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• W2024275972 abstract "Reviewed by: The Other Invisible Hand: Delivering Public Services through Choice and Competition Jessica M. Robbins, PhD (bio) The Other Invisible Hand: Delivering Public Services through Choice and Competition. Julian Le Grand, Afterwords by Alain Enthoven and Lord David Lipsey. Princeton, NJ: Princeton University Press, 2007. Paperback (2007). 208 pp., 5½ × 8½. e-Book (2008). ISBN: 978-1-4008-2800-5. This slim, generally easy-to-read volume by an English economist, formerly a policy advisor to Prime Minister Tony Blair, makes the case for promoting “choice and competition” as a strategy to improve the delivery of public services, including health care. The context of most of the health care discussion is Great Britain’s National Health Service (NHS), so American readers with little familiarity with that system will be at a disadvantage, although most of the discussion remains accessible. Le Grand describes three basic strategies for managing the provision of public services. The “trust” model assumes that public services providers will do the right thing with minimal outside direction, compulsion or incentives. The “command and control” or “targets and incentives” model, probably most familiar to American providers in the context of health management organization incentives, uses specific mandates with financial penalties attached to failure to comply. “Choice and competition,” the approach Le Grand champions, introduces some type of market approach in which providers must compete for customers (who may be payors or patients, in the health care context) who have choices. Le Grand’s description of these three approaches and their principal strengths and weaknesses is accessible, brief, and generally convincing. Providers like systems based on trust, but are not always altruistic. Targets and incentives do change provider behavior, but not always in the desired direction, as means of “gaming the system” (for example by dumping difficult patients) frequently emerge, and providers generally loathe these systems. Well-designed “choice and competetion” systems induce providers to improve their performance not by central mandates but by permitting consumer choice, which allows for greater initiative for providers in determining how to meet consumer needs. Importantly, consumers prefer having choices. Le Grand acknowledges some of the key concerns about choice and competition in the public service context. For example, patients may have inadequate information with which to make good choices, and aspects of quality care that are less visible to [End Page 289] the patient at the point of choice may be undervalued. Le Grand argues that systems can be designed to ensure that patients have adequate information. He also argues that public services should incorporate aspects of all three of the models he describes (“trust” and “command and control” as well as choice and competition), not be sold in an unbridled market. While Le Grand is clear on the failures of the other models under real-world conditions, he does not confront the reality that his preferred model is similarly unlikely to emerge in an ideal, perfectly-balanced form that will effectively evade potential problems. His assures the reader that “reforms can be designed to encourage providers to meet the needs of the less well off ” (p. 61), but will they? He acknowledges the need for some form of oversight and regulation, worries about the tendency of government agencies to respond to political pressure and lobbying, and introduces “independent agencies” as the method of ensuring oversight without these vulnerabilities. Experience in the United States, at least, suggests that while regulatory agencies designed to be independent may be less responsive to short-term political pressures, they are often strongly influenced by the industries they regulate, including those industries’ lobbyists. Le Grand asserts that “topping up” (where wealthier patients are able to supplement their care in inequitable ways) could “simply not be permitted.” Well, it is simply not permitted under the NHS now, and yet crops up (most recently in schemes to enable patients to pay for cancer drugs not covered under NHS) regularly. It is much easier to say that systems can be designed to avoid these problems than to make it so. The book includes two post-scripts with useful intentions. One is “An American Perspective,” by Alain Enthoven. Enthoven, however, does not really explore how the models discussed by Le Grand..." @default.
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• W2024275972 title "<i>The Other Invisible Hand: Delivering Public Services through Choice and Competition</i> (review)" @default.
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• W2024275972 doi "https://doi.org/10.1353/hpu.0.0111" @default.
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