My wife works for the National Health Service and, like me, she is motivated by an intrinsic value system that is complex and multifarious. For her, money is not the main issue in her doing well at her job or indeed in receiving recognition from patients and peers.

The problem I have with how "competition" in the National Health Service is being sold (badly btw) is that we're being told that it is there to give people more choice and to drive efficiencies and to push up standards. In a free and open market that often makes sense up to a point but the National Health Service is a closed and internal market that is not based on free market principles. Besides, the good stuff about "competition" is only half the story. "Competition" is based on a simple idea: that there are not enough resources to go round for everyone so one must compete to be top dog and have first dibs on those resources. So "competition" means there will be winners and losers. And the more you think about that the more you realise what kind of drivers or motivators are going to be introduced through "competition" to create winners and therefore, losers.

So why, when the idea of a National Health Service is that we have universal health care for all, should we be introducing a system of winners and losers? Upon what criteria will this system of "competition" be judged and what does losing mean? A closed hospital? A closed unit? And if that is the case who is the real loser when the idea of the National Health Service is universal health care for all?

I'm convinced that the majority of people, like my wife, who work for the National Health Service, do so from of a value system in which money is quite a long way down their list of priorities, of what they regard as important in order for them to do their job well.

So in what way will "competition" reflect that value system?

Because coming back to the idea of motivation and what science tells us about it I'm struggling to see what kind of motivational principles "competition" will bring into the National Health Service. Based upon where capitalism has led us in recent years I doubt very much that they will be the right ones.

The idea of "competition" just doesn't stack up in the context of the National Health Service. As Pink outlines in his talk what motivates people to perform well is proven to be complex and is not something that can be systemised, e.g. by introducing free market concepts such as "competition", but - and this is the important point - is something that can genuinely be supported and shown to deliver the kinds of cost-effective and efficiency results that pleases "marketeers" if we choose to think differently about problems and problem solving. And let's face it problem solving doesn't get much bigger (© Greg Wallace) than a National Health Service providing universal health care.

Using Pink's analysis each problem as presented will always require evaluation using differing and often unique sets of judgements and responses in order to deal with it and overcome it. It's a really simple idea: complex problems can't always be solved simply. That dynamic - and let's face it common sensical - approach to problem-solving requires the right kind of working environment, one that is built on accepting and acknowledging that motivating people to come up with the best solution should really reflect the value system that the people working in the market aspire to. And science says money ain't it and by implication that says to me that "competition" ain't it either.

My point is that you can only get the required level of problem-solving that delivers real results we can all applaud if the people charged with delivering those solutions are working in a market such as the National Health Service which is built on the right motivational principle, that the real freedom of choice and the real driver for improving the standard of service in the National Health Service is for people that work in the National Health Service to be able to apply their skills based on the value system that they bring to the table.

...is as big a weasel word as 'competition'. Given the choice, all most people would want is for their local hospital to be as good as it can be across the whole spectrum of medical problems, within reason. They don't want to be offered the 'choice' of going to a better hospital 100 miles away.

One day I hope to be smart enough to write something like that here

Is that no one has the political courage to dismantle the structure of the NHS and replace it with something better. The NHS has become a giant totem of the left and synonymous with universal healthcare – to suggest anything different invites accusations of letting poor people die in their beds.

Yet virtually no country has copied this model of healthcare; a monolithic purchaser and provider might have made sense in the 1940s but makes less sense today. In addition, we've had successive governments spending huge amounts of time tinkering with the thing to very little effect and the consternation of all the staff.

Where I live (Germany), there's a mixture of public, private and not-for-profit providers, coupled with a social insurance system (be it state or private). You have the choice of what kind of insurance to have and no one is uninsured (like in the US). There's choice built into the system, waiting lists are non-existent and health outcomes are generally superior.

I knackered my leg skiing in February — I was able to hobble to a GP around the corner (who I wasn't registered with), get an appointment that morning, then visit a sports injury clinic the same afternoon. This would be unheard of in the UK, yet we still cling to this 'envy of the world' nonsense.

Indeed. If anyone's interested in some further reading, this is a great book that proves that point (and has loads of fascinating stuff about how fallible human judgement is, and how to compensate for it): Irrationality, by Stuart Sutherland

Seems to me that we're stuck with this big scary institution that everyone loves but everyone knows is broken. Experience has shown that throwing limitless money at it doesn't fix the problems. What can be done? We can't knock it down and rebuild from scratch like it were a building, I genuinely don't think anyone knows the answer.

The other extreme of a service provided by US profit making commercial organisations is obviously undesirable but there may be something the third sector can do? It's worth remembering that Bupa and Nuffield Health - the UK's two largest hospital chains - are non-profit making organisations (I believe Nuffield is still a charity). Maybe greater use of these organisations, funded direct from government via shadow fees rather than from private health insurance or billing at the point of use?

To prevent the inevitable descent into party political bickering, I should point out that I dont believe either of the parties have the answer...

Following the sheer ongoing disaster that was rail privatization I simply do not trust this government to do a good job of introducing "competition" (ie privatization) on a service we all depend on.

Plus they have no mandate for this anyway.

Really that's it.

'competition' does not exist in this arena as a means to delivering the same or better 'services' for less money, thereby increasing the 'choice' that the 'customer' may exercise in choosing one provider over another. That is just what the politicians want the most stupid amongst us to believe.

Competition exists in the form of PFI tendering for centrally doled out cash that's already earmarked to pay for the provision of services. The driver, from the point of view of the provider, is therefore to bid for the most easily delivered services, leaving the most complex and expensive services to remain the responsibility of, er, the NHS.

Brilliant.

Leave it alone.

Reform the financial sector, then fix education. Youth unemployment, a living wage and housing need to be sorted next.

The NHS? In the experience I have had of it, (recent cancer scare, turned out not to be, but operation required) it's working better than a hell of a lot of other things in this country.

there are umpteen politicians getting payed by pharmaceutical companies and private healthcare firms to push these reforms through.
When David Cameron talks about "deciding upon qualified providers," I think it's safe to assume that the "providers" who get decided upon, will be the same ones who are currently paying Patricia Hewitt and her colleagues to get the bill passed. So much for opening up the market to competition.
When rail privatisation was being proposed, it was suggested that operators would cut corners at the risk to people's lives, yet this was denounced as an outrageous accusation. But that's exactly what happened - the Southall Train Crash Enquiry put the blame squarely on privatisation. In a competitive environment, sooner or later, you cut corners to protect profit. I don't see why that wouldn't happen in a 'competitive' NHS, when there's over £100billion profit to be made.

95% of the NHS work is done by private businesses working under contract to the PCTs. The dentists do all the simple stuff and get paid for it, the complicated things get referred for the salaried parts of the service (community dental services or hospitals). This worked well for many years. Lots of small businesses trotting along, providing a fine service. Then bigger business stepped in and worked out that by creating chains of practices, paying lip-service to patient care and jumping through lots of contractural hoops, there were large sums of money to be made. And so there are. Contracts are bought and sold, huge sums change hands and patients suffer. The increase in legislation makes running small businesses increasingly stressful and inefficient.

This is the problem with PFIs and money.

Small businesses care for patients very well and, in the process, maybe make a bit of a profit.

Big businesses make profits very well and, in the process, maybe care for patients a bit.

qualified to make is that it has always been there for me and my family when we needed it. I don't really want much more from it than that.

by Aah_bisto ... as I mention above my wife is a GP and she's certainly not motivated professionally by money, and neither are the very many other healthcare professionals we know - they are motivated by patient care, frustrated by tinkering in the way the NHS is run, concerned about efficiency and largely aloof from the political pressures that affect the NHS.

As I say above, British spending on healthcare has consistently been a lower proportion of GDP than other similar Western economies, so viewed through that prism the NHS is extremely successful.

This problem seems to me to be largely one of ideology. To the free-market right the NHS is an affront - if a large bureaucratic institution can be seen to work then it undermines their free-market ideology, therefore they seek to undermine it at all costs. To the left, the NHS is a beacon of centralised, managerialised excellence, so on both sides it's a political football.

But only for a few more weeks. Budget cuts (the ones Cameron is denying are happening) have already seen a dozen front line health workers made redundant, and public health jobs were next in line. Even if she had survived this cull (odds 1 in 3) 2 more years of cuts will follow as Lanley's plan is invoked.

She's been fortunate enough to find work elsewhere. And such is the despair at what lies ahead droves of her colleagues are jumping before they are pushed. Cameron and La La would have us believe that this is what we need anyway - this is the faceless bureaucracy that is weighing the NHS down. But what they are really losing are former nurses, midwives and doctors. People with front line hands on experience that are now using that knowledge to commission and coordinate healthcare provision in a way that GP's have neither the skills or the interest.

The NHS has it's faults. The PCTs could stand some reform. But Lansley's plans are based on dogma, not a coherent, thought out, or even mandated analysis of what is needed.

A few years ago I tore my cruciate ligament playing football. I went to see my doctor, who mis-diagnosed it. It went un-repaired. I then damaged the same ligament further coming off a mountain bike on the South Downs. I was advised to have an MRI scan, waited 14 months to get an appointment, when the injury was mis-diagnosed again. I attended group physio at the hospital for 12 weeks before the nurse actually spoke to me one-on-one, only to apolgise for the fact that my physio programme should have changed six weeks earlier, but she hadn't had time to deal with me. This is now more than two years after the original injury, and I can barely walk down the street for fear of my knee collapsing.

By the time I injured it for a third time (which I managed lying in bed - it was that fragile) I was working for a company that had a decent benefits package, including private health care. I saw a Harley Street specialist the same morning, got an MRI within 45 minutes, had an exploratory operation the following day, and the ligament replaced within a couple of weeks. It's been fine ever since.

I don't think for a moment that this is a typical experience, and I don't really have a point at the end of all this, but it does highlight the gulf between the best and worst levels of service.

One thing that free provision does is distort people's view of what medecine costs - mostly we only pay the parking at the hospital and complain about that. When my GLW had an emergency C section she counted 12 medical staff in the room (and me hiding from the blood). The twins than had a month in intensive care. Never cost us a penny (we even got a free parking pass). What did that cost the NHS, and what would it have cost in the USA. Certainly tens of thousands I estimate.
Generally we underestimate the value of the NHS. I have used BUPA, and the rooms are nice and it is great to get an appointment at a time that suits me. But it is often the same specialist I would have seen anyhow. People don't think that the 10 minute NHS appointment would have been charged at £90 privately. Without recognising that it is difficult to have a debate.

As someone who makes a living waffling about public sector procurement, I think getting GPs to replace PCTs is daft. Most businesses don't know how to effectively purchase complex services - GPs will either need to be trained, to outsource or do it badly. I would rather they stuck to medicine and outsourced the admin - in which case why not just stick with PCTs? Reform them maybe.

...albeit in a small, largely insignificant role. The diversity of the conditions that it treats and the volume of patients that walk through the doors is mind-blowing . The framework designed to organise everything ultimately caters for the needs of individuals; there are times when you need to get your head away from the production line mentality and treat the people in front of you on a case by case basis.

One department where I worked was recently visited by an outside team of efficiency consultants, who immediately set about contradicting their remit by being too large in number and intent on getting in the way. At one point, in a scene reminiscent of mime artists at Covent Garden, they were actually walking behind us counting our footsteps. Their report amounted to a basic description of the job with recommendations as to how the process might be streamlined. What they also witnessed, but wilfully failed to acknowledge, were the many variables faced by staff, which are as important as the core work. If a patient presents themselves in the department and requires some assistance that takes you out of your normal routine, then you have a duty of care to help them, or to refer them to someone who can. The efficiency experts approached the job from the angle of improving productivity and driving down costs but shied away from these intangibles that are difficult to quantify.

My experience of working the NHS is that if you follow your job description to the letter then you probably aren’t doing a very good job. Getting the best for patients requires that you make more work for yourself; it requires that you notice when things are going wrong or could be better, and that you then take action to ensure a more favourable outcome. In doing so you shoulder a greater burden both in workload and responsibility, if things go wrong. Yet time and time again I have watched members of staff who had nothing further to gain, go above and beyond what was being asked of them in order to help patients. There is a woman who would have come into the hospital yesterday morning, who will never know the strings that were pulled and the effort made on her behalf to ensure that she got the best possible care. All of that behind the scenes organisation took time and effort that will never show up on any balance sheet, will never to be acknowledged by senior management, and will soon be forgotten by the people who arranged it. None-the-less it was the right thing to do and the patient might have slipped through the cracks in the system if all of this hadn’t been done.

Over the past few years I have watched the NHS adopt a more corporate mindset, sometimes, it seems, at the expense of patient care. Budgeting and raising funds is important but often money seems to take precedence. In a major redevelopment of the hospital site, the area that houses the well-known high street coffee chain and the well-known high street newsagents were finished months before the new outpatients department which remains incomplete, with patients struggling to locate their appointments and often having to sit in improvised waiting areas that were not designed to accommodate large groups of people.

It worries me that the business ethos being imposed on the NHS will begin attracting the wrong type of person into the organisation at the expense of the good people who will either move on, or will be guided by management whose skewed principles place patient care secondary to profit.

When I left Britain 20 years ago it had institutions like British Rail, the BBC and the NHS. BR was shabby, but it worked. I took a train from London to the Kyle Of Lochalsh and Skye once - do they still have that? Last Xmas I went back and had a choice of trains to Leeds, only they were all cancelled due to the snow.
The BBC? Maybe choice is a good thing there. I like listening to 6Music, but I found the Christmas TV choices were rubbish on all 116 channels. Couldn't even find Von Ryan's Express.
So will the NHS improve if I have a choice of GPs and hospitals? Maybe you will find it easier to see a doctor in a commercial 'skin cancer check' clinic or some other moneyspinning venture. The sad fact is that doctors ARE motivated by money, especially when they've got a massive student loan to pay off. When you introduce choice and competition you'll find that doctors choose what's best for them. And it's often not what's best for the less well off, the isolated and the people who are least able to make the right choices for themselves.

May I recomend a view of the BBC documentary of Gerry Robinson, the management guru; at Barnsley Hospital. He did eventually get the Orthopeadic department working in a more effective fashion, but it was a hell of a struggle. None of the groups in the NHS - nursing, doctors, admin, management want to bend. They are exceptionally instructive programs.