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

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Leave will leap on the immigration rise, but Brexit would not make much difference

Non-EU migration is still well above the immigration cap, which the government is still far from reaching. 

On announcing the quarterly migration figures today, the Office for National Statistics was clear: neither the change in immigration levels, nor in emigration levels, nor in the net figure is statistically significant. That will not stop them being mined for political significance.

The ONS reports a 20,000 rise in net long-term international migration to 333,000. This is fuelled by a reduction in emigration: immigration itself is actually down very slightly (by 2,000) on the year ending in 2014, but emigration has fallen further – by 22,000.

So here is the (limited) short-term significance of that. The Leave campaign has already decided to pivot to immigration for the final month of the referendum campaign. Arguments about the NHS, about sovereignty, and about the bloated bureaucracy in Brussels have all had some utility with different constituencies. But none has as much purchase, especially amongst persuadable Labour voters in the north, as immigration. So the Leave campaign will keep talking about immigration and borders for a month, and hope that a renewed refugee crisis will for enough people turn a latent fear into a present threat.

These statistics make adopting that theme a little bit easier. While it has long been accepted by everyone except David Cameron and Theresa May that the government’s desired net immigration cap of 100,000 per year is unattainable, watch out for Brexiters using these figures as proof that it is the EU that denies the government the ability to meet it.

But there are plenty of available avenues for the Remain campaign to push back against such arguments. Firstly, they will point out that this is a net figure. Sure, freedom of movement means the British government does not have a say over EU nationals arriving here, but it is not Jean-Claude Juncker’s fault if people who live in the UK decide they quite like it here.

Moreover, the only statistically significant change the ONS identify is a 42 per cent rise in migrants coming to the UK “looking for work” – hardly signalling the benefit tourism of caricature. And though that cohort did not come with jobs, the majority (58 per cent) of the 308,000 migrants who came to Britain to work in 2015 had a definite job to go to.

The Remain campaign may also point out that the 241,000 short-term migrants to the UK in the year ending June 2014 were far outstripped by the 420,000 Brits working abroad. Brexit, and any end to freedom of movement that it entailed, could jeopardise many of those jobs for Brits.

There is another story that the Remain campaign should make use of. Yes, the immigration cap is a joke. But it has not (just) been made into a joke by the EU. Net migration from non-EU countries is at 188,000, a very slight fall from the previous year but still higher than immigration from EU countries. That alone is far above the government’s immigration cap. If the government cannot bring down non-EU migration, then the Leave argument that a post-EU Britain would be a low-immigration panacea is hardly credible. Don’t expect that to stop them making it though. 

Henry Zeffman writes about politics and is the winner of the Anthony Howard Award 2015.