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Is safety safe in the market’s hands?
  1. Cam Donaldson
  1. Professor Cam Donaldson, Institute of Health and Society, 21 Claremont Place, Newcastle University, Newcastle upon Tyne NE2 4AA, UK; cam.donaldson{at}

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There is no doubt that the proposal to establish market-based control mechanisms for patient safety is both interesting and intriguing. However, I am not optimistic that Coiera and Braithwaite’s (C&B’s) proposal (see page 99) will see the light of day1. My objections are based on three fundamental flaws that I see in the foundation for this proposal: first, as an economist, I question whether “safety” can be considered a public good in the same way that the environment might; second, I am not convinced that emissions trading has worked sufficiently well to justify basing a safety strategy on such an approach; and, finally, I propose that our healthcare systems have not been particularly effective in managing resources or priority setting, and I make an economist’s attempt at addressing opportunities that still exist in this domain.

I should add that I am not wholly comfortable with the premise of a lack of widespread uptake of quality and safety measures in healthcare. Intuition would lead one to agree. But what is optimal in provision of safety measures? Indeed, it has become almost an anathema to question the health gains from what might often be disproportionately large amounts of resources invested in measures put in place in response to an unsafe incident. I raise this doubt early because it reflects where I will head with my own proposed next steps. However, it also reflects a related issue, to which I will also return, encapsulated in Woolf’s categorisation of safety as a “subset” of broader medical errors which are in turn a subset of “lapses in quality.”2 How can a market …

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  • Competing interests: None.

  • Funding: Supported by the Health Foundation in Health Economics.

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