Diversity and choice in mental healthcare Commentary on . . . Cooperation or competition?

Independent sector psychiatrists believe that they work hard for the benefit of vulnerable people. Differences between them and National Health Service colleagues are not clear cut in terms of motivation or quality of care. However, unfair generalisations are made about the diverse ‘private sector’, with selective comparison such as with the worst of US healthcare. Although there are many examples of excellence in the UK state, commercial and charity sectors, global economic changes are bringing risk of care failures from which no area can be immune. We should all be working together to protect our patients from the mistakes of others.

Laurence Mynors-Wallis's editorial comes at an important time for mental health services, subject as they are to immense political change and economic pressure. He presents a familiar, critical perspective on attempts to further widen the range of providers of National Health Service (NHS) care. I try here to respond, in the spirit of constructive dialogue, with a very different but equally personal viewpoint.
Psychiatrists who care for NHS patients in the private and voluntary sectors naturally work best if they feel they are involved in a widely shared, positive endeavour for the benefit of vulnerable people. It can therefore sometimes be dispiriting when NHS colleagues, despite some inclusive gestures, stigmatise those in the independent sector. Wellmeaning professionals working outside the NHS, whether in commercial or charitable organisations, have recently seen the services they work in tarred with the high-profile failures of others, whereas no one would think to associate all NHS teams with the various scandals in similar areas of intellectual disability and elder care within the NHS.

Idealists v. mercantilists -not a clear-cut division
For example, in a lead letter in this journal, Dr Alistair Stewart cited specific failures of private equity groups, branded the independent sector as 'a polite fiction', and complained of 'the private sector milking the money which most taxpayers think is going to the NHS'. 1 Dr Mynors-Wallis similarly presents state cooperation and market competition as incompatible moral opposites. He references the founding NHS principles of 1948, and quotes a Royal College of General Practitioners report as the authority on how patients are too vulnerable to be consumers in a profit-based market system. 2 Yet fee-forservice programmes delivered by general practitioners are obvious examples of profit-driven healthcare, and of course all NHS professionals are paid for their work.
In reality, the entire provision of NHS care is a human patchwork of cooperation and competition for patients and resources, and surely it always was. Nevertheless, Dr Mynors-Wallis longs for the days before the 1989 purchaser-provider split, arguing that administrative costs have gone up with the internal market. Interestingly, a recent McKinsey analysis found that, despite widespread beliefs to the opposite, NHS management costs remain low by international standards. 3 The point is -the market is not the cause of the NHS's problems. elaborate, defensive arguments to deny patients any choice as to where resources for their care should go. The failures of US healthcare are repeatedly used as a smokescreen for this. In response to an editorial on market choice, 4 Dr Morris Bernadt focused entirely on profit, sharp practice and fraud in US healthcare, contrasting this with the NHS as an example of 'a system based on trust and common purpose'. 5 Dr Mynors-Wallis also presents the atypical US healthcare system as the 'salutary' example of competition not working, in contrast to the current NHS being based on 'planning and coordination'. He nevertheless admits that market and state-run healthcare are not inherently better or worse, a view supported by detailed work from the World Health Organization. 6 He does not however make any reference to insurance-based and other market systems of universal access, especially in Europe, which perform well in comparative studies. 7

Sweeping one's own backyard
Dr Mynors-Wallis does see room for improvement in NHS mental healthcare, concerning repeated assessments, rigid service boundaries, and variable productivity. However, later rehearsing the 'cherry picking' view of the independent sector, he fails to make the connection that NHS services and trusts also exclude whole groups of patients, for a wide variety of clinical reasons, when they feel they do not have the resources to care. Dr Mynors-Wallis also raises the risk of services being fragmented by the market, even though fragmentation already exists between service boundaries. Perhaps such shortcomings might be addressed by patient choice and competition? From an independent sector perspective, the NHS at present has the transaction costs he fears, but without the cost and quality benefits of choice for patients, as the large, often inefficient, monopoly foundation trusts remain dominant.

Facing the same challenges
One area of agreement is the difficulty designing choice mechanisms in acute services. Dr Mynors-Wallis suggests that competition should be only tentatively tested out. This rather overlooks the fact that in large areas of social and community mental healthcare, commercial and charity providers play a major role already. The government in England has been pursuing 'marketisation' right across public services for decades now, driven by the perceived failure of the state model to provide satisfactory value in quality and cost. Ultimately, it should be service user and taxpayer satisfaction which is the outcome-driving change. I agree that producing more objective measurement of outcome in mental health is critical in guiding this. However, there are as yet only rare examples of large mental health providers publishing outcome data for entire service user populations. 8 The truth is that in-house NHS services across the UK include both shining examples of excellence and dedication, and also scandalous failures of care and management, just as in the diverse 'independent sector'. All sectors have cooperation and competition between and within teams and organisations, and all co-exist within wider society and the global economy. It is important to understand that all sectors have been caught up in the same economic cycle, and this accounts for a rash of recent failures, with probably more to come. In the prosperous years huge and unsustainable government investment in public services helped all our patients, but the consequent public debt has brought severe reductions in spending, especially in social care, the full impact of which we are yet to see. Similarly, when credit boomed, the for-profit, commercial sector built many modern hospitals and community homes, from which NHS mental health patients have greatly benefited. Without such growth many vulnerable people would otherwise be homeless or in prison. However, just like in the government sector, this was based on irresponsible borrowing, leading now to similarly severe financial and quality challenges.
In the downturn, mental health patients are among the most vulnerable people affected, as care providers including many community mental health charities struggle to survive. I would encourage NHS colleagues to acknowledge good work done by psychiatrists and mental health teams in every sector, and balance critical comments with examples of good clinical practice wherever they occur. It is painful to see the fallout of the international debt crisis roll through our society and affect the most vulnerable. The responsibility rests perhaps with key decision makers in international public and private finance, but let us not become so conflicted that we waste our energies blaming each other in the mental health world. Let us embrace diversity of choice for patients, and pursue the best possible services that society can afford for vulnerable people.