Blog: Competition and health care quality – the debate continues

The coalition government remains committed to extending the role of competition in the NHS. It is hoped that market reforms encouraging competition between hospital providers will lead to an improvement in care quality. There is some evidence to suggest that competition may have a contribution to make in improving health care performance, but as we described in our policy summary on the topic, this effect remains hotly contested.

Much of the discussion continues to focus on the publication by Cooper et al which estimates that NHS market reforms introduced in England in 2006 led to a 7% relative reduction in heart attack deaths.1 The Prime Minister, David Cameron, quoted this study in a speech in which he argued that ‘put simply: competition is one way we can make things work better for patients.’2

However, writing in this week’s edition of the Lancet, Allyson Pollock, professor of public health research and policy at Queen Mary, University of London, and colleagues set out their view that the authors of this study have ‘chosen to base causal conclusions on a fundamentally flawed analysis.’ In a detailed critique, they argue that a statistical association is not the same as causation and, therefore, the study does not prove that competition improves health.3 Pollock et al also take issue with the approaches used to assess competition, as well as the use of acute myocardial infarction (AMI) mortality as a quality measure. The study by Cooper et al looks at ‘potential for choice’ based on the number of hospitals offering certain elective surgery procedures, such as hip and knee replacements, within a given distance of the patient’s GP. Pollock and colleagues also note that differences in outcomes are largely due to differences in medical treatment that are not products of competition. As such, they contend, the research should not be cited as evidence in support of choice and competition.

The authors of the key studies about competition in the English NHS together offer a response to these criticisms.4 Bloom and colleagues note that they have not all unilaterally supported competition and caution against ‘launching inaccurate attacks on research that one does not like for ideological reasons.’ They argue that AMI is an appropriate quality measure as it correlates well with overall mortality and patient satisfaction. The authors also point to the consistent results from three studies by their separate research teams as lending weight to their collective findings.

One thing both groups agree on is that more research is needed to understand the potential impact of competition in health care.5 However, as another recent review by Bevan and Skellern in the British Medical Journal describes, there are several challenges involved in carrying this out.6 These include how to measure both the intensity of hospital competition and the quality of care. Bevan and Skellern conclude by noting that mortality rates for a single condition or surgical procedure are not a good measure of overall care. Acute hospitals typically have a mix of good and poor services. In addition, econometric studies assume that competition for elective surgical procedures ultimately leads to improvements across the board in hospital quality, yet we do not completely understand what managers and clinicians do in response to competition that might affect patient outcomes.

LUKPM has noted before that the evidence base for the government’s proposals to increase competition relies on ‘heroic but dubious assumptions.’7 The role it should play in the policy mix is unclear because the mechanism by which patient choice affects outcomes remains an open question. However, the debate shows no signs of going away.

Blog by: Lancet UK Policy Matters Team

References
1. Cooper Z, Gibbons S, Jones S, McGuire A. Does Hospital Competition Save Lives? Evidence From The English NHS Patient Choice Reforms. The Economic Journal 2011 121(554): F228–F260

2. The London School of Economics and Political Science. LSE research on hospital competition is referenced in the Prime Minister’s speech on the NHS. Available at http://www2.lse.ac.uk/newsAndMedia/aroundLSE/2011/HospitalCompetition.aspx. (Accessed 19 December 2011).

3. Pollock A, Macfarlane A, Kirkwood G, Majeed FA, Greener I, Morelli C, Boyle S, Mellett H, Godden S, Price D, Brhlikova P. No evidence that patient choice in the NHS saves lives. The Lancet 2011; 378(9809):2057-2060.

4. Bloom N, Cooper Z, Gaynor M, Gibbons S, Jones S, McGuire A, Moreno-Serra R, Propper C, Van Reenen J, Seiler S. In defence of our research on competition in England’s National Health Service. The Lancet 2011; 378(9809): 2064 – 2065.

5. Pollock A, Macfarlane A, Kirkwood G, Majeed FA, Greener I, Morelli C, Boyle S, Mellett H, Godden S, Price D, Brhlikova P. In defence of our research on competition in England’s National Health Service — Authors’ reply. The Lancet 2011; 378(9809):2065-2066

6. Bevan G, Skellern M. Does competition between hospitals improve clinical quality? A review of evidence from two eras of competition in the English NHS. BMJ 2011;343:d6470

7. Black N. Preliminary findings on competition in healthcare should not be over-interpreted. BMJ 2011; 343:d4731