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
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?