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
VALERY HACHE/AFP/Getty Images
Show Hide image

A tale of two electorates: will rural France vote for Emmanuel Macron?

His chief rival, Marine Le Pen, was campaigning as the “candidate of the forgotten” years before Donald Trump entered politics.

It was a wet night in Paris, but hundreds of people were queuing outside the Antoine Theatre. It was standing room only to see Emmanuel Macron tonight, as it has been for weeks.

The 39-year-old former investment banker gave his usual energetic performance, delivering a well-practised pitch for a progressive, business-friendly and unabashedly pro-European France. His reward: a standing ovation and chants of Macron, président!

This theatre appearance on 8 March was an appropriate stop for a campaign that has been packed with more political drama than a series of House of Cards. Ahead of the first round of voting in the French presidential election on 23 April, the centrist independent has gone from underdog to the man most likely to beat the Front National’s Marine Le Pen. His other main rival, François Fillon of the right-wing Republicans, has been hampered by allegations that he paid his wife and children as parliamentary assistants, despite scant evidence of them doing any work.

Macron, meanwhile, has been attracting support from disenchanted voters on both left and right.

“It’s a new party, a new movement, a new face,” said Claire Ravillo-Albert, a 26-year-old human resources student and ex-Socialist in the queue outside the theatre. “We’re worlds away from the old Socialists and the Republicans here.”

Macron is not a typical outsider, having made millions in banking before serving as an advisor to François Hollande and as economy minister from 2014 to 2016. Nor can his ideas be described as radical. He is “of the left”, he says, but “willing to work with the right”.

For many he seems to embody an enticing alternative to the tired political class. Macron has never run for office before and if successful, would be the youngest president of the modern French republic. Many recruits to his one-year-old party En Marche! are young and relatively new to politics.

“I think he’ll change the French political landscape, and we need that,” said Olivier Assouline, a bank worker in an immaculate grey suit. “He knows business, he knows the state. I think he’s the right person at the right moment,” said the 44-year-old, who previously voted for right-winger Nicolas Sarkozy.

Many queuing for the rally were underwhelmed by Socialist achievements over the past five years – not least the dismal state of the economy – and had little enthusiasm for Fillon, a social conservative and economic Thatcherite.

Macron’s manifesto sticks firmly to the centre-ground. He has promised tax cuts for companies and millions of poor and middle-class families, as well as a few offbeat ideas like a one-off 500-euro grant for each 18-year-old to spend on books and cultural activities.

“With his central positioning, Macron is taking from everywhere – he has the capacity to seduce everyone,” says Frédéric Dabi, deputy director at the polling company IFOP. They estimate that Macron will take half the votes that went to Hollande when he won the last presidential election in 2012, and 17 per cent of those that went to runner-up Sarkozy.

Outside the theatre, the line was split between voters from the left and the right. But there was one word on almost everyone’s lips: Europe. At a time of continental soul-searching, Macron’s converts have chosen a candidate who backs the European Union as a guarantor of peace and celebrates free movement.

“He’s unusual in that he puts that centre-stage,” said Emma, a 27-year-old legal worker who preferred to be identified by her first name only. “Macron offers a good compromise on economic issues. But for me it’s also about Europe, because I think that’s our future.”

With Fillon and Socialist candidate Benoît Hamon both languishing behind in the polls, the second round of the presidential vote, on 7 May, is likely to be a contest between Macron and Le Pen. These are both candidates who claim to have moved beyond left-right politics, and who are both offering opposing visions of France.

This is also a tale of two electorates. Le Pen was campaigning as the “candidate of the forgotten” years before Donald Trump entered politics, traipsing around deindustrialised towns appealing to those who felt left behind by globalisation.

In the queue to see Macron were lawyers, PR consultants, graphic designers; students, gay couples and middle-class Parisians of multiple ethnicities. These are the representatives of a cosmopolitan, successful France. It was hard not to be reminded of the “metropolitan elite” who voted against Brexit.

Macron has called for investment in poorer communities, and his campaign staff pointedly invited onstage a struggling single mother as a warm-up act that night.

Yet his Socialist rival, Benoit Hamon, accuses him of representing only those who are doing pretty well already. It is hard for some to disassociate Macron from his education at the Ecole Nationale d’Administration – university of choice for the political elite – and his career at Rothschild. One infamous incident from early in the campaign sticks in the memory, when he told a pair of workers on strike: “You don’t scare me with your t-shirts. The best way to pay for a suit is to work.” For Macron, work has usually involved wearing a tie.

IFOP figures show him beating Le Pen soundly in when it comes to the voting intentions of executives and managers – 37 per cent to her 18 per cent. But when it comes to manual workers, she takes a hefty 44 per cent to his 17. He would take Paris; she fares better in rural areas and among the unemployed.

If Frédéric Dabi is to be believed, Macron’s bid for the centre-ground could pay off handsomely. But not everyone is convinced.

“He’s the perfect representative of the electorate in the big globalised cities,” the geographer Christophe Guilluy told Le Point magazine in January.

“But it’s the peripheries of France that will decide this presidential election.”