Why markets don’t work in healthcare

Like any commercial company, the BMJ Group uses management consultants to help develop strategy and implement change. By and large we have found them a good investment. The NHS and the Department of Health use them too, spending a reported £30m in England on these services between 2006 and 2010. Should we care about how such a tiny proportion of the NHS’s £100bn annual budget is spent? Perhaps we needn’t worry too much about the money, which can be accounted for, but should worry about the nature and extent of the influence, which is harder to keep tabs on. With their ethos and skills deeply embedded in the private sector, are consultants inevitably encouraging the privatisation of the NHS?

In this week’s feature, Peter Davies examines the elite of the breed, McKinsey and Company (doi:10.1136/bmj.e2905). With 400 health consultants globally, of whom 150 are medically qualified, McKinsey is beloved of health systems around the world. It provides necessary objectivity and missing skills. But its famously low profile prevents close public scrutiny, and its well-used revolving door sees senior associates moving easily to and from influential positions in government, prompting one health policy analyst to call them “a commercial version of the higher civil service.” Mark Britnell is one former senior civil servant who has stepped through the revolving door and now works for KPMG. Interviewed by Rebecca Coombes, he defends management consultants and his decision to join them (doi:10.1136/bmj.e3239). They have, he says, a small but important role to play in the development of the NHS. But how do we manage the conflicts of interest these relationships pose? We don’t.

Anyone who hoped that critics of the health bill would give up and go home once the bill was passed will be disappointed. Following their recent paper on how provisions in the bill could lead to the break up of the NHS (doi:10.1136/bmj.e1729), Allyson Pollock and colleagues turn to the effects of the bill on routine health data (doi:10.1136/bmj.e2364). They find much to alarm them. The NHS in England is moving, they say, from a structure based on the populations of defined geographical areas (which collectively covered the whole of England) to one based on “shifting populations” covered by the new clinical commissioning groups, which have no responsibility for geographical areas. The authors foresee difficulty in gathering meaningful data on healthcare needs and outcomes, and potentially an end to allocation of resources on the basis of need.

Their nightmare scenario, unspoken in this article but clearly haunting it, is American healthcare. In our first BMJ Essay published this week, Arnold Relman gives his own no-holds barred account of the US system (doi:10.1136/bmj.e3052). How, he asks, does the US system manage to spend twice as much as some other countries and yet achieve, on average, much worse outcomes? His answer: “the US alone among advanced Western countries has allowed its healthcare system to become a market and its physicians to behave as if they were in business.”

Pollock and colleagues offer no solution to the problem they identify. Relman does: private but non-profit multidisciplinary groups of salaried physicians, paid for by a single public plan providing universal access to comprehensive care. It sounds familiar. But he thinks the US will have to go bankrupt first.