Impact case study database

Between 1991 and the start of the impact period, UK government policy focused increasingly on introducing elements of patient choice into healthcare provision, under the assumption that increased competition between providers would motivate improvements and result in better patient care. In 2012, the Health and Social Care Act 2012 took this much further, seeking to make competition the organising principle of the NHS.

As discussed in the underpinning research, Beckert’s work on patient choice challenges uncomplicated understandings of competition as a mechanism towards improvements in care, showing that competition can reinforce existing inequalities and that choices may be driven by concerns other than patient care. His membership of a series of academic panels and steering groups for stakeholders such as the Competition and Markets Authority, NHS Improvement, the Nuffield Trust and the Institute for Fiscal Studies has allowed him to share his findings with decision-makers in the sector and to influence the actions not only of these groups, but of top policymakers at NHS England and the Department of Health. The effect can be seen in the long-term plan published by the NHS in January 2019, which makes explicit the intention to move the service away from its current emphasis on competition to favour collaborative ways of working instead.

Impact on hospital mergers

As attested by Kate Collyer, who was Director of Economics at the Competition Commission between 2012 and 2014, and subsequently (until 2018) the Deputy Chief Economic Adviser at the Competition and Markets Authority, Beckert’s research as expressed in paper [2] heavily influenced the methodology used by the Competition and Markets Authority to investigate hospital mergers during the impact period, as well as the CMA’s guidance on NHS mergers more generally [A].

Beckert has had an ongoing role as an academic panel member for the Competition Commission (2007-14) and Competition and Markets Authority (2016-present), as well as position on the economics reference group of the Co-operation and Competition Panel (now known as NHS improvement), since 2013. His 2012 paper on hospital choice [2], which was co-authored with Collyer, reflected on the methodology used by NHS Improvement and the Competition and Markets Authority to assess demand-side aspects of hospital mergers in England. The empirical approach to simulating the effect of mergers between hospitals that was laid out in that paper was then used by the CC and CMA in the competitive assessment of a series of hospital mergers in England, starting with the Royal Bournemouth and Christchurch Hospitals/Poole Hospital NHS Foundation Trust merger inquiry, which ran from January to October 2013.

The CMA has been involved in three hospital merger investigations, all of which fall within the census period: the Bournemouth and Christchurch/Poole merger inquiry that concluded in (October) 2013 (the merger was denied), the Ashford and St Peter's Hospitals (ASP)/Royal Surrey County Hospital inquiry in 2015 (approved), and Central Manchester University Hospitals/University Hospital of South Manchester inquiry in 2017 (approved). Beckert’s methodology was used as the basis for decision-making in each instance. As well as these three full merger inquiries, Beckert’s work also supported decision-making in the further five cases of proposed mergers which were approved without a full investigation being completed: Heatherwood and Wexham Park Hospitals/Frimley Park Hospital (June 2014); Chelsea and Westminster Hospital/West Middlesex University Hospital (January 2015); University Hospitals Birmingham/Heart of England (September 2017); Derby Teaching Hospitals/Burton Hospitals (April 2019); and Aintree University Hospital /Royal Liverpool and Broadgreen University Hospitals (August 2019). In every case, the CMA used Beckert’s research to assess the likely impact of the merger on care for the patients served by these hospitals, with the appendices in each case (which lay out the details of the decision-making) referring explicitly for their methodology to the Bournemouth/Poole decision of 2013 [C].

The above list covers all hospital merger inquiries ever undertaken by the CMA. Beckert’s research has therefore impacted every hospital merger decision that the CMA has made.

The purpose of the CMA’s intervention is to weigh up the potential benefits of a merger (which include greater financial efficiency, as resources are not duplicated across different settings, and a more efficient use of staff time as departments combine) against its potential costs (if competition with other providers motivates hospitals to focus on reducing waiting times, improving facilities, and extending service provision to attract patients, a merger removes the incentive to do this).

The outcome of this evaluation and therefore the benefits to patients in the local area are different in each case. But in every instance, by giving the Competition and Markets Authority the ability to make decisions that more accurately reflect the reality of a merger’s impact on the patients served by the hospital trusts, Beckert has helped to ensure that a patient population of approximately 7,000,000 is best served by their local NHS provision and that public money is spent efficiently. The income involved in any merger must be above £70 million (GBP70,000,000) in order for the Competition and Markets Authority to become involved; so with eight mergers in question, these decisions have directly influenced how a minimum of £560 million (GBP560,000,000) of public money has been spent.

Beckert’s ongoing work with the Competition and Markets Authority has continued to reflect his developing research. In 2017 and 2018, he was invited to lead a series of research meetings with the organisation to develop its in-house health care demand modelling, part of the organisation’s ongoing commitment to strengthening its in-house research capabilities in anticipation of recurring health care merger and market analyses. His 2018 paper [3] further refined his approach by adding a structural model of GP pre-selection decisions, estimable on observational data and permitting counterfactual analysis. This was a critical innovation which contributed to the CMA’s array of analytical tools because GP surveys suffer from extremely low response rates, as noted in the Final Reports of the Bournemouth and Christchurch merger investigation.

Impact on NHS policy

Beckert’s work on how expanded competition in publicly funded healthcare can exacerbate existing inequalities of access [3, 7] has helped to shape and to stimulate an ongoing debate on the ways that any benefits of competition actually accrue to patients. His research demonstrates that competition primarily benefits those people who can make it work for them, either on their own initiative or by being given suitable advice. Wealthy patients do twice as well as poorer patients under the system and white patients six times as well as their black equivalents. Beckert’s initial academic study into this phenomenon [2, 3] as well as his work on econometric methodology [4] was quickly seized upon by the Health Foundation, a major campaigning healthcare charity, whose chief executive suggested that Beckert translate his results into a policy paper [6] aimed at health policy practitioners.

As attested by that chief executive, Beckert’s work has helped those working in the sector to better understand the complexities of patient choice: it is now recognised that many groups of patients do not actively choose their provider of care. As a result, policymakers are now less focused on patient choice as being such a strong force for improvement in care or outcomes for patients. Instead collaboration and integrated care are now favoured means to improve care [B]. The NHS Long-Term Plan, which was published in 2019 and which sets out spending plans for the five-year, £20.5 billion (GBP20,500,000,000) NHS budget settlement announced by the government in 2018, is exemplary. This plan focuses on ‘collaboration, rather than competition, as an organising principle’ [D]: a significant change to the way in which the NHS is run. The reach of Beckert’s work therefore potentially affects all the population in England – circa 55 million people.

Impacts beyond the NHS

Beckert’s research has also influenced the work of international bodies engaged with the question of choice and competition in healthcare markets. The OECD’s working party on competition and regulation, part of the Directorate for Financial and Enterprise Affairs, cites Beckert [2] in a paper on ‘Designing Publicly Funded Healthcare Markets’ for the information he offers on the factors affecting patient choice [E]. This paper served as the background for a best-practice roundtable on healthcare markets, details of which were disseminated across OECD member states.

Beckert’s work with the Healthcare Foundation offers another route to international impact through the Healthcare Foundation’s involvement with other international bodies such as the WHO European Observatory on health systems and the OECD [B]. The Healthcare Foundation’s ongoing discussions with these bodies are informed by their work with Walter, influencing the policymakers who comprise their membership. It is therefore anticipated that Beckert’s research will benefit those other countries whose healthcare systems have seen the rise of competition as an organising principle; particularly those countries of the former Eastern Bloc, whose healthcare systems have been privatised and subject to competition [B].