Tuesday, 20 November 2012

NHS, the internal market and dirty tricks

There was an article yesterday about NHS procurement. Purchasing is not exciting, which is a shame, because getting it right is massively important. When we do hear about it in the news it's often tabloid-manufactured outrage that some kind of custom object needed for some reason is more expensive than a mass-market one.

But this case, this is genuinely shocking. Not simply because of the numbers (although half a billion a year is nothing to be sniffed at), but because of this quote:

Joe Stringer, from Ernst & Young, said the discrepancies were "staggering", and he warned that the problem was getting worse. Trusts, he said, were reluctant to share information for fear of helping their competitors.

I posted a brief note on twitter about this yesterday, and it got retweeted a lot. Some people replied, blaming the Tories. They've missed the point. The internal market in the NHS was already there. There are hundreds of little NHS purchasing departments making small orders and unable to use mass buying power to get good rates, even if they had been sharing information.

And they have a disincentive to share best practice, because of the NHS internal market. Trusts aren't being compared to some platonic ideal of efficient, they're simply trying to be as efficient as they can be compared to their rivals. That means not giving away their lead, if they've got one, say by having the best purchasing people. This is fine when you are selling potatoes or shirts, but when we're talking about providing medical care from state funds, it's another matter entirely.

If trusts already are reluctant to share information, to the general detriment to the health service as a whole (and it's not me or some leftist bloggers that's saying that, it's Ernst and Young), why should it stop there? This is already an ethical violation, but since it has taken the form of lack of action rather than action, it gets a bit of a pass. But the lines between not acting when you should and acting when you shouldn't can be rather blurred. Inaction is not neutrality. The internal market creates perverse and direct financial incentives for unethical actions. I fear it is only a matter of time before we see the first NHS dirty tricks scandal.