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
Getty
Show Hide image

Leader: Trump and an age of disorder

Mr Trump’s disregard for domestic and international norms represents an unprecedented challenge to established institutions.

The US presidency has not always been held by men of distinction and honour, but Donald Trump is by some distance its least qualified occupant. The leader of the world’s sole superpower has no record of political or military service and is ignorant of foreign affairs. Throughout his campaign, he repeatedly showed himself to be a racist, a misogynist, a braggart and a narcissist.

The naive hope that Mr Trump’s victory would herald a great moderation was dispelled by his conduct during the transition. He compared his country’s intelligence services to those of Nazi Germany and repeatedly denied Russian interference in the election. He derided Nato as “obsolete” and predicted the demise of the European Union. He reaffirmed his commitment to dismantling Obamacare and to overturning Roe v Wade. He doled out jobs to white nationalists, protectionists and family members. He denounced US citizens for demonstrating against him. Asked whether he regretted any part of his vulgar campaign, he replied: “No, I won.”

Of all his predilections, Mr Trump’s affection for Vladimir Putin is perhaps the most troubling. When the 2012 Republican presidential nominee, Mitt Romney, warned that Russia was the “number one geopolitical foe” of the US, he was mocked by Barack Obama. Yet his remark proved prescient. Rather than regarding Mr Putin as a foe, however, Mr Trump fetes him as a friend. The Russian president aims to use the US president’s goodwill to secure the removal of American sanctions, recognition of Russia’s annexation of Crimea and respect for the murderous reign of the Syrian president, Bashar al-Assad. He has a worryingly high chance of success.

Whether or not Mr Trump has personal motives for his fealty (as a lurid security dossier alleges), he and Mr Putin share a political outlook. Both men desire a world in which “strongmen” are free to abuse their citizens’ human rights without fear of external rebuke. Mr Trump’s refusal to commit to Nato’s principle of collective defence provides Mr Putin with every incentive to pursue his expansionist desires. The historic achievement of peace and stability in eastern Europe is in danger.

As he seeks reconciliation with Russia, Mr Trump is simultaneously pursuing conflict with China. He broke with precedent by speaking on the telephone with the Taiwanese president, Tsai Ing-wen, and used Twitter to berate the Chinese government. Rex Tillerson, Mr Trump’s secretary of state nominee, has threatened an American blockade of the South China Sea islands.

Mr Trump’s disregard for domestic and international norms represents an unprecedented challenge to established institutions. The US constitution, with its separation of powers, was designed to restrain autocrats such as the new president. Yet, in addition to the White House, the Republicans also control Congress and two-thirds of governorships and state houses. Mr Trump’s first Supreme Court appointment will ensure a conservative judicial majority. The decline of established print titles and the growth of “fake news” weaken another source of accountability.

In these circumstances, there is a heightened responsibility on the US’s allies to challenge, rather than to indulge, Mr Trump. Angela Merkel’s warning that co-operation was conditional on his respect for liberal and democratic values was a model of the former. Michael Gove’s obsequious interview with Mr Trump was a dismal example of the latter.

Theresa May has rightly rebuked the president for his treatment of women and has toughened Britain’s stance against Russian revanchism. Yet, although the UK must maintain working relations with the US, she should not allow the prospect of a future trade deal to skew her attitude towards Mr Trump. Any agreement is years away and the president’s protectionist proclivities could yet thwart British hopes of a beneficial outcome.

The diplomatic and political conventions embodied by the “special relationship” have endured for more than seven decades. However, Mr Trump’s election may necessitate their demise. It was the belief that the UK must stand “shoulder to shoulder” with the US that led Tony Blair into the ruinous Iraq War. In this new age of disorder, Western leaders must avoid being willing accomplices to Mr Trump’s agenda. Intense scepticism, rather than sycophancy, should define their response.

This article first appeared in the 19 January 2016 issue of the New Statesman, The Trump era