The Health and Social Care Act was controversially enacted by the coalition government, introducing competition into the NHS. Looking at the market in state funded social care that was created over 20 years ago, Marianna Fotaki draws lessons for the NHS and about how markets in state funded care services operate when resources are constrained. She finds that the introduction of competition had a negative impact on the quality of care, the pressure of the competitive market has led to the de-professionalisation and casualisation of the social care workforce, and that the failure of care providers is an inevitable consequence of any care market with significant impacts for patients and service users.
The Health and Social Care Act 2012 seeks to create a market in state funded health care services and to enable private sector providers to bid for NHS services. The aim is to capture the benefits of a competition through providing better quality services more efficiently. A similar market in state funded social care was created over 20 years ago and provides the best available example to policy makers about how markets in state funded care services operate when resources are constrained. As such, it is reasonable to ask whether what has happened in social care may also happen in the NHS in the future. This is particularly relevant as the new NHS market in England is also being created at a time of significant resource constraints. The report published by the independent think-tank the Centre for Health and the Public Interest (CHPI) identifies a number of important lessons from the operation of social care markets over the past two decades and asks whether they could be repeated in the new NHS in England.
First, the introduction of competition in order to reduce costs has had a negative impact on the quality of care. A market in social care was introduced, in part, as a way of keeping the costs of state-funded social care under control. However, by restricting the funding available to local authorities to provide care services at a time of increased need, successive governments have forced local authorities to award contracts to the lowest-cost operators in the independent sector without sufficient concern for quality. In many instances this has, this driven down the quality of care to the ‘minimum quality level allowed’. Indeed the current Care Minister, Norman Lamb, has acknowledged that the current system ‘incentivises poor care, low wages and neglect, often acting with little regard for the people it is supposed to be looking after’.