David Green

NHS Reform: In praise of ‘cherry-picking’

The British Medical Association (BMA) has always been a trade union with elements of professionalism on the edges. Its report this week on the NHS reforms was the work of unadulterated, self-serving trade unionism. Our modern trade union leaders would have been embarrassed to publish it, even Bob Crow.

It tries to portray competition as the opposite of co-operation, when competition is the opposite of monopoly, in this case a public sector medical monopoly. Competition describes an arrangement under which teams of people co-operate with each other to find better ways of serving customers than rival teams of collaborators. The co-operation of which the BMA speaks is a weasel word for producer domination.

The BMA says it wants integration, which it also contrasts with co-operation. And here its argument is more subtle. There is a case for integration when the term refers to co-ordinated rather than episodic management of treatment. Doctors don’t always agree about either the diagnosis or the treatment and patients will often find it useful to rely on a single trusted adviser. But even so, integration is not the opposite of competition. When health care works well, the two go hand in hand.

The most familiar examples of integrated care, under which the work of GPs, hospitals, diagnostic services and long-term care are under unified management, are provided by American health maintenance organisations such as Kaiser Permanente. A now famous study in the British Medical Journal in 2002 found that Kaiser Permanente cared for a cross-section of the population similar to that of the NHS and that it provided services of a higher standard, while making efficient use of available funds. But Kaiser’s heartland is in California, where it faces intense competition from rivals who are trying to provide even better care within the insurance premiums that customers are prepared to pay.

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