In defence of our research on competition in England's National Health Service
2011; Elsevier BV; Volume: 378; Issue: 9809 Linguagem: Inglês
10.1016/s0140-6736(11)61708-x
ISSN1474-547X
AutoresNicholas Bloom, Zack Cooper, Martin Gaynor, Stephen Gibbons, Simon Jones, Alistair McGuire, Rodrigo Moreno‐Serra, Carol Propper, John Van Reenen, Stephan Seiler,
Tópico(s)Health Services Management and Policy
ResumoIn their Comment (published online Oct 10),1Pollock A Macfarlane A Kirkwood G et al.No evidence that patient choice in the NHS saves lives.Lancet. 2011; (published online Oct 10.)https://doi.org/10.1016/S0140-6736(11)61553-5Summary Full Text Full Text PDF PubMed Scopus (41) Google Scholar Allyson Pollock and colleagues misrepresent our research.2Bloom N Propper C Seiler S Van Reenan J The impact of competition on management quality: evidence from public hospitals.http://cep.lse.ac.uk/pubs/download/dp0983.pdfGoogle Scholar, 3Cooper Z Gibbons S Jones S McGuire A Does hospital competition save lives? Evidence from the NHS patient choice reforms.Econ J. 2011; 121: 228-260Crossref Scopus (234) Google Scholar, 4Gaynor M Moreno-Serra R Propper C Death by market power: reform, competition and patient outcomes in the National Health Service.http://www.bris.ac.uk/cmpo/publications/papers/2010/wp242.pdfGoogle Scholar Although such work might run counter to Pollock and colleagues' prior beliefs, this is not grounds to dismiss it. Nowhere in their review have Pollock and colleagues given evidence that the reforms we studied have harmed patients' outcomes. Instead, they dismiss the research as "flawed" and criticise the data in our analysis in an effort to undermine our findings, which they view as supporting the current UK Government's policies.Researchers have little influence over how politicians use their academic work. But how researchers discuss evidence that does not support their prior beliefs is of fundamental importance. We have not unilaterally supported competition. Gaynor5Gaynor M Competition and quality in health care markets.Foundations Trends Microecon. 2006; 2: 1-84Crossref Scopus (64) Google Scholar has pointed out that competition in health care is not always beneficial. Charlesworth and Cooper6Charlesworth A Cooper Z Making competition work in the English NHS: the case for maintaining regulated prices.J Health Services Res Pol. 2011; 16: 193-194Crossref PubMed Scopus (8) Google Scholar have expressed doubts over the empirical support for price competition. Likewise, the views of Cooper and Propper on this issue were reported by Timmins.7Timmins N U-turn on NHS pricing welcomed.Financial Times. March 4, 2011; Google Scholar Much of our concern over price competition is based on research by Propper and colleagues,8Propper C Burgess S Gossage D Competition and quality: evidence from the NHS internal market 1991–1996.Econ J. 2008; 118: 138-170Crossref Scopus (168) Google Scholar who used techniques and data similar to those used in our three current papers2Bloom N Propper C Seiler S Van Reenan J The impact of competition on management quality: evidence from public hospitals.http://cep.lse.ac.uk/pubs/download/dp0983.pdfGoogle Scholar, 3Cooper Z Gibbons S Jones S McGuire A Does hospital competition save lives? Evidence from the NHS patient choice reforms.Econ J. 2011; 121: 228-260Crossref Scopus (234) Google Scholar, 4Gaynor M Moreno-Serra R Propper C Death by market power: reform, competition and patient outcomes in the National Health Service.http://www.bris.ac.uk/cmpo/publications/papers/2010/wp242.pdfGoogle Scholar to show that price competition during the National Health Service internal market increased hospital death rates. Interestingly, Pollock and colleagues have not voiced displeasure with that research.There is nothing wrong with opposing the current Government's health reforms and nothing wrong with criticising research—this is part of the healthy competition of political and scientific ideas. However, launching inaccurate attacks on research that one does not like for ideological reasons is not only bad science, it also damages the long-run attempt to make evidence-based policy a reality rather than rhetoric. Indeed, our three papers are part of a wider academic effort to assess the effect of policies and investigate their causal effects by use of statistical analysis.9Ibens G Wooldridge J Recent developments in the econometrics of program evaluation.J Econ Lit. 2009; 47: 5-86Crossref Scopus (2186) Google ScholarPollock and colleagues omit key details about our research. For example, they argue that a key shortcoming of the study by Cooper and colleagues3Cooper Z Gibbons S Jones S McGuire A Does hospital competition save lives? Evidence from the NHS patient choice reforms.Econ J. 2011; 121: 228-260Crossref Scopus (234) Google Scholar was that it failed to account for percutaneous coronary intervention. However, Cooper and colleagues directly controlled for whether or not patients had an angioplasty. Further, mindful of the roll-out of cardiac networks, Gaynor and colleagues4Gaynor M Moreno-Serra R Propper C Death by market power: reform, competition and patient outcomes in the National Health Service.http://www.bris.ac.uk/cmpo/publications/papers/2010/wp242.pdfGoogle Scholar controlled for hospitals' share of patients who were receiving thrombolysis treatment before hospital arrival and primary angioplasty, and for those discharged on aspirin, β blockers, or statins.Pollock and colleagues also lambast the use of acute myocardial infarction (AMI) as a quality measure, arguing that "the fact that they might be correlated with waiting times or length of stay for elective knee replacement or hip replacement does not make them a valid proxy measure of safety or quality of elective care". However, Cooper and colleagues3Cooper Z Gibbons S Jones S McGuire A Does hospital competition save lives? Evidence from the NHS patient choice reforms.Econ J. 2011; 121: 228-260Crossref Scopus (234) Google Scholar also showed that AMI mortality correlates with overall mortality and hospitals' patient satisfaction. Furthermore, Gaynor and colleagues4Gaynor M Moreno-Serra R Propper C Death by market power: reform, competition and patient outcomes in the National Health Service.http://www.bris.ac.uk/cmpo/publications/papers/2010/wp242.pdfGoogle Scholar examined a battery of measures constructed by the National Clinical and Health Outcomes Knowledge Base, and found that greater competition was linked to improvements in length of stay, overall hospital mortality rates, and overall mortality rates excluding AMI care.Pollock and colleagues do not even accurately present the other work that they cite. Contrary to their assertions, Bradford Hill10Bradford Hill A The environment and disease: association or causation?.Proc R Soc Med. 1965; 58: 295-300PubMed Google Scholar argued in favour of the type of quasi-natural experiments we implemented, stating "occasionally, it is possible to appeal to experimental or semi-experimental evidence…here the strongest support for the causation hypothesis may be revealed". Indeed, Bradford Hill also lavished praise on Snow,11Snow J On the mode of communication of cholera. 2nd edn. John Churchill Publishing, London1855Google Scholar who examined the causes of cholera outbreaks in London in what is regarded as the first use of difference-in-difference regression.12Angrist JD Pischke J-S The credibility revolution in empirical economics: how better research design is taking the con out of econometrics.J Econ Persp. 2010; 24: 3-30Crossref Scopus (652) Google Scholar This is the same strategy we used to test the effect of competition.3Cooper Z Gibbons S Jones S McGuire A Does hospital competition save lives? Evidence from the NHS patient choice reforms.Econ J. 2011; 121: 228-260Crossref Scopus (234) Google Scholar, 4Gaynor M Moreno-Serra R Propper C Death by market power: reform, competition and patient outcomes in the National Health Service.http://www.bris.ac.uk/cmpo/publications/papers/2010/wp242.pdfGoogle ScholarNo study is perfect, which is why we have peer review and open science. However, the fact that three studies by separate research teams produced consistent results strongly fortifies our collective findings. More work surely needs to be done to understand the changes competition has brought about in England. However, the way forward should be to look objectively to see what is driving our findings, rather than dismissing the results out of hand because they conflict with prior beliefs.An extended point-by-point response to the Comment by Pollock and colleagues can be found online. We declare that we have no conflicts of interest. In their Comment (published online Oct 10),1Pollock A Macfarlane A Kirkwood G et al.No evidence that patient choice in the NHS saves lives.Lancet. 2011; (published online Oct 10.)https://doi.org/10.1016/S0140-6736(11)61553-5Summary Full Text Full Text PDF PubMed Scopus (41) Google Scholar Allyson Pollock and colleagues misrepresent our research.2Bloom N Propper C Seiler S Van Reenan J The impact of competition on management quality: evidence from public hospitals.http://cep.lse.ac.uk/pubs/download/dp0983.pdfGoogle Scholar, 3Cooper Z Gibbons S Jones S McGuire A Does hospital competition save lives? Evidence from the NHS patient choice reforms.Econ J. 2011; 121: 228-260Crossref Scopus (234) Google Scholar, 4Gaynor M Moreno-Serra R Propper C Death by market power: reform, competition and patient outcomes in the National Health Service.http://www.bris.ac.uk/cmpo/publications/papers/2010/wp242.pdfGoogle Scholar Although such work might run counter to Pollock and colleagues' prior beliefs, this is not grounds to dismiss it. Nowhere in their review have Pollock and colleagues given evidence that the reforms we studied have harmed patients' outcomes. Instead, they dismiss the research as "flawed" and criticise the data in our analysis in an effort to undermine our findings, which they view as supporting the current UK Government's policies. Researchers have little influence over how politicians use their academic work. But how researchers discuss evidence that does not support their prior beliefs is of fundamental importance. We have not unilaterally supported competition. Gaynor5Gaynor M Competition and quality in health care markets.Foundations Trends Microecon. 2006; 2: 1-84Crossref Scopus (64) Google Scholar has pointed out that competition in health care is not always beneficial. Charlesworth and Cooper6Charlesworth A Cooper Z Making competition work in the English NHS: the case for maintaining regulated prices.J Health Services Res Pol. 2011; 16: 193-194Crossref PubMed Scopus (8) Google Scholar have expressed doubts over the empirical support for price competition. Likewise, the views of Cooper and Propper on this issue were reported by Timmins.7Timmins N U-turn on NHS pricing welcomed.Financial Times. March 4, 2011; Google Scholar Much of our concern over price competition is based on research by Propper and colleagues,8Propper C Burgess S Gossage D Competition and quality: evidence from the NHS internal market 1991–1996.Econ J. 2008; 118: 138-170Crossref Scopus (168) Google Scholar who used techniques and data similar to those used in our three current papers2Bloom N Propper C Seiler S Van Reenan J The impact of competition on management quality: evidence from public hospitals.http://cep.lse.ac.uk/pubs/download/dp0983.pdfGoogle Scholar, 3Cooper Z Gibbons S Jones S McGuire A Does hospital competition save lives? Evidence from the NHS patient choice reforms.Econ J. 2011; 121: 228-260Crossref Scopus (234) Google Scholar, 4Gaynor M Moreno-Serra R Propper C Death by market power: reform, competition and patient outcomes in the National Health Service.http://www.bris.ac.uk/cmpo/publications/papers/2010/wp242.pdfGoogle Scholar to show that price competition during the National Health Service internal market increased hospital death rates. Interestingly, Pollock and colleagues have not voiced displeasure with that research. There is nothing wrong with opposing the current Government's health reforms and nothing wrong with criticising research—this is part of the healthy competition of political and scientific ideas. However, launching inaccurate attacks on research that one does not like for ideological reasons is not only bad science, it also damages the long-run attempt to make evidence-based policy a reality rather than rhetoric. Indeed, our three papers are part of a wider academic effort to assess the effect of policies and investigate their causal effects by use of statistical analysis.9Ibens G Wooldridge J Recent developments in the econometrics of program evaluation.J Econ Lit. 2009; 47: 5-86Crossref Scopus (2186) Google Scholar Pollock and colleagues omit key details about our research. For example, they argue that a key shortcoming of the study by Cooper and colleagues3Cooper Z Gibbons S Jones S McGuire A Does hospital competition save lives? Evidence from the NHS patient choice reforms.Econ J. 2011; 121: 228-260Crossref Scopus (234) Google Scholar was that it failed to account for percutaneous coronary intervention. However, Cooper and colleagues directly controlled for whether or not patients had an angioplasty. Further, mindful of the roll-out of cardiac networks, Gaynor and colleagues4Gaynor M Moreno-Serra R Propper C Death by market power: reform, competition and patient outcomes in the National Health Service.http://www.bris.ac.uk/cmpo/publications/papers/2010/wp242.pdfGoogle Scholar controlled for hospitals' share of patients who were receiving thrombolysis treatment before hospital arrival and primary angioplasty, and for those discharged on aspirin, β blockers, or statins. Pollock and colleagues also lambast the use of acute myocardial infarction (AMI) as a quality measure, arguing that "the fact that they might be correlated with waiting times or length of stay for elective knee replacement or hip replacement does not make them a valid proxy measure of safety or quality of elective care". However, Cooper and colleagues3Cooper Z Gibbons S Jones S McGuire A Does hospital competition save lives? Evidence from the NHS patient choice reforms.Econ J. 2011; 121: 228-260Crossref Scopus (234) Google Scholar also showed that AMI mortality correlates with overall mortality and hospitals' patient satisfaction. Furthermore, Gaynor and colleagues4Gaynor M Moreno-Serra R Propper C Death by market power: reform, competition and patient outcomes in the National Health Service.http://www.bris.ac.uk/cmpo/publications/papers/2010/wp242.pdfGoogle Scholar examined a battery of measures constructed by the National Clinical and Health Outcomes Knowledge Base, and found that greater competition was linked to improvements in length of stay, overall hospital mortality rates, and overall mortality rates excluding AMI care. Pollock and colleagues do not even accurately present the other work that they cite. Contrary to their assertions, Bradford Hill10Bradford Hill A The environment and disease: association or causation?.Proc R Soc Med. 1965; 58: 295-300PubMed Google Scholar argued in favour of the type of quasi-natural experiments we implemented, stating "occasionally, it is possible to appeal to experimental or semi-experimental evidence…here the strongest support for the causation hypothesis may be revealed". Indeed, Bradford Hill also lavished praise on Snow,11Snow J On the mode of communication of cholera. 2nd edn. John Churchill Publishing, London1855Google Scholar who examined the causes of cholera outbreaks in London in what is regarded as the first use of difference-in-difference regression.12Angrist JD Pischke J-S The credibility revolution in empirical economics: how better research design is taking the con out of econometrics.J Econ Persp. 2010; 24: 3-30Crossref Scopus (652) Google Scholar This is the same strategy we used to test the effect of competition.3Cooper Z Gibbons S Jones S McGuire A Does hospital competition save lives? Evidence from the NHS patient choice reforms.Econ J. 2011; 121: 228-260Crossref Scopus (234) Google Scholar, 4Gaynor M Moreno-Serra R Propper C Death by market power: reform, competition and patient outcomes in the National Health Service.http://www.bris.ac.uk/cmpo/publications/papers/2010/wp242.pdfGoogle Scholar No study is perfect, which is why we have peer review and open science. However, the fact that three studies by separate research teams produced consistent results strongly fortifies our collective findings. More work surely needs to be done to understand the changes competition has brought about in England. However, the way forward should be to look objectively to see what is driving our findings, rather than dismissing the results out of hand because they conflict with prior beliefs. An extended point-by-point response to the Comment by Pollock and colleagues can be found online. We declare that we have no conflicts of interest. No evidence that patient choice in the NHS saves livesThe Health and Social Care Bill 2011 has been framed to abolish direct parliamentary control and public accountability for the National Health Service (NHS) in England. In the face of enormous public opposition to the Bill, the UK Government stood down the legislative process between April and June, 2011. Prime Minister David Cameron used the temporary pause to advance the case for the Bill and argued "Put simply: competition is one way we can make things work better for patients. This isn't ideological theory. Full-Text PDF In defence of our research on competition in England's National Health Service – Authors' replyIn their response to our Comment, Nicholas Bloom and colleagues make four main points. The first is the claim that we misrepresented their research.1 They follow this by saying that "nowhere in the review have Pollock and colleagues given evidence that the reforms we studied have harmed patients' outcomes", but omit to acknowledge that this was not the purpose of our Comment. They then claim that our criticism was politically motivated, and that what they assume are our prior beliefs (without knowing what these are) led to a lack of objectivity. Full-Text PDF
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