NHS doesn't stand for "National High Street"

Providers in the new NHS must be free to integrate care in the patient interest, even if this has the effect of reducing competition argues Chris Hopson, the new chief executive of the Foundation Trust Network.

On the High Street, competition law creates a competitive market by ensuring a range of different suppliers, fostering competition based on price, avoiding monopolies and probing vertical integration in the supply chain (for example, supermarkets owning dairies).

But there are other models for preserving the consumer interest which recognise that certain areas of our national life have specific characteristics that require a different approach.

Last month, for example, saw a highly publicised row between two train operating companies bidding for a long term, monopoly, franchise. The franchise deliberately runs for long enough to enable the operator to earn a sufficient return on the expensive infrastructure needed to provide a quality customer service.

Last month also saw the closure of the football transfer window, which restricts the times when clubs can buy new players. Clubs also now have to abide by new Financial Fair Play rules which are designed to create a level playing field by restricting the amount of money wealthy owners can invest to "buy success".

What does all this have to do with the NHS? The Health and Social Care Act, passed earlier this year, marks the next stage in the journey away from a single, all encompassing, command and control health service. It continues work begun by the previous Labour administration to create a more plural system where, in some areas of care, a wider range of providers compete to provide services for patients. As a result, patients have greater choice rather than, for example, being forced to use the closest NHS hospital.

But the health sector is not the High Street. Competition is based on quality, not price, with the price of an increasing range of treatments determined by a single tariff, to be set in future by a central Commissioning Board and the sector regulator. There also needs to be a strong emphasis on integrating care, defined by the NHS Future Forum as "integration around the patient, not the system". The Forum went on to argue that "outcomes, incentives and system rules (i.e. competition and choice) need to be aligned accordingly".

It's easy to see why integrating care is so important. An 80 year old frail patient with multiple problems needs a joined-up network of acute and primary care services where geriatricians, nurses, physiotherapists, and podiatrists all understand the individual patient's needs, and the care provided has no gaps - an integrated care pathway.

Diabetic patients in Bolton now have a centre staffed by specialists that care for inpatients at the local hospital but also care for patients at home by working with GPs. The very GPs who, in future, are likely to have commissioned the centre to provide this service. Elderly patients in several Surrey care homes are visited by hospital based geriatricians who advise staff and help to prevent patients being admitted to hospital unnecessarily.

These are all examples of good, joined-up, care: benefitting individual patients, reducing cost and providing better value for money for the taxpayer. But they do involve integration across the NHS, between different organisations that may be commissioning or competing with each other to provide services. Some might argue this reduces competition.

The Foundation Trust Network, which represents the vast majority of acute, mental health, community and ambulance providers in the NHS, is co-hosting fringe sessions at all the party conferences to explore how the NHS can achieve the right balance between integration and competition. It's an important question as the detailed rules for the new NHS are finalised over the next six months.

We'll also be particularly focussed on the importance of the NHS sustaining a flourishing and vibrant set of public providers over the longer term. The way the new rules are formulated will have a crucial impact here. If we get them wrong, there's a danger, to focus on another cause celebre in the competition world, that these organisations could turn into the dairy farmers of the healthcare sector. They might end up working for payments that do not cover costs; forced to sign up to short term contracts that offer no incentive to invest in innovations that improve quality and efficiency and facing an uncertain financial future.

Chris Hopson is the chief executive of the Foundation Trust Network

Photograph: Getty Images
A woman in an Indian surrogacy hostel. Photo: Getty
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The Handmaid's Tale has already come true - just not for white western women

Why, if the fate of the fictional Offred is so horrifying, is the fate of real-life women in surrogacy hostels causing so little outrage?

When anti-choice Republican Justin Humphrey referred to pregnant women as “hosts”, I found myself wondering, not for the first time, whether everything had got “a bit Handmaid’s Tale.”

I’m not alone in having had this thought. Since Donald Trump won the US election, sales of Margaret Atwood’s dystopian novel have spiked and we’ve seen a plethora of articles telling us how “eerily relevant [it] is to our current political landscape.” In an interview during Cuba’s international book fair, Atwood herself said she believes the recent “bubbling up” of regressive attitudes towards women is linked to The Handmaid’s Tale’s current success: “It’s back to 17th-century puritan values of New England at that time in which women were pretty low on the hierarchy … you can think you are being a liberal democracy but then — bang — you’re Hitler’s Germany.”

Scary stuff. Still, at least most present-day readers can reassure themselves that they’ve not arrived in the Republic of Gilead just yet.

For those who have not yet read it, The Handmaid’s Tale tells the story of Offred, who lives under a theocratic dictatorship in what used to be the United States of America. White, middle-class and college-educated, Offred once enjoyed a significant degree of privilege, but now belongs to a class of women whose sole purpose is to gestate offspring for high-status couples. Much of the shock value of the story comes from the contrast between Offred’s former life – in which she had a name of her own - and her present-day existence. If this can happen to someone like Offred, it is suggested, surely it can happen to any of us.

Or so that is what a white, middle-class reader – a reader like me – might tell herself. Recently I’ve started to wonder whether that’s strictly true. It can be reassuring to stick to one narrative, one type of baddie – the religious puritan, the pussy-grabbing president, the woman-hating Right. But what if it’s more complicated than that? There’s something about the current wallowing in Atwood’s vision that strikes me as, if not self-indulgent, then at the very least naive.

In 1985, the same year The Handmaid’s Tale was published, Gina Correa published The Mother Machine. This was not a work of dystopian fiction, but a feminist analysis of the impact of reproductive technologies on women’s liberties. Even so, there are times when it sounds positively Handmaid’s Tale-esque:

“Once embryo transfer technology is developed, the surrogate industry could look for breeders – not only in poverty-stricken parts of the United States, but in the Third World as well. There, perhaps, one tenth of the current fee could be paid to women”

Perhaps, at the time her book was written, Correa’s imaginings sounded every bit as dark and outlandish as Atwood’s. And yet she has been proved right. Today there are parts of the world in which renting the womb of a poor woman is indeed ten times cheaper than in the US. The choice of wealthy white couples to implant embryos in the bodies of brown women is seen, not as colonialist exploitation, but as a neutral consumer choice. I can’t help wondering why, if the fate of the fictional Offred is so horrifying to western feminists today, the fate of real-life women in surrogacy hostels is causing so little outrage.

I suppose the main argument of these feminists would be that real-life women choose to be surrogates, whereas Offred does not. But is the distinction so clear? If Offred refuses to work as a handmaid, she may be sent to the Colonies, where life expectancy is short. Yet even this is a choice of sorts. As she herself notes, “nothing is going on here that I haven't signed up for. There wasn't a lot of choice but there was some, and this is what I chose.” In the real world, grinding poverty drives women of colour to gestate the babies of the wealthy. As one Indian surrogate tells interviewer Seemi Pasha, “Why would I be a surrogate for someone else if I don't need the money? Why would I make myself go through this pain?"

None of the feminists who expressed shock at Justin Humphrey referring to pregnant women as “hosts” have, as far as I am aware, expressed the same horror at surrogacy agencies using the exact same term. As Dorothy Roberts wrote in Killing The Black Body, the notion of reproductive liberty remains “primarily concerned with the interests of white, middle-class women” and  “focused on the right to abortion.” The right not just to decide if and when to have children, but to have children of one’s own – something women of colour have frequently been denied – can be of little interest of those who have never really feared losing it (hence the cloth-eared response of many white women to Beyoncè’s Grammy performance).

As Roberts notes, “reproductive liberty must encompass more than the protection of an individual woman’s choice to end her pregnancy”:

“It must encompass the full range of procreative activities, including the ability to bear a child, and it must acknowledge that we make reproductive decisions within a social context, including inequalities of wealth and power. Reproductive freedom is a matter of social justice, not individual choice.”

It’s easy to mock the pretensions to pro-life piety of a pussy-grabbing president. But what about the white liberal left’s insistence that criticising the global trade in sexual and gestational services is “telling a women what she can and cannot do with her body” and as such is illiberal and wrong? “Individual choice” can be every bit as much of a false, woman-hating god as the one worshipped by the likes of Humphrey and Trump.

One of the most distressing scenes in The Handmaid’s Tale takes place when Janine/Ofwarren has just given birth and has her child taken from her:

“We stand between Janine and the bed, so she won’t have to see this. Someone gives her a drink of grape juice. I hope there’s wine in it, she’s still having the pains, for the afterbirth, she’s crying helplessly, burnt-out miserable tears.”

Right now there are women suffering in just this way. Only they’re probably not white, nor middle-class, nor sitting in a twee white bedroom in Middle America. Oh, and they’re not fictional, either.

The dystopian predictions of 1985 have already come true. It’s just that women like me didn’t notice until we started to be called “hosts”, too.

Glosswitch is a feminist mother of three who works in publishing.