-paper by UNISON has shown that patients do not desire a choice of provider. They want a good, local service, free at the point of use. I.E. the NHS.

    I am concerned that those without the financial means or personal health to be able to travel would find their choice restricted.

  395. John Bickerstaffe says:

    The idea that further cuts within the NHS will result in improvement is dangerous.

    For many years the NHS has been asked to accept cuts and we are again being asked to do the same. We are now in a position where all savings that could have been made have been made, so any further changes will directly affect frontline services.

    The idea that a private provider will produce a more cost effective service is also dangerous. Private providers will offer the minimum of service as they are in business to make a profit. (Remember hospital cleaning services being privatised?).

    As clinicians within the NHS are asked to do more, their will to remain in the NHS providing an excellent service dwindles. Then the burden of doing more with less resources is left to those who believe in the NHS and who have stayed in post so far but these clinicians get to a point where they find the situation unbearable. The current freeze on recruitment does nothing to help this situation and so the circle continues.

    Mr Lansley is correct the amount being spent yearly on health care is increasing every year – it always will do as the number of new treatments available increases yearly as does the ever-aging population (this is not news).

    NHS staff have been asked to put up with the following in recent years:

    Pay freeze for the past 3 years
    Pay freeze for the next 3 years
    An increase in the number of years they have to work before they can now retire
    An increase in payments to their pension
    A reduction in their final pension

    Morale amongst NHS staff is at an all time low.

    Bear in mind if you continue that strikes are a real option throughout the NHS. Where does this leave the politicians then when patients aren’t being seen? Remember the next election will be here sooner than you think.

  396. Steve Jones says:

    Re: competition.

    The Conservatives added competition to the rail network, with awful results. Now our railways cost much more than other countries. Now the same party wants to add competition to the NHS. I fear the same result will happen. Only this time, it is lives at stake, not just transport.

    I can’t see any direct benefit to me by adding competition. I just see a race to the bottom, with big business gouging profits out of sick people. That’s the last thing Britons want – some sort of half-baked “competition” ideas. My advice: run the NHS properly. Don’t think that some political “competition” dogma can do that for you – you just need good people who know what they are doing.

    Re: choice. More political dogma, I’m afraid. Just give me one good thing, rather than a wide choice of half-baked ideas. I just want the treatment, not some puzzle dreamed up by a right-wing free-market zealot. Choice is a “nice-to-have”. Good treatment is a must-have, and I’d choose it over more “choice” every time!!

  397. Karen says:

    There is enough competition in the private sector. The NHS may not work for everyone but it is a viable alternative to paying for treatment. Right now the public has a choice, pay for treatment privately or use the NHS, if you remove the NHS you remove one of the choices, how does that help?
    As a country we NEED the NHS, we also need politicians who care about EVERYONE, not just the people who have lots of money.
    The majority of the people of this country do not want to lose the NHS because we know that without it we are doomed to the kind of health system actively failing the majority of American people right now. There, if you have insurance or can pay privately you’re just fine, if you haven’t you go without and maybe die! Why the hell would we want that here?
    You only have to ask Americans and they’ll tell you they would love a NHS like ours. I am not blind to it’s faults, I know it needs improving, but it works hard for us and it is a free service provided by the country’s people for the benefit of it’s people.
    It needs saving, not scrapping.
    GET YOUR HANDS OFF OUR NHS!!!

  398. Julian Wilson says:

    I was about to remind the listening excercise of the recent research provided to the government by Unison. I was about to point out that most patients’ choices are based on two simple questions “how close to home?” and “how soon”. But Hannah Walter puts it so much better than I could.

    The notion of ‘choice’ is not about giving taxpayers and vulnerable, infirm and elderly patients what they want, it is about giving private healthcare companies the greater share of the ‘market’ of healthcare they and their shareholders want.

  399. Christopher Pankhurst says:

    The proposals which are intended to open up the NHS to private profit is the most dangerous of all these damaging proposals. The result of allowing private firms into the health system would be to destroy the integrity and patient-centred approach of the NHS, where devoted employees work hard in the interests of patients. It would replace this with a profit-centred system, and would spell the end of care available depending only on need.

    It is well known that US health care costs approximately (people argue about precise figures) five times British health care, but in the US, only 60% of people receive it. All international surveys show that the current British system (with its inevitable problems) is far and away the most efficient way of providing care. The US system does not simply give more competitive provision; it simply adds a whole system of fees, charges and percentages between the taxpayer and the care system, in the form of insurance salesmen and their costs.
    It is beyond belief that the government should be trying to move the most cost efficient and comprehensive service in the world towards the least efficient and selective system which operates in the USA.

  400. Beth-Anne Mancktelow says:

    ‘Competition’ may result in organisations trying to be more efficient, however, there is the possibility that inappropriate goals or targets are set as benchmarks for success. For instance, a speedy pathway for a hearing aid fitting might be seen as appropriate, yet this follows the outdated biomedical approach to healthcare – where you are simply attempting to address an impairment of an organ. Instead, the World Health Organisation recommends following a biopsychosocial approach, whereby you consider the individual in their entirety and the impact of the problem (e.g. hearing loss) and how this limits their life. When one does this, it is clear that a broader rehabilitation approach is necessary and not simply the application of a device. This is based on evidence and the government should take time to review the evidence-base for intervention, particularly for long-term conditions. Thus the fitting of a hearing aid, although speedy in a competitive market, will not provide the additional necessary support in order to facilitate increased participation in everyday life as defined by the individual. If we are driven entirely by competition, we will lose sight of the World Health Organisation’s principles and revert to an archaic system of healthcare delivery where faulty organs are ‘fixed’. It just isn’t possible. Keep the NHS as the primary provider – it follows evidence-based approaches and includes rehabilitation as a necessary part of healthcare.

  401. Tom STocker says:

    Is there any way that patients can break free of the post-code lottery and choose where they recieve outpatient treatment with the hel[p of their GP? This should improve services and reduce complacency of local services (with protected A and E and services that people can only access locally like routine treatments for chronicly ill patients with a need for many contact hours with nhs services)? But there’s also a danger to it – what if there’s collusion between GPs and consultants? How would this be monitored and prevented? Without any controls in place it’s a pretty risky move?

  402. David Robinson says:

    I wonder what will happen to all of these comments when the listening exercise concludes. Will anything be published? Since the “Liberating the NHS” consultation finished, I haven’t seen any documents that tell me the outcome of the consultation: the views or concerns expressed; the government just pushed ahead until the rising furore prompted the current pause. Who does a consultation and then doesn’t publish the results?

    The government have tried to bamboozle us with economically-driven arguments for change. In fact, the NHS is internationally recognised as offering excellent value for money, is envied by many other countries, and has been working hard to save money as part of its QIPP programme with truly spectacular savings. Now, organisations are being told to set aside all those savings to pay for all the redundancies they’ll need to make (so that’s morale-boosting, natch), and the infrastructure support people who like everyone have been instrumental in making savings continue to be villified by the politicians (though less so than previously now that clinical areas have lent their support). The proposed changes will cost a fortune to implement. “Liberating the NHS” was never about saving money: it was all because a few politicians bought that boloney that was spouted in the USA in response to Obama’s proposed health reforms, that a free-to-use, socially-funded, non-competitive and non-profit health service is somehow “being a bit Commie”.

    Government, if you really are listening, listen to this… If it ain’t broke, don’t fix it. The NHS was performing better than ever before you started meddling, and was in the process of leaning and saving money without your ridiculous idealogical and unaffordable crusade. Bear in mind that if you manage to destroy the NHS your political careers will be forever tarnished, probably terminally. Oh, and please publish the findings of your consultation.

    (By the way, for the record I’m not the same David Robinson as wrote the “NOBODY” email earlier on: we are a common name I guess. Just wanted to clarify these are two different people, not the same person banging on :-) But I firmly endorse the views of my namesake)

  403. LJ Hutchins says:

    I am really worried about plans to involve private companies in healthcare provision. I don’t believe that introducing competition into the NHS will improve services and I also don’t believe that it is what patients want. Much the same as with schools, we just want to know that we can use our local GP practice or hospital and get a decent service.

    While there may be some areas of public policy where competition can improve effectiveness, it would be a disaster for healthcare as circumstances in the US demonstrate. I fear that companies will cherry-pick the profitable parts and let the rest go hang. I think that voluntary organisations will not have a hope of competing against the tendering power of big multinational companies intent on extending their reach into public services.

    I think these ‘reforms’ are more about promoting an extreme market-based ideology that does not have mainstream support among the British electorate – hence the fact that the Conservative Party was not able to secure a majority in parliament. I don’t believe the NHS can ever be safe in the Tories’ hands and I think the proposals now being discussed show claims made to the contrary during the general election were lies.

    I think the government should be governing for the people who elected it, not for business interests. And I think these pernicious proposals should be scrapped.

  404. Mark says:

    If the principle behind competition in the NHS is to improve services then ‘groundrules’ need to be fair to all parties. In a growing number of cases qualified/willing providers are employing NHS medical and clinical staff on a sessional or cost or case basis, as additional to their full time substantive contracts with local NHS Trusts. As such the Trusts carry significant overhead costs for training, education and clinical management, in addition to the emergency service rota. If willing providers wish to employ NHS staff then as a minimum they must pay a contribution equivalent to the NHS Trusts. Without this their ability to under cut tariff rates is an unfair advantage on NHS Trusts. Given the commercially confidential nature of these arrangements, it could be argued that clinicians should not be allowed to work for directly competing organisations without explicit agreement of both parties. Examples are emerging where clinicians employed by alternative providers to provide ‘pile them high, sell it cheap procedures’ are undermining the viability of their employing Trust and its ability to provide a comprehensive range of services to the local population…..that certainly does not sound like improvements in services to me ….rethink needed fast !!!

  405. Felix Shaw says:

    These changes are the opening of flood gates to privatization of the NHS, and is a stealth tactic being employed to get us towards the US system of HMO fat cats. Do we really want poor people dying from preventable diseases, families being bankrupted to pay for treatments and people working until their dying day to pay for medication, because that what happens in the US and its what will happen here. These changes are a terrible risk and it will be a tragedy if they go through. I have written to my Lib Dem MP (Simon Wright) asking him to vote against them.

  406. Dene Stevens says:

    Pursuit of financial sustainability alone (without environmental and social sustainability) is not …. sustainable.

    An excellent way of creating choice and competition for the NHS is to ensure the social and environmental impacts of products/services are reported in a transparent way by healthcare providers. This will drive up the quality of healthcare by enabling patients to make ethical decisions and commissioners to purchase sustainable products/services. For example, contract wording could state: “the Provider will ensure a process and system is in place to measure, monitor and reduce carbon significantly across the organisation”.

    Procurement in the NHS is responsible for 60% of the entire NHS carbon footprint. Making sure that carbon reduction is addressed systematically across the service will help reduce this percentage dramatically, drive up quality and reduce costs.

    Measuring and reporting on sustainability is an important element to measuring excellence and quality while providing choice and competition. The more information and choice patients and commissioners have, the greater the competition. An ability to assess the sustainability credentials of an organisation means users can choose services more ethically, something which the public is increasingly demanding.

    This must be sufficiently sophisticated to take account of the circumstances of each patient. For example, a hospital in Inverness may score 10/10 for carbon management, but clearly that doesn’t mean that the most carbon-efficient choice for every patient would be to travel there to receive treatment. This also accords to some extent with the wish of many people simply to have confidence that their nearest hospital provides a friendly efficient and evidence-based service. However in cases where care can be delivered remotely, then carbon-efficiency becomes location independent. Any mechanisms that would accelerate the development (and patient acceptability) of remote care services would enable wider competition independent of location, and more carbon-saving.

    I believe that public health should also be working more to identify how choice and competition can be better fostered in areas that can achieve multiple benefits in cost, carbon and health. For example, introducing more transparency into the market for private renting, by ensuring more full information on the energy efficiency of lets, would enable tenants to put more weight on this when choosing a property, ‘nudging’ landlords to improve the efficiency of their properties, thus addressing fuel poverty, improving a difficult part of the housing stock and reducing national energy demand.

  407. Hilary Kinsler says:

    Competition is a massive waste of taxpayers money. The reality, especially for those who need the NHS most such as the elderly, is that they need local services to be as good as possible. Billions and billions of pounds are wasted on managers and commissioners which could be spent on clinical services which are at breaking point. Scrap the expensive, wasteful, purchaser provider split, scrap the market, invest in clinical services, cut the wasted billions spent on management, scrap foundation trusts and measure and publish outcomes and make service users groups compulsery. Much much cheaper, miles better and doesn’t involve privatising the NHS.

  408. Holly Lyne says:

    I seriously doubt the effectiveness of competition within the health service. I think that cooperation is actually the way to go in order to provide safe, efficient and effective care and choice for everyone.

  409. Eugene McGuigan says:

    I do not agree with either of the words (choice or/and competition). These are not words of the National Health Aervice. They are the Conservative weasel words for greed and selfishness. Private enterprise is in the business of
    (1) making Money
    (2) killing off the competition.
    I will put up with this make believe farce with regard to transport and utilities.
    I will not put up with it when it comes to the NHS.
    Lansley and other shades of government must realise that the NHS belongs to the people and not business.
    I will not condone any structural change which interferes with the concept of the NHS and will do all I can to fight profiteering from illness and death

  410. Alan Shaw says:

    Private companies should not be part of service provision. The NHS has improved greatly over recent years and there are many good examples of improving efficiency. Let the Foundation Trusts drive efficiency and quality forwards – the mechanisms are already in place with incentives to do this. Centralisation sounds attractive with presmued economies of scale – but does not necessarily work in a labour intensive CARING organisation like the NHS.
    Please stop using the NHS as a political football and allow it’s empoyees, clinicians and managers to do what they do best and continue the good work of recent years.

  411. Teresa says:

    It shouldn’t be about competition but rather best practice and helping to elevate and improve care across the board, by introducing competion you end up with hospitals trying to be out-do other hospitals rather than mutual cooperation in becoming the best they possibly can. Introducing market forces can only lead to a deteriation of patient care.
    The NHS is not perfect, it has too many managers and there’s always a new government coming along trying to show off by changing it – usually for the worse. The NHS is world leader in healthcare provision, and even today 65 years after its’ inception the NHS remains unbeaten. It works, and it works well – more often than not at any rate.

    Scrap the plans and keep our NHS out of the hands of private business.

  412. S. Aspinall says:

    This is a typical Tory tactic, sell to the highest bidder. The NHS may not be perfect but it does a fine job. The last thing patients want when they are ill is to have to decide where they want to receive treatment. Most people want to be close to home so family and friends can visit. Look what happened when energy was privatised; prices soared and now we have a confusing nightmare of different schemes by different companies all out to make money. It may have given us more choice but it certainly hasn’t made energy any cheaper by encouraging competition, quite the opposite.

    I have family in the States who thought private healthcare was great until their insurance company didn’t want to insure them anymore because they became ill.

    David Cameron wouldn’t have got a look in had people known what they had in mind when we went to the polls. He should tell Andrew Lansley to leave our NHS alone. People have long memories and this government will never be forgiven if they destroy the NHS.

  413. Shane MacSweeney (Vascular Surgeon) says:

    Cameron says he will not gamble with the NHS but that is exactly what he is doing. Privatisation and competition may well have some benefits but is also has the capacity to do major harm, destabilise other services, “cherry pick” easy cases and leave high risk expensive cases untreated. It will take time to work out how to maximise any advantages and minimise the downside, by all means run some pilot projects but wholesale, rapid privatisation is a wreckless gamble which will cost millions with no guarantee of a better service at the end and a good chance of a worse one.

  414. Paul Weatherill says:

    I would like to say as a long term cardiac/heart failure patient that the standard of care has certainly dropped during the last 2 or 3 years, it is not the nurses fault but the managers who treat patients as numbers and not as patients, these managers are not there for the benefit of the patients but the past and present governments in providing a cheap service like a fast food outlet so they can meet their targets.
    Recently i had to suffer the agony of a gall stone moving in my gall bladder in November last year it was not picked up at that time it was not until this January that i decided that the pain was to unbearable to bear and asked to be admitted in to hospital, whilst in hospital it took approx 4 days for them to decide that my gall bladder was the problem, even though me the patient had told them on numerous occasions that the problem was with my gall bladder, it was a further 6 weeks before it was taken out by microsurgery but on the day following the removal i suffered a heart attack, a request was made 5 time for a cardiac doctor to come and see me but they did not come, i was eventually discharged on the saturday evening at 5pm, a week and a half later i suffered another heart attack and was admitted to the same hospital, 2 days later suffered another heart attack (this was my 8th one since July 2001) the doctors did not believe me when i told them i had a heart attack until the got the blood results back 12hrs later, it is now nearly 3 months since the last one and it will be another month before i find out what they are going to do to me.
    I have to put up with this because unlike the southern half of this country of ours, my other cardiac hospitals are more than 60 miles away from where i live, i would rather they ensured the doctors went back to treating the patients rather than trying to reach so called target figures at the expense of the care for the patients.
    Just so you know i have had a double heart bypass already, suffer from heart failure, an ectopic heart beat, a leaking heart valve and are a type 2 diabetic sufferer
    More emphasis should be placed on the correct care and treatment of the NHS patients and employ only the necessary experienced managers to run the hospitals, at the moment there are too managers and not enough staff running the hospitals

  415. Chris Torrero says:

    If you ask the average person what they think the main problem is with the NHS, they will tell you that it is getting to see a doctor in the first place and the need to “book in advance” to be ill.

    It’s amusing that the BMA are perfectly happy for individual hospitals to compete, but at the same time want GPs to form “consortia”, thus eliminating competition.

    The first priority should be to give the patient real purchasing power in the form of a voucher good for his/her share of the practice overheads. This voucher can then be taken to any (yes any) GP’s surgery (as out of hours visits can now be provided by deputising services) thus making the payment follow the patient’s choice. Payment for treatment would be separate and continue as at present. One useful benefit of this would be that patients in employment would be able to be treated by a GP near their workplace, making the process more convenient.

    It is notable that in places where GPs compete for patients, such as Spain and Australia, evening surgeries are not a distant memory as in the UK.

  416. Francis Deutsch says:

    The question is misconcveived. It need first be shown that competition and patient choice will actually drive and not hinder NHS steady and continuous improvement.

    Regards choice, I want to rely on the recommendation of my trusted G.P. – I am unable to choose between local consultants, whose ability and standing is not in the public view until there is a major scandal or s/he retires. In serious or complex matters convenience of access and quality of food are very secondary issues, which may give an impression of patient choice, as effective as moving the deckchairs on the Titanic !

    Competition is appropriate for small shops in a High Street. Medical services need to be planned on the widest possible scale to meet a demand which is almost always caculable. To maximise use of scarce resources requires co-operation not competition.

    There is no reason why the not-for- profit sector should not contribute – co-operation is basic to this sectors’ approach. Not so the commercial sector who needs always to take economies of scale into consideration; otherwise profits are too doubtful.

    Minimal reading about the the provision of medical services and health insurance in the USA is persuasive in showing that a commercial approach to medical services spells the death of a compassionate, careing public service ethos. Furthermore the USA health services are known to be amongst the most expensive in the world, and among average and low wage earners adequate health insurance cover is considered unaffordable. US public health care is therefore internationally judged to be inadequate.

    If, as is alleged, and seems likely, this is “creeping privatisation” we are overwhelmed with examples of this providing a poor service for the consumer. The great utilities are regional monopolists and their continuous price rises are barely held in control by a weak public interest controller and give rise to regular loud and ineffective public protests. Postal charges have ‘gone through the roof’ because of cherry picking by the private sector. I only need to mention rail – their failings are daily headline news.

    We are assured that part of this is irrelevant because the NHS will remain free at point of use. The assurance is insufficient: the service may be free but access is charged for by punitive parking fees in England. Is it the hospital or a contractor who benefits from the very high charges for use of the hospital telephone service? or hospital TV cards? These might only be the first step: medical services remain free but “hotel charges” for in-patients are already occasionally mentioned.

    A public service can only be a good service if it is publicly provided, transparently controlled and ultimately answerable to Parliament.

  417. Margaret Bevan says:

    This consultation question assumes – without actually making the case – that choice and competition will drive improvement in the NHS.
    If you are an ordinary person, diagnosed with a serious illness, you do not want to be offered ‘choices’ or to have to weigh up the pro’s and con’s of competing providers.
    You want your well-qualified, local GP to refer you, promptly, to your local, well-staffed and properly equipped hospital, which will treat you quickly, with the most up to date techniques available.
    If all NHS hospitals were properly staffed and funded and managed by medical experts, why would we need choice or competition?
    If NHS services are put out to tender by any willing provider, then the competition will be to provide the service more cheaply than one’s rivals, in order to win the contract and to maximise profit for shareholders. This could be achieved by using less effective treatments, rationing healthcare, having longer waiting times and fewer staff.
    It seems sensible not to take this risk.
    Instead, let us look at improving the service provided by the NHS.
    I have seen no argument to convince me that this is best achieved through complicating treatment with the need for competing healthcare providers to maximise their profits

  418. Alan Pool says:

    Patient choice is irrelevant if it is a choice between 3 poor providers just interested in making a profit and not giving the patient the best treatment.
    I am only concerned with having one excellent hospital run by the NHS in my area. I don’t need 2 or 4, I just want one that I can be sure of doing what is necessary for my family when we need it, free at the point of use.

  419. John says:

    David Cameron prior to being elected stated that evolution not revolution was needed in the NHS, having been elected, what is proposed is clearly revolution. The NHS in its current form is one of the countries most treasured institutions, it may not be perfect and there is room for improvement but the fundamental principles of the current format are entirely sound.

    What the coalition government is trying to intoduce via the back door is a privatised American heath system. Whilst competition may be fine in the business world to reduce costs this concept does not tranfer to a healthcare system where the main goal should not be purely financial profit.

    Patient care needs to be at the heart of the NHS not ruthless competition and profiteering by private company’s whoose main goal will be financial profit.

    Many healthcare proffesionals have stated that the proposed reforms would be a monumental disaster for patient care, they would lead to enormous inequalities with private company’s cherry picking the lucrative areas and ignoring the non-profitable areas.

    I am fundamentally opposed to changing the current structure of the NHS. Scotland is retaining the “old” system and data has clearly indicated that patient care has gradually improved at the same time that costs have been reduced. If this can be done in Scotland it can be done in England and Wales

  420. Void Exercise says:

    This listening exercise has to be stopped and corrected.
    I am deeply outraged that this listening exercise has been designed and implemented in the way it is.

    - There is not enough publicity. No one I know (family or friends) know that there is a listening exercise, let alone how to get involved

    - The interface has been just designed so that new participants cannot read what others have said. Am I supposed to make my point without reading the 529 other ideas that others are discussing below me?

    - 4 different sections make the navigation more difficult, and sythetizing the information impossible. This is a good way of preventing anyone from being in the position of making their point

    - There is no summary of what is being discussed which can be easily reached from this page. A document stating clearly what changes we are exactly discussing should be visible at all times.

    - There is no information on how these random comments by users are going to be processed, valued or used. There is no statement on what guarantees that they are going to be even read by someone

    - Any ethical and true listening exercise should start by listening to patients and citizens, who are the ones sustaining whatever system we come up with, and the ones suffering the consequences of any bad choice in this respect. The only section of society who seem to be giving their view here are mostly doctors, nurses and other institution workers who are aware of this sham.

    Shame on this listening exercise, Shame on Mr Andrew Lansley. Shame on our government. Shame on this authoritarian and corporation-driven proposals.
    We are citizens. We are patients. We are tax-payers. We are consumers. We have the right to be listened to, and above all, we have the right to be respected. Stop insulting us. Stop lying to us.

  421. John de Bradford says:

    Choice, Choice, Choice is the mantra.

    We do NOT want to choose a hospital. We want a good one nearby.

    We do NOT want a choice of ambulance provider in an emergency. We want one there as fast as humanly possible.

    We DO want some choice when we have elective surgery but we want it quickly.

    Satisfaction with the NHS is at an all-time high. Why is there a proposal to break the coalition agreement which repeats what David Cameron said during the election campaign: “There will be no top-down reorganizations of the NHS”?

  422. Rachael Wood says:

    In my experience of working for the NHS for over 15 years I am hugely concerned that the proposed changes such as introducing competition and private providers will undermine the excellent, equitable and co-operative services which are currently provided.

    At a time of austerity money will be spent on huge re-organisation and continued to be spent on administrative costs – including ‘branding’, marketing and advertising – how can this be cost effective or an improvement? I do not believe ‘competition’ will drive up standards nor is there an evidence base for this. Why are government advisers claiming huge profits are to be made by private health care companies and that we will be moving towards an insurance based system when this is not what the public wants.

    I am also concerned about the meaningfulness of the targets services are being measured on and that at the same time as claiming to be putting patients and need at the centre of health care, the exact oppposite is happening.

    Most people support the NHS as a publically funded and publically run organisation and I do not feel the government has a mandate to make the changes that are proposed. I fear that if these changes are pushed through, future generations will look back very negatively at the decisions made by today’s politicians. I only hope they truly listen to us.

  423. Darren Bayley says:

    In response to your question “How can we best ensure that competition and patient choice drives NHS improvement?” it is clear that you have made the decision that competition is the best driver of improvement.

    I strongly contest this point.

    Most patients want a strong local service. One usually has a single local NHS Trust to service the area, it is often not practical to shop around and travel outside of one’s area. Even if your GP is commissioning this care on patients behalf this is problematic. This is especially true when faced with chronic conditions requiring long-term treatment plans.

    Does anyone honestly believe that the concept of competition can be applied universally to public services, I personally do not.

    I work for the private sector and agree that in a commercial organisation competition drives improvement. However the NHS is not a commercial organisation, although I believe that at least partial privatization is the ultimate goal of these plans. It must be treated differently. With these ill thought-through plans the Government is putting the very future of the NHS at risk.

  424. Jan says:

    Mr Lansley are you really listening? I have just spent the best part of two hours reading ALL of the comments posted here. If you do the same you will be left in no doubt as to what the people of England want.

    We want collaboration not competition. We want an equitable local service when we need it. We want it free at the point of delivery.

    We do NOT want to be told we have to travel a couple of hundred miles to access treatment or that there is no money left in the budget. We do NOT want the NHS left with the most acute cases because the private sector has cherry-picked the ‘soft’ ones. We do NOT want EU competition law applied to NHS services. We do NOT want the private providers or insurance companies making a profit out of our ill health. This last point is morally indefensible!

    Whilst other posters have expressed their detailed opinions from a basis of knowledge & experience & far more eloquently than I can, I have no less passion & belief in the NHS. These changes were not proposed in either manifestos and therefore you have absolutely NO MANDATE to implement these changes.

    You ask ‘How can we ensure that competition & patient choice drives NHS improvement?’ This is such a loaded question & so obviously aimed at getting the answer you want. You are presenting a fait accompli & the NHS is being set up to ‘fail’. You will then say it’s not working so we’ll have to get rid of it entirely.

    So Mr Lansley are you really listening or has the decision already been made? Just remember you are a servant of the people of this country & as another poster has already said, ‘ignore the will of the people at your peril’. You must publish the findings of your consultations if you want to retain any credibility.

    Listen to what we are saying and SCRAP THE PLANS NOW!

  425. shurleea Harding says:

    Choice for patients with mental health problems is a real must! Patients can choose their GP, the sex, the nationality etc. and which doctor they wish to to see within their practice. In mental health is nearly always a foreign doctor who has poor English language skills, they repeatedly asks the same questions and the cultural background of some of them makes it difficult for patients to engage.

    Female patients are expected to talk to a foreign male doctor about issues like child abuse, often the doctor coming from a country that practices child abuse e.g. FGM.

    Mental health patients need a wider choice that enables them to open up and recover more quickly.

    Appointments should not be rigid, e.g. 20 minutes and out the door, and psychiatrist have to available in the same way that GP’s are, when a patient is unwell the can ring for an appointment and be seen, not have to wait fro their next fixed appointment that may be months away.

    Mental health patients ALWAYS get poor choice, if indeed any re who they see. Psychiatrists always think they know best when often the patient knows what works best for them

    Unfortunately the NHS treats mental health patients like brainless people and it is about time they realised they are just like everyone else and need help!

  426. Edward Hibbert says:

    By forcing choice on patients, you discriminate against those people least able to make those choices. People who are ill are often – precisely _because_ they are ill – not in any fit state to spend time, effort and money informing themselves before making a choice. Choice is meaningless unless it is informed.

  427. Siobhan says:

    The way this question is framed is shockingly leading. Choice may not improve quality at all. This consultation is shambolic

  428. mandie says:

    Choice is only choice when there are real options. I want Quality of care close to home that is able to meet my and my families needs. If you have a very complex condition, there is unlikely to be choice, the private providers will not want to provide for us, we are not profit making.
    I have had many dealings with the NHS over many years and want to say it is not Broken, it needs tweaking not destroying. Leave it alone and let those who know devise this not inexperienced politicians trying to make a name for themselves.

  429. Les Fawcett says:

    Why do you say you need choice? When there is a limited amount of funding available, this makes no sense – also it suggests that some organisations may be better than others. Standards need to be developed around clinical best practice and quality assessments to ensure ALL providers are equal in their delivery of care – then anyone can go to their local hospital to be treated well… which is what the vast majority would do given the choice anyway!

    Competition is the biggest threat in the reforms, not because of the way in which the private sector will move in, but because it will stop NHS providers talking to each other – I remember fundholding where GP’s and Hospitals truly hated each other. What the NHS needs is integration of services, and clinicians can do this best in collaboration. When there are competeting pressures, this won’t happen so you will need a layer of commissioning managers who would have to struggle to force each change through.

  430. alison redway says:

    Patients don’t care about competition.
    They just want to know that they can access good quality healthcare locally.
    There are plenty of high quality health care staff in this country and it doesn’t make sense to organise them in a way that introduces competition between them. Systems that emphasise cooperation between health care staff and are are based on a focus of patient care are likely to be more effective. Competitive systems change the emphasis to marketing and accountancy because of the need to take business from each other in order to be profitable.

  431. Robert Reynolds says:

    The Heath and Social Care Bill 2011 has called forth a magnificent range of thought on NHS improvement. A holding operation, for patient-care and staff-training, is now needed to allow reformulation. Much good may yet come from the turmoil in progress.

    As the Bill stands, institutional chaos would endanger both care and training, the latter casting a long shadow on future care.

    I have posted a comment in Section 4 (training), but in case the review is ‘run in lanes’ I hope that mention of democracy (given evident democratic deficit) will be seen to justify copying here:

    So much good sense from so many respondents. The objective is widely shared of ‘a good hospital, reasonably close, in a national service sharing best practice’. Even to think of ‘the service we all wish’ is to think of democratic expression. We may thank the Coalition proposal for raising the fundamental choice to be made between democracy and variants of ‘human husbandry’.

    As a retired doctor, also a patient and a relative, I welcomed the promise of the Health and Social Care Bill 2011, at first sight the ‘liberation’ of all to ensure ‘equity’ and ‘excellence’, within a reformed system of Health and Social Care, preserving the 1948 NHS principle of ‘treatment free at the point of need’.

    Unfortunately, definition was lacking as to the meaning of principal terms:

    1. The ‘liberation’ intended is for competition, in pursuit of profit, leaving quality to be defended by ‘regulation’ rather than advanced by secure conscience and free communication.

    2. The promised ‘equity’ in care will continue to be ‘as far as might be deserved’, inequality of access left to be dictated by inequality of political power or insurance cover, poverty left as deserved and to be only palliated by state or private charity.

    3. The hoped-for ‘excellence’, serving the top end of a market with unequal access, might easily be both exclusive and precarious in its isolation, and its impact on national statistics might be overwhelmed by a long tail of poorer performance, emulating the United States in value-for-money failure.

    Many have drawn attention to the downstream semantic deficiencies of the Bill and of the Listening exercise. We are invited to comment on four groups of questions, in areas sensibly to be addressed only alongside each other:

    1. With respect to the leading question, ‘how can we best ensure that competition and patient choice drives NHS improvement’, we should rather be asking ‘what steps must be taken to liberate inventiveness and care and funding as appropriate to democratic ambition?’

    At present we can only guess at the dimensions of ‘patient choice’ that in a democratic society might be thought ‘worth the bureaucracy’: given equality ‘in the market’ we might wish to choose our surgeon, priority in non-urgent procedures, the latest of room facilities, etc.

    In a democracy the essentials of health care would not be delivered in ‘a levelled playing field’ for the material elevation of doctors or managers or share-holders.

    Even if, in a democratic society, global and sectional healthcare budgets were adequate, competition would play a part in the allocation of funds for individual training, for particular research projects, for service developments, for new sites, etc.

    Healthy competition would be on merit, for society, not tainted by fear or greed possessing concerned individuals.

    We do not have to choose between systems half-understood in America or Europe, or in recent party propositions: we can choose democratic liberation.

    2. With respect to the vital question ‘how can we make the NHS properly accountable to the public, and make sure that patient involvement is at the heart of its decision making’, we might trust to luck (!), to political salesmanship (and luck!), to simple humanity (our care for the unfortunate, and luck!), to humanity expressed through inherited belief systems (injunctions to care, and luck!), or to the social contract offered by democracy.

    A democratic society might make mistakes, but it will tend to make its own ‘luck’, to afford what is wanted and what is deserved, by the agreement and contribution of all.

    If we give up income inequality (to give and not to count the cost), and set a savings maximum at a reasonable level (my cup runneth over), we will free ourselves from fear and greed, enabling trust and liberating conscience.

    We need openness rather than ‘transparency’ (having to watch out and ‘seeing through’ each other’s dastardly schemes), and rational trust rather than ‘accountability’ (having to defend or hide the hardly defensible).

    GP-led Commissioning, set-up out-with democracy, cannot emulate democracy: no more than could PCTs working to ‘equality agendas’ in recent years.

    Including the voices of other health professionals, patient representatives and politicians, and replicating much of past structural complexity, will quite soon be found essential in preserving or in re-creating the creaky NHS of today.

    The current proposal appears set up to allow a shake-down to a system of local private NHS-franchise-holders, sized for viability (comparable to PCTs), and like PCTs offering competition or co-operation according to population geography.

    Adopted as proposed, much bathwater and a few babies will no doubt be thrown out, much more of financial bureaucracy will no doubt be added, and the transition costs (financial and human) might alongside other looming problems within months or a very few years precipitate final demand for democracy.

    3. With respect to the linked questions, ‘ how can we ensure that advice and leadership from NHS staff themselves on improving services and tackling patient needs are at the heart of the health service’, and ‘what more could we do to ensure that commissioners collaborate to fit around the lives of patients and carers, and the particular circumstances of certain conditions’, let there be freedom of movement of people towards worthwhile work, and freedom of voice to attract funding towards worthwhile work, no personal financial advantages and fears to corrupt, just the joy of the worthwhile and the ever better.

    In all of the scandals that over decades have continued to emerge, in ‘our NHS’ as elsewhere, ‘someone knew’ or had concerns.

    Our great need is for the liberation of all, making all representative of all. Only income equality can deliver the security required for universal freedom of conscience.

    The logic has to be faced – every labourer treated as worthy of hire – if we are to enjoy the fruits of democracy, an end to the rush to use up the Earth, a future of not hundreds but millions or billions of years.

    4. With respect to the question ‘how can we make sure that NHS staff in the future have the right skills to meet changing patient needs’, the need is to respond to demand, and if possible anticipate both increase and decrease in demand, erring on the side of over-provision, trusting in the good sense of trainers and trainees, all aiming for ‘careers of service’ rather than ‘careers of shelter or financial advantage’.

    There is scope for far more cross-fertilisation of ideas and practices, with earlier recognition of need to adapt, or focus more narrowly, or move on, unimpeded by personal and family financial considerations.

    Strategic planning will always be difficult, more so with commercial secrecy. Past arrangements were poor, the current I am not involved with, the proposed will have to be proved in a context of chaos, I would guess leading to greater variation in quality, increased emigration, and even greater reliance on imported labour with attendant difficulties of integration here and of loss from countries of origin.

    Until we have genuine democratic government – all free to represent all – we can only guess what systems of care and investment a democratic society would choose. Until we have such a democratic context, it must be the responsibility of pro-democratic governments both to lead towards democracy and to frame legislation as far as possible as if for a democratic society.

    We live in a society that has worked and fought for democracy. If a democratic future is wished, then each generation must educate the next to that end. In the spirit of Benjamin Disraeli, truly to ‘educate our masters’ we must show willingness to educate ourselves. As a start we need to have a shared language, recognising ambiguities and clarifying central intents in the use of words, aiming for sharable understanding based on a logical sequence of value choices. I would commend the prime choices of faith in the worth of caring, and trust in the wisdom of genuine democracy, not to ‘officiously strive’ but to ‘give care to others’ as we would wish for ourselves.

    The Coalition has to deal with the world of today, but we all today could affirm our choice for a democratic future, taking account of life’s trials and seeking to reform the NHS as if for all, for patients and relatives and staff and society as a whole.

  432. Jeanette Bailey says:

    Which are the types of services where choice of provider is most likely to improve the quality?

    In my experience of working 23 yrs in the health service competition is only useful when like for like services are provided. e.g. the episode of care should contain all the follow-up services that historically would have been provided e.g out-patient therapy. It is no good a GP purchasing a THR from a private provider if the F/U O.T and Physio is not provided.

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

    Contracts and Service Level agreements provide for this as the NHS will be able to bid for services along side other providers, however the contract manager must ensure that the successful provider can deliver on the quality target’s within the contract to ensure patient safety and that satisfactory outcomes are achieved.

    What else can be done to make patient choice a reality?
    Listen to the Users views, we currently already allow patients to choose thier hospital provider of thier choice. This can be extended to include more providers as long as they met the quality standards already set by the exisiting providers.

  433. Brian Harper says:

    If we are “all in this together” could we hear a lot more about cooperation and stop thinking all can be cured by competition.
    The production of baked beans can be left to the market, healthcare cannot.
    A successful organisation requires people to work together, not be at each others throats.
    I want good care provded close to me, monitor,advise and if necessary compel but avoid naked competition at all costs.

  434. john ingamells says:

    I believe the ‘competition and choice’ proposals are something of a mirage and will only lead to the carving up of profitable elements within the NHS.
    I recall Thatcher’s argument of private provision of utilities, trains, etc. leading to improved service and more value for money. Can anyone seriously look at the disastrous outcome of the privatization of trains as offering cheaper, more efficient, spacious trains. No, it is simply about profit and squeezing as much from the minimum amount of carriages, leaving crowded environment. Additionally, they seem to remain open to taxpayer subsidies.
    As for the utilities, we have more expensive, less accountable ‘choice’, where they operate in a manner akin to a cartel.
    The NHS cannot be allowed to be cherry picked by private companies, UK or Worldwide established. I have no trust in anyone, politician or other, to provide control or safeguards for patients.
    Patients merely want effective, expert healthcare provision offered promptly as near to home as possible. All hospitals should acquire the standards suitable for all patients wherever they live. It is the duty of Government and health providers to ensure that.
    In my experience, the last people to offer adequate knowledge and accessibility to Consultants, etc. are GP’s. I have no faith that the proposals involving them having budget and control of access, will work. I feel it will lead to inefficiency, self interest for the GP practice,and in many cases patients being denied access to treatment on budgetary grounds.
    The NHS requires more investment in training and staffing of nursing care at practice and hospital levels.
    I do not trust this coalition to do right for the NHS. They are solely obsessed with profit and ideology.

    • Michael Burt says:

      I completely agree John I have already tried to post a comment but it would appear I have been unsucsessful or it has been censored, PRIVATIZING the NHS in any way would be a disaster.

  435. Nina Smith says:

    I too am very concerned that cherry picking will have an adverse knock-on effect on those NHS hospitals who lose out because of it. The NHS generally functions very well and we do not want it damaged for ideological reasons.
    But I want to use this opportunity to advocate what I consider to be one of the major overhauls needed in primary care, which is that GP practices should be open 7 days a week and 365/366 days a year. Opening hours should be as a minimum 07.30-19.30 M-F, and 9-1 at weekends and public holidays. Illness and the need to consult a doctor or a practice nurse is not confined to 9-6, Monday to Friday.
    I also do not want the reforms to be another opportunity for the earnings of GPs, senior hospital doctors and NHS administrators/managers to be uplifted by more than inflation. Indeed, these groups did so well out of the changes brought in by the previous government, and this was a sigbnificant factor in NHS budget increases not being as effective as they could have been. Indeedd, there is a strong case for a 5 year incomes freeze, thus enabling significant savings that can be used to improve services such as by increasing clinical staffing levels, purchasing of the latest equipment and making new and effective drugs available.

    • Susan Olsen says:

      Health is not a commodity that can be bought and sold in the market place. What has someone’s health got to do with shareholders making profits. I find it immoral for this to be even considered. Benchmarking and raising standards are surely the best way of improving services. American and foreign health companies are chafing at the bit to get their hands on NHS money and this must be resisted at all costs. If this reform goes ahead the NHS will be diminished, and the public may have to travel miles to get treatment as their local hospital will no longer be able to offer the services required. The cost of the reforms is exorbitant and in these cash-strapped times why is the Gov’t even considering it.

  436. Rachel Eden says:

    I believe that the Conservative manifesto and coalition commitments should be stuck to: no top down reorganisation and not privatisation.

    I believe a massive expansion in private providers will be highly detrimental and the removal of the requirement on the secretary of state to ensure universal health care provision is extremely damaging. The universality of the NHS is a fundamental principle.

    Stop these reforms before you kill the patient! And stop your MPs sending out misleading letters claiming that doctors and nurses are in support of the changes. We’re not stupid!

  437. John Lackie says:

    The question presupposes an answer, yet it is by no means clear that ‘competition and patient choice’ are the best way (or even a way) to drive improvement in the NHS. I am not convinced that introducing the possibility of private healthcare providers making a profit for shareholders will drive improvement (rather the opposite) and patient choice is very often irrelevant, especially for those who live in remote rural areas where distance forces the choice.

  438. Thomas Jennings says:

    I don’t want choice of provider within the NHS. I’m not in the place to make choices about how healthcare is provided. The government and the NHS is. If multiple companies are used to supply various parts of the system, I certainly do not want to have to make a choice about which one to use.

    If sticking with the idea of multiple providers the level playing field must be controlled by the government. The idea of the government is to regulate business and ensure private companies don’t leave the NHS in a mess.

    Finally, I don’t want patient choice. I am not a doctor. I do not have the time or capacity to research my own treatment. Leave it to the NHS.

  439. Dave Berry says:

    PCT’s are non profit making organisations, put in place to oversee commissioning and ensure there is standardisation of procedures and equipment across the service. Open this to the free market and the whole structure will break down at the cost of tax payers lining the pockets of private enterprise. I cannot think of any of the privatised utilities that have benefited the consumer.
    Also GP’s should have enough work on board without distractions from commissioning matters.
    I am already seeing the problems of outsourcing where support previously done by the PCT has gone to an external supplier. Their software is incompatible and adversely affected a practice managers PC. This will be the tip of the iceberg.

  440. Robert Reynolds says:

    Competition for healthcare improvement was today discussed on BBC R-4′s World At One, a health economist dismissing as suspect the fears of a Trade Union. Given that we all have ‘collective affiliations’, and blind-spots, it may be worth exploring the issues raised