• To understand how competition could be used more effectively in primary and secondary care services in England, this working paper explores how policies affecting competition have been implemented and promoted in health systems in five countries: France, Germany, the Netherlands, Norway and Portugal.
  • In conventional markets, customers are attracted to particular suppliers by a more appealing combination of price and quality. But in health care, patients are usually insulated from costs and may find it difficult to judge quality due to information asymmetries and their infrequent use of services.
  • This means that the question – what do we expect or want of competition? – is not so easily answered in health care settings, and lessons from other sectors might not apply.

Download the working paper Competition policy in five European countries: What can be learned for health policy in England?

Key points

  • Proximity to the health care provider, rather than quality, remains the key driver of patient choice.
  • There is potential tension between stimulating quality competition and controlling expenditure because restrictions on hospital treatments imply that money does not follow the patient, and hospitals may react by making access more difficult or letting their waiting times increase.
  • Information for assessing proposed hospital mergers requires improvement, particularly information on quality.
  • There is limited scope for further expansion in the use of private providers to treat NHS patients given the current focus on controlling expenditure.
  • The economic rationale for controlling entry of providers into general practice is unclear.
  • Selective contracting for patients with chronic and multiple conditions to reduce fragmentation of care raises concerns for competition and regulation. This is because of the long-term nature of the implied contracts and the restricted pool of potential providers willing to bid for these contracts.

Further reading

NHS competition policy and the EU

Nearly two years ago, the Health Foundation commissioned a team of researchers at the University of York to investigate how and whether competition works in five European health systems – France, P...



Ronald Dane

A very interesting analysis but where does it take us. we are where we are from where it can be very difficult to find a path towards an ultimate goal. If there is one!


The problem is people are naive. When you need specialist care there is no better place for you than a big acute centre. Local hospitals and services will never have the resources to provide the care you need. I warned my dad of this and it was very hard to watch him suffer at the local hospital out of "convenience". He died without even the most basic of end of life care.

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