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Contestability: a middle path for health care

Quietly in the night, competition in British health care has slipped away, its passing unremarked and little noticed by those who brought it into this world. The death sentence was first signalled by William Waldegrave when he was secretary of state for health. As Mr Waldegrave commented at the time, the NHS market “isn't a market in the real sense … it's competition in the sense that there will be comparative information available.”1 The change of direction was confirmed by Virginia Bottomley. In her valedictory speech in 1995 Mrs Bottomley extolled the virtues of planning and collaboration; the word “competition” scarcely crossing her lips.2 Her successor, Stephen Dorrell, has echoed this line, most notably in a personal letter to the chairs of health authorities and trusts. In his letter Mr Dorrell referred to the achievements of the NHS management reform, and at no point did he mention markets and the benefits that would arise from competition in future. Indeed, when was the last time any health minister urged those in the NHS to leave behind the legacy of planning and grasp the competitive opportunities available to them?

The decoupling of markets and health care is not a uniquely British phenomenon, as developments in Sweden and to a lesser extent the Netherlands indicate. After a decade in which competition was seen as …