Robert Royce, PhD

I recently took a trip to the United States, and whilst flicking through the in-flight magazine I came across a major difference between U.S. health care and its British counterpart. Many of the advertisements in the magazine — we call them “adverts” — were from U.S. providers promoting themselves as the place to come to for health issues ranging from blocked arteries to crooked teeth. There were three pages on “best doctors in America” complete with smiling physicians (no crooked teeth on display). And on the way from the airport there were large billboards advertising various local providers.

This set me thinking: Would you see a United Kingdom hospital promoting its services anywhere, let alone in an in-flight magazine or on a roadside billboard? The answer: It would be most unlikely.

Why is this? Britain’s National Health Service (NHS) has supposedly been operating an internal market, with varying degrees of enthusiasm, since 1991. There is also the private health care market, which not only provides services to the nearly 11% of the U.K. population that has some form of private insurance, but also, according to Laing and Buisson’s Health Cover U.K. Market Report 2013, delivers 4.8% of the acute services for the NHS.

Privately owned elective treatment centers provide services to NHS patients in direct competition with NHS hospitals. In short, all these providers, both NHS and private, are supposed to be competing with each other for the attention and custom of the British public. If they are indeed genuinely competing, then they manage to do so whilst being particularly bashful about promoting their own virtues in contrast to those of their rivals.

The U.K. has a variety of national quality indicators covering such areas as waiting times, mortality rates, infection rates, patient satisfaction measures, and patient-reported outcome measures (PROMS), all of which lend themselves to reporting in a league table format.

The payment system is supposed to be based on the principle that the more patients you treat, the more income you receive. Empowering patients to make informed choices by providing accessible information and increasing one’s choice of provider are supposed to be forces for beneficial change and a key objective of governmental reform of health care. So why isn’t there more effort by providers to differentiate themselves and attract more customers/patients?

Web sites tell the tale

Evidence that they aren’t making this effort includes a survey I undertook in 2012 (Royce, R., “Trusts Lose Ground in Online Marketing Race,” Nov. 15, 2012, Health Service Journal, London). Trusts are the NHS organizations that run one or more hospitals in a particular region, and I evaluated the Web sites of the 27 NHS trusts in London. The idea was to establish the degree to which each organization was actively promoting its performance against national quality indicators, what attempt it made to explain those quality indicators, and how user-friendly its Web site was.

The results were singularly underwhelming. It turned out that a number of these multimillion-dollar organizations have poorly developed Web sites. In three cases, the sites repeatedly crashed. Furthermore:

  • Only two trusts provided waiting times on their sites. No trust showed this information as part of its specialty/physician profiles.
  • One trust Web site had no search field.
  • Nineteen trusts had information on subspecialty interests by physician. One academic health science center had detailed profiles of consultants and their publications, while another did not even have subspecialty interests shown — just a list of consultants for the specialty concerned.
  • Three trusts did not have a specific part of the Web site for primary care physicians (known in the U.K., as in bygone days in the States, as general practitioners, or GPs). This is significant, as elective patients have to be referred via GPs in the U.K., where patients cannot directly access a specialist.
  • Searches for “PROMS” brought a zero return for 15 trusts.
  • Searches for “patient satisfaction” brought a zero return from four trusts, with a range for the others from 3 to 1,517 results.
  • Not one trust set out its PROMS score in relation to a specific service — for example, hip replacements. Moreover, trusts did not set out outcome measures, volumes, lengths of stay, or patient satisfaction results for any specific procedure, consultant or specialty, with the exception of a few specialist areas including pediatric cardiac surgery, infertility, and, in one case, hip replacements.

This kind of performance might serve to reinforce negative views about the public sector’s ability — and enthusiasm — when it comes to operating in a competitive manner, but interestingly, the private sector does not appear to be much more proactive. You are unlikely to find adverts promoting shorter waits and better patient satisfaction at private facilities, even though both are likely the case. Overall, there is a marked reluctance on the part of providers, both NHS and private, to contrast their performance with local competitors.

What might account for this reticence? Perhaps providers do not believe that the active promotion of quality measures really influences the public or GPs. Perhaps it is thought that any positive influence won’t be strong enough to make the investment in advertising worthwhile at the expense of something else. Perhaps there is nervousness about saying “We are performing well” when future league rankings might in fact show “us” slipping. Perhaps providers are not spending much time trying to differentiate their services in the public arena because they think influencing GP referral practices remains much more important than influencing would-be patients — although even if true, this wouldn’t explain why more isn’t done to market directly to GPs. Perhaps the answer lies in a view that the additional income that extra patients will bring in will not match the effort and expense of capturing and treating those patients.

Speak no ill of family

All of the above might serve as partial explanations — and to some degree may have a resonance in the U.S. marketplace. But even when taken together, they do not fully explain the lethargy in self-promotion. In the U.K., there is also a social dimension to consider. Until quite recently, restrictions by the General Medical Council (the body that regulates doctors’ conduct) effectively prohibited doctors from promoting their services, areas of expertise, or (for private services) prices. Culturally, that prohibition probably still holds considerable sway.

Clinicians also feel a need to be careful that any self-promotion is not seen as undermining fellow professionals. For hospitals, the notion that they are in competition with each other must itself compete with the much longer-­established view that the NHS is a “family” and that a “duty of partnership” prevails.

Invisible but nevertheless real boundaries appear to exist in what is deemed unacceptable managerial action, and actively trying to increase market share at another party’s expense through the use of advertising appears to be one of them. This social dimension also applies to the private-sector enterprises, sensitive as they are to any accusation that they might be actively undermining the public’s faith in NHS services.

This may keep corporate feathers unruffled, but at what cost in terms of improved responsiveness to consumers? And what is its impact on the desire to improve quality and efficiency? It can be disputed whether advertising helps or hinders the aim of creating informed, empowered consumers. But in any case, you are unlikely to see a “Best Doctors or Hospitals in England” advert in your in-flight magazine any time soon.

Robert Royce, PhD, is European correspondent for Managed Care and an independent health care consultant.

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