The Impact of the Market-oriented Reforms in the UK and Sweden: case study - cataract surgery

In the early 1990s, a set of market oriented reforms was introduced into health care systems of the UK and Sweden, two exemplary cases of the reliance on planned budgeting and integrated provision of services. In the pursuit of increased efficiency, several County Councils in Sweden have followed public competition model while in the UK internal market reforms were introduced. It was expected, that the separation of functions of planners and purchasers from those of providers, would achieve higher allocative efficiency but it would also enhance users' satisfaction with care. This thesis used cataract surgery as a case study to trace the impact of competition among providers and the separation of purchasers' functions from the former on the set of selected indicators: choice, information, quality, responsiveness and efficiency. Qualitative research methods were employed to record the perception of changes of those indicators for patients, primary care providers, eye surgeons, managers and purchasers. A set of open ended and standardised questionnaires was designed to elicit the views of all actors involved and to measure the likely transformations. These data were then compared with quantitative figures obtained from hospital registers and national league tables where numbers of operations performed as day/inpatient cases, prices for service and waiting times for the first specialist appointment and cataract surgery were examined. Four study sites from outer London and the only existing large provider of eye services to Stockholm County Council were selected and used for the purpose of international comparison. The analysis of the data showed that the quasi-market reforms have resulted in a change of the attitude of secondary providers, which had some positive influence on quality of care expressed in reduction of waiting times at the outpatients' department and as tailored appointments for the surgery. Some improvements in the amount and type of information given to purchasers and patients could be detected, although as far as direct users were concerned, the demand for it has not been fully satisfied. However, the impact on choice available to patients and purchasers alike seemed to be adverse, an effect that was particularly strong in the UK case and which was precisely the opposite of what reforms proclaimed. This was partly a result of disincentives introduced by the reforms but it also reflected the ambivalence that patients had towards enacting their choices. Another finding was that General Practitioners were on the whole poorly informed about the changes and were unable to comment on many of the issues asked. This raises questions about the uncritical endorsement of vast responsibilities into the hands of intermediaries alongside the recent changes of the NHS. Responsiveness measured as changes in the waiting times for the first specialist appointment and for the cataract surgery itself showed an uneven trend. Both decreased in the short-term and then increased to the pre-reform levels after this issue ceased to be the priority on the governments' agendas, implying that these short lived effects must have been rather a result of specific interventions and not the consequence of the market's work. It was also demonstrated that those providers who successfully responded to the market incentives and delivered services of high quality efficiently, were also more keen to shift to the technologies with cost-saving potential. However, there was no clear evidence of the impact of those changes on the prices of service despite the increases in the numbers of operations. The overall conclusions are that market reforms even in its modest form were hardly allowed to work and when they worked they did not always produce what theory predicted. This was a result of the half-hearted belief in their effectiveness, the lack of clarity in policy formulation and conflicting objectives being pursued simultaneously, which possibly explains why most respondent groups could not see any major changes.