No evidence to support Competition in the NHS – Ben Goldacre (The Guardian)

I have never heard one politician use the word “evidence” so persistently, and so misleadingly, as Andrew Lansley defending his NHS reforms.

Since he repeatedly claims that the evidence supports his plan, let’s skim through what we can find on whether GP consortiums work, the benefits of competition, and the failures of the NHS.

I’m not in favour of, or against, anything here: all health service administrative models bore me equally. But when Andrew Lansley says all the evidence supports his interventions, as he has done repeatedly, he is simply wrong. His wrongness is not a matter of opinion, it is a fact, and his pretense at data-driven faux neutrality is not just irritating, it’s also hard to admire. There’s no need to hide behind a cloak of scientific authority, murmuring the word “evidence” into microphones. If your reforms are a matter of ideology, legacy, whim, and faith, then like many of your predecessors, you could simply say so, and leave “evidence” to people who mean it.


Andrew Lansley has repeatedly denied that he is introducing competition on price. This is disturbing behaviour: his bill explicitly introduces price- based competition, it’s in paragraph 5:43 of his NHS Operating Framework.

Does variable-price competition work in healthcare markets? It’s hard to measure, but the evidence even on fixed-price competition – where you compete on quality – is mixed1. There are various ways to assess it: often people choose an outcome – like the number of people who survive a heart attack – and compare this outcome in areas of more intense or less intense competition. Sometimes competition makes things worse, sometimes better.

Working from first principles2, markets where people compete on price as well as quality will probably make quality worse, because prices are easy to measure, while quality is not. The evidence seems to support this theory. The introduction of variable price competition in New Jersey in the 1990s3 was associated with a worsening death rate from heart attacks, while in the UK4, stopping variable price competition was associated with improvement. It’s hard to measure either way, but despite his using the word repeatedly, again, the “evidence” does not support Lansley here.

Lastly, there is the justification for reform. Both Lansley and Cameron overstate our mortality figures to claim that the NHS is failing. Everyone wants more improvement, but money does not produce an immediate and visible reduction in mortality from one thing. Interventions take time to have an impact, especially on things that kill you slowly, and treatment isn’t the only factor affecting how many people die of something. But just take two things, mortality from cancer has fallen every year since 1995, and heart attack deaths have halved since 1997.

The government claims that our rate of death from heart attacks is double that in France, even though we spend the same on health. Health economist John Appleby6 instantly debunked this claim in the BMJ, and his piece will become a citation classic. From static 2006 figures in isolation the government is right: but the trajectory of improvement in the UK is so phenomenal that if the straight line continues – as it has done for 30 years – we will be better than France by 2012.

Ben Goldacre, The Guardian, Saturday 5th February 2011

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