Your recent articles on the NHS (November 1993) were particularly interesting. To correct one inaccuracy, district health authorities do not become self-governing Trusts. It is Acute and Community hospitals who used to be directly managed by DHAs who are now able to opt out of local health authority control. Health authorities are now required to purchase health care services from a range of hospital and other providers on behalf of their local populations. Providers of health care compete with each other to attract this business through the internal market.
I thought it may be useful to make one or two comments about the internal market and how a number of contradictory effects are now clearly discernible:
1. Competition in the classic sense is rarely a reality. With the exception of large conurbations, many hospital providers, particularly bog-standard district general hospitals, occupy almost a monopoly position. Similarly, the “host” district purchasers are often near monopoly buyers of services. Many of the alleged benefits from free competition like choice, cost efficiency are largely illusory.
2. Large specialist centres of medical excellence, many located in London, are now under threat. A district purchaser will tend to contract with local general hospitals and community units to obtain the basic expected standard services for its local population. To contract with a specialist centre almost on the off chance a very small number of cases may arise needing its services is seen as very risky and expensive, limiting the ability of the purchaser to maximise the benefit to the most number of people within limited resources. Although currently protected by various methods of national and regional funding, the constant push to devolve funds down to districts and to widen the scope of the market will exacerbate this threat.
3. An opposite tendency is where two large general hospitals are forced into competition despite together covering a vast area. The effect of market forces if both survive, is to encourage rationalisation and specialisation. That is, each concentrates on a narrower range of services in which each feels it has an advantage over the other. In addition to the obvious waste of skills and experience associated with “rationalisation”, the fundamental principle of local access to the full range of standard services is undermined. Patients and families will need to travel much greater distances to obtain diagnosis, treatment and follow-up. The choice of services available to the purchaser also narrows, reinforcing tendencies to monopoly.
4. The purpose of competition is of course to eliminate competition. This is seen in an increased number of mergers and takeovers on both purchaser and provider sides of the market table. The increased market and bargaining power associated with (say) the creation of a large district purchaser through merger is matched in double quick time by the merger of the local provider units to redress the balance and to prevent one being played off against another. Sooner or later, the internal market will seize up completely and all pretence of choice and competition will vanish. We will be left with a recreated national structure formed through takeover and closure, highly authoritarian, run by autocratic managers and non-elected business representatives, and totally unresponsive or sympathetic to the wishes and aspirations of health workers, patients, their families and the wider community as a whole. Being “successful” products of a market system and ravaged by the ideology of commercialism, the remaining Trusts (self-governing hospitals) will be ripe for privatisation. You can just see it: “support your local hospital — buy shares in the ’public flotation’”. One way to raise needed money for cash starved hospitals. The ideological value of getting people to identify with particular methods of capitalist restructurings through privatisation is well known.
Enough of the pessimism. The only point of understanding how and why capitalist institutions change and adapt is to understand that this change whether left to the market or apparently influenced by politicians will never be to the benefit of working people. A world-wide health service (perhaps including a tremendous diversity of models of health care) can only happen when capitalism is replaced on a world-wide basis by socialism, The people’s health and wellbeing will only ever be safe in the hands of the people themselves.
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