Chris,
No offence - was having fun being Mr. Grumpy.
Re the serious debate: I do feel strongly that the health reform
industry in England has (what's the quote from Harold Wilson) taken
minutes* and wasted years.
(*in this case, produced myriads of policy changes in
cyclical and indeed circular direction of travel)
I know you can have 'integrated care' in a market context, or shall we say
in a 'post-purchaser/provider split' politics. Competing HMOs/Enthoven's
original model of managed competition (for Bismarck rather than Beveridge
contexts): in England, citizens could choose among 'HMOs' ie
commissioner/provider organisations with no geographical catchment basis as
PCTs/CCGs had/have.....OR.....HAs/ PCTs/CCGs could be the
purchaser/commissioner choosing among 'integrated care organizations' ie the
citizen is still with the geographical purchaser, which chooses among
different 'integrated' providers.
But to me these are Heath Robinson-esque, tortuous means of ticking the
'market' box. This is done either on the grounds of ideology or out of
pragmatism (ie Old Tory/ New Labour/Coalition neo-liberalism is the only
show in town) ....OR on the grounds that integrated care without competition
is bound to lead to what Simon Stevens calls doctors colluding behind the
bike-sheds.
But the 'empirical' question then becomes: is 21 years of market economics
moderated by 'garbage-can' (Cohen, March and Olsen) politics more
efficient/effective than a planned, integrated health service with
appropriate targets and outcome criteria? Put it another way: if all the
investment' in commissioning/the market/whatever had been applied instead to
improving and integrating a non-market NHS, would we have got just as much
benefit or more?
Best, Calum
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