In a recent editorial piece (BCMJ 2003;45[9]:427) Dr Brian Day suggests that competition among hospitals is what is needed to improve health care delivery in Canada.

I’m sure that hospitals in BC would find this very useful—especially in places like Campbell River, Golden, or Smithers. If they don’t live up to the standards of things such as availability of staff, as laid out by Dr Day, then they will be black marked and the only hospital in town can have its funding cut because it doesn’t meet the standard. Hey, I thought it was “easier to compete when there is no competition.”

Of course patient choice is always a better thing. Given this “—they naturally choose to go to the better hospitals.” Does this mean all patients will choose to go to the better one? If so, that lesser hospital won’t be around much longer, so we shouldn’t have to worry. Nothing like those market forces to stamp out the competition. Wait a minute; maybe it is “easier to compete when there is no competition.”

Of course what we really want to avoid here are patients talking among themselves about which hospital is better. They must make their decision of preferred hospital strictly on the assessment system as outlined by Dr Day. If they don’t then it is dangerously possible that not everyone will choose the better hospital. What will that do to our competition model?

Or could it be that not everyone actually gets to choose? Those less fortunate will have to take their sorry souls to the lower-grade hospital because they can’t afford the good hospital. But if that low-end hospital can just hang on long enough, that better hospital, where everyone else is going, will eventually have a longer waiting list and they can come back to this low-end hospital. Maybe then the formerly low-end hospital will have to change its name to something like “Three Star Hospital” so that people will know that it is not the place it used to be and that everyone can feel safe again and come back to it. Of course then everyone will.

On the other hand, maybe a private hospital could really be competitive and advertise heavily to convince enough people to give up large sums of money to have their surgery done. And by combining this with a political campaign of tax cuts justified by all the money they had to pay to get their surgery, they will keep the public hospital from gaining an upper hand. Of course everyone is still free to choose, and that should keep the two systems separate but equal.

—Donald J. Young, MD
Victoria

Dr Day responds

Dr Young appears to dislike the thought that competition and ranking of performance might lead to enhanced effort and results. I assume he would advocate that we no longer bother to keep score in hockey and football, and that we cease timing the results in track and field or ski racing. After all, that is unfair to the inferior performers. On the question of whether competition is good for the consumer, Dr Young appears to think not. We will have to agree to differ. Dr Young’s paranoia about the fear of privatization is not relevant to this model. The scheme is already operating successfully in the public system in Britain, where the program so far includes only National Health Service hospitals. His assumption that hospitals in smaller communities would suffer when faced with competition is misguided and insulting to their performance and potential. In fact, many would likely outperform larger hospitals in many areas. A small entity, be it a hospital, restaurant, hotel, medical practice, or orthopedic surgeon implies neither inferiority nor the inability to compete.

—BD