Health Care Analysis7: 91–98, 1999.© 1999Kluwer Academic Publishers. Printed in the Netherlands.

For Debate

Is Competition Good for Medicine?

EDWARD A. HARRISHonorary Physician (retired), Green Lane Hospital, Auckland, New Zealand

Introduction

It is nowadays a widely professed article of business faith that, under allconceivable circumstances, the key to excellence is competition. But amongthe commercial aristocracy the intrinsic efficiency of well-run monopolies iswell understood, as it was understood by Adam Smith (1776). Competitionis for the peasantry. Efficient corporationscooperate. They diligently seek tobuy out their suppliers. They take over or merge with their competitors if theycan, and collude with them if they cannot.

I therefore wonder why comprehensive, universal, state-funded health careshould be thought so unbusinesslike by the high priests of the New Right. Interms of cost alone, there is ample evidence that it is more economical than asystem of separate, competing, multiple funders and providers. Marcia Angellcited data up to 1990 (Angell, 1993) showing that the USA spent, per citizen,half as much again ($2566) as Canada ($1770), and nearly three times asmuch as Britain ($972) on health care.

So does competitive medicine, perhaps, providebetter medical care? Aclinical career of nearly 50 years has convinced me that good medicinedemands the fullest cooperation of all health professionals. Complete open-ness with each other, frequent mutual consultation about their clinical cases,and readiness to identify mistakes are essential. Competition for patients,in particular, is wholly destructive of these aims. I recently came upon thefollowing case history. As disasters go, it is fairly minor, but it may illustratethe point without exciting undue emotion. Small disasters are thankfully morecommon than the big ones, but this is cold comfort for those who suffer them.

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A Case History

Mrs A. B., nearing 50 years old, has found breathing difficult since the birthof her first child, when she was 24. This was diagnosed by her general practi-tioner (GP) as asthma. The diagnosis stuck. From then on, she was treatedprogressively with the full pharmacological arsenal of anti-asthma drugs,including steroids. Recently her current GP, at last unsure of how to deal withher persistent symptoms, referred her to a respiratory physician at a reputablepublic hospital.

Here, a careful history rapidly identified the ‘hyperventilation syndrome’(HVS) as the cause of her symptoms. It has nothing whatever to do withasthma. Drugs are of no help. The physician arranged for Mrs. A. B. to seethe hospital physiotherapist to be taught breathing exercises. Her prognosis isvery good.

Features of HVS

Most people, I fancy, have had HVS at some time. I certainly have. Asa student, 50-odd years ago, while waiting forviva voceexaminations, Iremember pacing up and down, taking repeated deep breaths which failedto ‘satisfy my need for air’. Since I clearly associated these symptoms withmy anxiety, I was able to dismiss any thought that they boded ill. Without thisinsight, I should have had another, potentially permanent, reason for anxietyto supplement the temporary apprehension of what my examiners might doto me.

HVS and related syndromes have a long pedigree. Da Costa (1871)described a condition he called ‘irritable heart of the soldier’. Between theworld wars the same condition was variously designated ‘athlete’s heart’,‘soldier’s heart’, and ‘cardiac neurosis’, emphasizing the palpitation that mostpatients reported, and reflecting frequent confusion, among doctors as well aspatients, with organic disease of the heart. Breathlessness at rest or on mildeffort was a constant feature. Sir Thomas Lewis (1943) sought to distinguishit by a new name, ‘effort syndrome’. Even this name misleadingly empha-sized effort. Wood (1941) urged a neutral designation such as ‘Da Costa’ssyndrome’. Wood’s own description (1941) clearly included all the featuresof HVS.

‘Hyperventilation syndrome’ seems an apt designation for those patients,very numerous nowadays, in whom excessive ventilation of lungs – ‘over-breathing’ – is the predominant feature. This variant, too, has long beenknown. A standard textbook of Medicine (Cecil and Loeb, 1959) had thisto say:

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The hyperventilation syndrome is a condition in which the patient issubject to repetitive overbreathing, forced respiration, yawning, sensa-tions of air-hunger and feelings of pain in the thorax. The earlysubjective symptoms produced by the induced reduction in carbondioxide concentration in the blood are dizziness, feelings of faintness,profuse perspiration and instability in walking. The hyperventilationsyndrome is probably the least recognized but most common manifes-tation of stress-producing fear and anxiety. . . [L]ater symptoms includepalpitations and complaints of heart pain and bandlike feelings aboutthe chest, followed by [tingling] in the fingers, toes or [around themouth] and, eventually, tetanic contractions. [Tetany, not tetanus!] In rareinstances, hyperventilation may lead to weak and irregular pulse, pallorand loss of consciousness.

There would be little to add to this excellent description today.

Discussion

The Patient

After 25 years of being labelled ‘asthmatic’, the patient in this story finds itvery difficult to accept that she doesn’t have asthma. After all, the doctors arenow telling her the opposite of what they told her for 25 years, and seem assure of their opinions as ever. Some of them, it is true, explain the reasonsfor their opinions better than others do, but it can be hard for non-medicalpeople to grasp the meaning of what, even if wrong, seems straightforwardto a doctor. Nor, usually, can a patient realistically hope, unaided, to evaluatethe real worth of any doctor’s clinical opinion (Harris, 1995).

To the extent that Mrs. A. B. does accept the new diagnosis, she hasunderstandable grounds for resentment. Over the last 25 years she has taken,and substantially paid for, a huge amount of medicines, including potentiallyharmful ones, that were quite useless for her real disorder. She has paiddoctors’ fees for consistently inappropriate advice. But she is among thegreat majority of patients who understand that doctors, either individuallyor collectively, can’t know everything, and who believe that they mostly dotheir best.

The Doctors

If HVS is so common, why is it still so often missed? Most respiratory physi-cians can tell of countless occasions on which a ‘difficult’ diagnosis turnedout, on referral, to be fairly obvious HVS. The referring doctor was either

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unaware of HVS, or could not afford the time to take a proper history, orhad some unaccountable ‘mental block’ where HVS is involved. It is incon-ceivable that his or her teachers at Medical School would have consciouslyomitted reference to so important – because so common – a disorder.

Medicine is not just a science, and certainly not an exact science. To aconsiderable extent clinical medicine is a craft, based on the sort of expertiseneeded by an art expert to recognize a lost Caravaggio. Misattributions arefrequent in the worlds of Art and Clinical Medicine. Two or three art expertswould be less likely than only one to miss a Caravaggio. In Medicine, twogood heads are usually better than one.

The Politicians

The doctors, then, face handicaps, not all of their own making, and of whichthey may not even be aware, that work to their patients’ disadvantage. Howmight a politician so administer the Health portfolio as to minimize the effectsof these handicaps?

i) TeachingFirst, the clinical training of medical students and junior doctors needsthe most scrupulous attention. In teaching hospitals it is basically of littleconsequence whether the teaching staff are paid by the University or by theHospital Authority. In a public system it all comes from the same purse. In thepresent pseudo-commercial structure it doesn’t, adding layers of unnecessaryand complex administration. Hair-splitting negotiations about the respectivefiscal contributions of University and Hospital Authority to the hospital’steaching function are time-wasting and destructive of the real aim. Goodwilland trust are essential.

Teaching hospitals, especially, should be staffed throughout by competent,experienced, intelligent and suitably academic senior doctors, whoever paysthem. All consultants and registrars should have a teaching role, and should befree from the distractions of running private practices. Given this, a hospitalmust then do everything possible to bring patients, teachers and studentstogether for unhurried teaching in wards and outpatient (OP) departments.This means that wards must allocate sufficient teaching time. That is notpossible unless visiting hours are restricted in some sensible way. It alsomeans that the hospital must run a sufficient variety of OP clinics, freelyavailable for reference by general practitioners, and with adequate facilitiesfor teaching. With very little ingenuity, visiting hours in the wards can bemade to fit in with teaching in the OP clinic. Patients such as Mrs A. B. maynever be admitted to the ward, but students will still see them, and hear theirstories at first hand, as outpatients. History-taking is a vital art in efficientclinical medicine and takes a long time to master.

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The last important need is for patients to understand that well-organizedteaching greatly improves their standard of care. ‘Being taught on’ is certainlyan imposition for the patient. Nowadays, however, patients are quite properlytold explicitly that they have a right to refuse participation in clinical teaching.Are patients led by this, perhaps, to think that teaching is unimportant for theircare? Those who refuse it miss the chance of much clinical benefit, valuableinformation and sometimes even entertainment. And bedside or outpatientteaching, since the patient is present, usefully trains an intelligent teacher toconsider very carefully the patient’s point of view – and more importantly toteach this attitude by example.

The idea of teaching may not come readily to commercially-trainedmanagers. It greatly slows ‘production’. It is as though the managers of alarge shipyard were required to make provision and time for the profes-sional training of marine engineers. (To complete the parallel, they wouldbe committed to engineering research as well.) For better or worse, hospitalsplay a vital part in the training of doctors. Hospital management must accordit due priority.

ii) CompetitionThe late Mr Enoch Powell (a former High Tory British Minister of Health)wrote in 1992:

We are at present witnessing within the National Health Service acomprehensive and unprecedented attempt to achieve a limitation and‘cut-off’ of political responsibility. ‘Devolution’ it would be wrong tocall it; for devolution implies retention of ultimate responsibility by thedevolver. The preferred euphemism is ‘reform’; but the attempted realityis ‘transfer’. “Let us”, the politicians have said, “divide the Service intoconvenient units. Let us then throw into the lap of each of them a financialallocation. Then we will tell them to get along as best they can. Let them,in a word, ‘compete’. Hey presto! The problem of comparing the incom-mensurable is solved: competition – competition for patients, competitionfor efficiency, competition for balancing the financial books – that will dothe trick. . . (Powell,1992).

The Fundamentalist New Right, to which most politicians nowadays seemfirmly to adhere, evidently hold that there are no social problems (or, onesuspects, any other problems) that competition cannot solve. It supposedlydoes this by what Martin Gardner (1983) called ‘the prestidigitation of[Adam] Smith’s nimble fingers (Smith, 1776). Competition, accordingly, isan implicit feature of the ‘business model’ of medicine, summarized (in part)by Pellegrino and Thomasma (1988) as follows:

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Health care is a commodity to be bought and sold in the marketplace. . . Thegood patient is one who contributes to a health economy by payingbills on time [and] by being a repeat customer for preferred services. . . The doctor must provide a ‘good product’ and stand behind it. . . notbecause it is morally owed to the patient but because it is good forbusiness to have a reputation for good service.

A ‘business-physician’ who is paid for each item of service, whether bythe patient or by the patient’s insurance company or firm, has an incentivenot to risk losing the patient’s custom by referring her to another prac-titioner for a second opinion. For GPs in comprehensive public schemes,paid by salary or capitation-fee, and for physicians in ‘Health MaintenanceOrganizations’ (HMOs), this incentive is not so acutely felt. So referralsfor help might burgeon in the absence of some extra constraint. HMOs andTreasury-dominated Ministers of Health therefore favour ‘fund-holding’ or‘budget-holding’ primary-care units. The doctor or unit is allocated a budgetfrom which external referrals for opinions or tests or hospital care must bepaid for. ‘The essence is motivate the provider to limit access to care byappealing to his or her self-interest’ (Pellegrino and Thomasma, 1988). Itpits the fund-holding GP against other fund-holding GPs and against thespecialists who are widely seen as dominating the public system.

Fund-holding is a competitive device that finds favour with many GPsin a public system. It gives the GP, for example, the financial incentive to dominor operations him(her)self rather than refer the patient to a surgeon. Is thisdesirable, as a general policy, even supposing that the diagnosis is correct? AsSir Douglas Black (1992) has written: ‘A minor operation has been defined asan operation done on somebody else. For oneself, preference might lie withsomeone who has undergone the full rigours of surgical training, abetted bya comparable anaesthetist if necessary. There are few operations with whichnothing can go wrong.’

How would ‘fund-holding’ influence the GP in our case-history? On theone hand, if her patient’s anti-asthma medication is somehow charged toher budget or fund, she would have an incentive to find a way of stoppingit. She might therefore opt for a (hopefully) one-off referral to the chest-physician for confirmation of her hunch that her patient didn’t have asthma,but instead a condition that didn’t need medication. On the other hand, howwould she get the hunch in the first place? If she had been in thehabit ofreferring her patients she might have had the hunch long before this, makingthe present referral unnecessary. Her patient might then have been saved fromyears of useless medication. In any case it seems pretty obvious that financialincentives are no proper basis for making essentially clinical decisions.

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Private monopolies, in many countries, are subject to (often minimal) anti-trust legislation, and they test it to the limit, not without success. Politiciansnowadays seem to reserve their really determined efforts for the splittingup of public monopolies, regardless of the difference thattheir efficienciesaccrue to the public purse. This illogical course may be dictated by the polit-ical unwisdom of selling off a public monopoly, intact, to a private buyer.Certainly sale is a common fate of a recently-dismantled public service,though of course it is routinely preceded until the last minute by minis-terial statements that ‘there is no intention’ to sell. Whither public medicalservices?

Envoi

Recent articles in this Journal have addressed the question ‘What would aSocialist health system look like?’ Of the numerous features it would have todisplay, none, in my view, is more fundamental than a structure that encour-ages the greatest possible cooperation of all concerned in medical care, solelyin the interest of patients. Demarcation disputes should never arise. Remu-neration should reflect reasonable estimates of training, responsibility andexcellence, at a general level that assures only freedom from worries thatdistract from what the central aims of a health worker should be. Havingspent 45 years in two systems – now regrettably, courtesy of the New Right,defunct – that broadly met these conditions, I can testify to their immensepotential for work satisfaction, high morale and – yes! – joy. I know of nocombination that beats that one for efficiency.

Acknowledgement

The late Sir Stanley Davidson, Regius Professor of Medicine in the Univer-sity of Edinburgh, set up a joint hospital service in Edinburgh, soon afterWorld War II, that for me has been a guiding model of what such a serviceshould aim for. It was a true collaboration between University and HospitalBoard. He had the great advantage of working with a far-seeing and intelli-gent Minister of Health, and with career administrators who were imbuedwith common sense and regard for social principle. His uncompromisingdirectness and contempt for humbug is badly needed today.

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