The focus on Cooper is really silly and the product of Cameron 
mentioning the LSE paper in a speech. There is a similar study by Martin 
Gaynor and Carol Propper (on the Bristol website and NBER) which offers 
similar conclusions for  the same issue. Both papers are about AMI rates 
in a particular market/London and generalisation from them would be even 
more silly than the current fixation with this interesting but narrow 
approach to exploring competition.
What is competition? Doctors compete every day to improve care. Are 
these efforts more cost effective than the results of competition 
offered by these authors?
Hopefully health policy wonks will recover from Cooper-itus quite soon!
Happy day!
Alan M

Oliver,AJ wrote:
> Some very strong conclusions being drawn from both sides here. See 
> what you think. It seems to me that there is some small amount of 
> evidence that competition may marginally improve some outcomes in some 
> contexts, so long as there is plenty of money flying about, and that 
> we need more evidence to conclude anything more than this. The 
> statement from the DoH at the end of the linked Guardian piece is 
> pretty awful though, but I suppose they are beholden to their 
> political masters.
>
>
>
> Begin forwarded message:
>
>> *From:* "Mcdaid,D" <[log in to unmask] <mailto:[log in to unmask]>>
>> *Date:* 28 July 2011 20:15:25 GMT+01:00
>> *To:* "Oliver,AJ" <[log in to unmask] <mailto:[log in to unmask]>>
>> *Subject:* *NHS competition study splits academic community*
>>
>> FYI – in the Guardian today – see also Evan Harris questions in the 
>> readers comments
>>
>>  
>>
>> http://www.guardian.co.uk/society/2011/jul/28/nhs-healthcare-competition-lse-study
>>
>> At the time of the Prime Minister's citing of this work there had 
>> been no version published following peer review. The paper in the 
>> Economic Journal deserves close scrutiny. There are a number of 
>> questions which need to be answered in the affirmative before one can 
>> rely on the assertion that NHS market (choice & competition) save lives.
>>
>> 1) is anyone, or sufficient people, actually making any choices?
>>
>> It is one thing to offer choice and another see any meaningful 
>> choices being made let alone based on a perception of improved 
>> outcomes. There is little evidence that anyone made any choice in 
>> these arrangements. Patients have a very limited number of cataracts 
>> or hips to have operated on so it is likely that very few will be 
>> "repeat" consumers able to base their choice on perceived or even 
>> actual good outcomes from previous experience. The outcome measure 
>> used as a proxy for better quality by Dr Cooper - deaths from acute 
>> heart attack - can hardly influence later patient choice. Dead 
>> patients don't make poor choices or any choice. Heart attack 
>> survivors are not likely to be choosing a hip replacement option any 
>> time soon. There is no good evidence to suggest that GPs are making 
>> recommendations to new patients for their elective surgery based on 
>> perceived or actual outcome measures let alone based on acute cardiac 
>> death rates.
>>
>> If no one is making choices based on improved quality, all you can 
>> claim is that a misplaced fear of choice being exercised against them 
>> by hospitals is making them improve their outcomes. There is no good 
>> evidence of this.
>>
>> 2. Is the differential effect on acute cardiac death an artefact of 
>> the difference between sparse and dense hospitals?
>>
>> It is at least possible that hospitals in the areas where there are 
>> multiple hospitals (likely to be in areas with population density, 
>> (even if Dr Cooper claims there is no correlation between hospital 
>> density and "urban-ness") will include teaching centres more likely 
>> to have taken up more quickly new advances which improve survival 
>> from acute heart attack (such as immediate "stenting" of blocked 
>> arteries) or that in those areas with more hospitals ambulance 
>> journeys are shorter so that more patients arrive more quickly and 
>> more suitable for recent novel more effective treatments. In other 
>> words this may all be an artefact of not living near hospitals with 
>> A&E departments.
>>
>> 3. Is death from heart attack a good enough proxy for elective 
>> surgery quality of care?
>>
>> Fundamentally it is dubious to use deaths from heart attack victims 
>> as a proxy for improved outcomes in elective surgery for in-growing 
>> toenails upwards. Especially when "better" proxies are available for 
>> elective outcomes.
>>
>> 4. Is there any decent cost-benefit return?
>>
>> Dr Cooper is claiming some health benefit of increase marketisation 
>> of the NHS. But nowhere as he has admitted does he identify the cost 
>> of all this and thus whether that money spent on markets would be 
>> more efficiently spent on doctors, nurses and treatments. Old 
>> fashioned but worth a try surely?
>>
>> There's four quick questions for you..
>>
>>  
>>
>>  
>>
>> David McDaid
>>
>> Senior Research Fellow, LSE Health and Social Care and European 
>> Observatory on Health Systems and Policies,
>>
>> London School of Economics and Political Science
>>
>> Houghton Street
>>
>> London
>>
>> WC2A 2AE
>>
>> e-mail: [log in to unmask] <mailto:[log in to unmask]>
>>
>>  
>>
>
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