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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Who will win in Copeland? The Labour heartland hangs in the balance

The knife-edge by-election could end 82 years of Labour rule on the West Cumbrian coast.

Fine, relentless drizzle shrouds Whitehaven, a harbour town exposed on the outer edge of Copeland, West Cumbria. It is the most populous part of the coastal north-western constituency, which takes in everything from this old fishing port to Sellafield nuclear power station to England’s tallest mountain Scafell Pike. Sprawling and remote, it protrudes from the heart of the Lake District out into the Irish Sea.

Billy, a 72-year-old Whitehaven resident, is out for a morning walk along the marina with two friends, his woolly-hatted head held high against the whipping rain. He worked down the pit at the Haig Colliery for 27 years until it closed, and now works at Sellafield on contract, where he’s been since the age of 42.

“Whatever happens, a change has got to happen,” he says, hands stuffed into the pockets of his thick fleece. “If I do vote, the Bootle lass talks well for the Tories. They’re the favourites. If me mam heard me saying this now, she’d have battered us!” he laughs. “We were a big Labour family. But their vote has gone. Jeremy Corbyn – what is he?”

The Conservatives have their sights on traditional Labour voters like Billy, who have been returning Labour MPs for 82 years, to make the first government gain in a by-election since 1982.

Copeland has become increasingly marginal, held with just 2,564 votes by former frontbencher Jamie Reed, who resigned from Parliament last December to take a job at the nuclear plant. He triggered a by-election now regarded by all sides as too close to call. “I wouldn’t put a penny on it,” is how one local activist sums up the mood.

There are 10,000 people employed at the Sellafield site, and 21,000 jobs are promised for nearby Moorside – a project to build Europe’s largest nuclear power station now thrown into doubt, with Japanese company Toshiba likely to pull out.

Tories believe Jeremy Corbyn’s stance on nuclear power (he limply conceded it could be part of the “energy mix” recently, but his long prevarication betrayed his scepticism) and opposition to Trident, which is hosted in the neighbouring constituency of Barrow-in-Furness, could put off local employees who usually stick to Labour.

But it’s not that simple. The constituency may rely on nuclear for jobs, but I found a notable lack of affection for the industry. While most see the employment benefits, there is less enthusiasm for Sellafield being part of their home’s identity – particularly in Whitehaven, which houses the majority of employees in the constituency. Also, unions representing Sellafield workers have been in a dispute for months with ministers over pension cut plans.

“I worked at Sellafield for 30 years, and I’m against it,” growls Fred, Billy’s friend, a retiree of the same age who also used to work at the colliery. “Can you see nuclear power as safer than coal?” he asks, wild wiry eyebrows raised. “I’m a pit man; there was just nowhere else to work [when the colliery closed]. The pension scheme used to be second-to-none, now they’re trying to cut it, changing the terms.”

Derek Bone, a 51-year-old who has been a storeman at the plant for 15 years, is equally unconvinced. I meet him walking his dog along the seafront. “This county, Cumbria, Copeland, has always been a nuclear area – whether we like it or don’t,” he says, over the impatient barks of his Yorkshire terrier Milo. “But people say it’s only to do with Copeland. It ain’t. It employs a lot of people in the UK, outside the county – then they’re spending the money back where they’re from, not here.”

Such views might be just enough of a buffer against the damage caused by Corbyn’s nuclear reluctance. But the problem for Labour is that neither Fred nor Derek are particularly bothered about the result. While awareness of the by-election is high, many tell me that they won’t be voting this time. “Jeremy Corbyn says he’s against it [nuclear], now he’s not, and he could change his mind – I don’t believe any of them,” says Malcolm Campbell, a 55-year-old lorry driver who is part of the nuclear supply chain.

Also worrying for Labour is the deprivation in Copeland. Everyone I speak to complains about poor infrastructure, shoddy roads, derelict buildings, and lack of investment. This could punish the party that has been in power locally for so long.

The Tory candidate Trudy Harrison, who grew up in the coastal village of Seascale and now lives in Bootle, at the southern end of the constituency, claims local Labour rule has been ineffective. “We’re isolated, we’re remote, we’ve been forgotten and ignored by Labour for far too long,” she says.

I meet her in the town of Millom, at the southern tip of the constituency – the opposite end to Whitehaven. It centres on a small market square dominated by a smart 19th-century town hall with a mint-green domed clock tower. This is good Tory door-knocking territory; Millom has a Conservative-led town council.

While Harrison’s Labour opponents are relying on their legacy vote to turn out, Harrison is hoping that the same people think it’s time for a change, and can be combined with the existing Tory vote in places like Millom. “After 82 years of Labour rule, this is a huge ask,” she admits.

Another challenge for Harrison is the threat to services at Whitehaven’s West Cumberland Hospital. It has been proposed for a downgrade, which would mean those seeking urgent care – including children, stroke sufferers, and those in need of major trauma treatment and maternity care beyond midwifery – would have to travel the 40-mile journey to Carlisle on the notoriously bad A595 road.

Labour is blaming this on Conservative cuts to health spending, and indeed, Theresa May dodged calls to rescue the hospital in her campaign visit last week. “The Lady’s Not For Talking,” was one local paper front page. It also helps that Labour’s candidate, Gillian Troughton, is a St John Ambulance driver, who has driven the dangerous journey on a blue light.

“Seeing the health service having services taken away in the name of centralisation and saving money is just heart-breaking,” she tells me. “People are genuinely frightened . . . If we have a Tory MP, that essentially gives them the green light to say ‘this is OK’.”

But Harrison believes she would be best-placed to reverse the hospital downgrade. “[I] will have the ear of government,” she insists. “I stand the very best chance of making sure we save those essential services.”

Voters are concerned about the hospital, but divided on the idea that a Tory MP would have more power to save it.

“What the Conservatives are doing with the hospitals is disgusting,” a 44-year-old carer from Copeland’s second most-populated town of Egremont tells me. Her partner, Shaun Grant, who works as a labourer, agrees. “You have to travel to Carlisle – it could take one hour 40 minutes; the road is unpredictable.” They will both vote Labour.

Ken, a Conservative voter, counters: “People will lose their lives over it – we need someone in the circle, who can influence the government, to change it. I think the government would reward us for voting Tory.”

Fog engulfs the jagged coastline and rolling hills of Copeland as the sun begins to set on Sunday evening. But for most voters and campaigners here, the dense grey horizon is far clearer than what the result will be after going to the polls on Thursday.

Anoosh Chakelian is senior writer at the New Statesman.