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
Photo: Getty Images
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Autumn Statement 2015: George Osborne abandons his target

How will George Osborne close the deficit after his U-Turns? Answer: he won't, of course. 

“Good governments U-Turn, and U-Turn frequently.” That’s Andrew Adonis’ maxim, and George Osborne borrowed heavily from him today, delivering two big U-Turns, on tax credits and on police funding. There will be no cuts to tax credits or to the police.

The Office for Budget Responsibility estimates that, in total, the government gave away £6.2 billion next year, more than half of which is the reverse to tax credits.

Osborne claims that he will still deliver his planned £12bn reduction in welfare. But, as I’ve written before, without cutting tax credits, it’s difficult to see how you can get £12bn out of the welfare bill. Here’s the OBR’s chart of welfare spending:

The government has already promised to protect child benefit and pension spending – in fact, it actually increased pensioner spending today. So all that’s left is tax credits. If the government is not going to cut them, where’s the £12bn come from?

A bit of clever accounting today got Osborne out of his hole. The Universal Credit, once it comes in in full, will replace tax credits anyway, allowing him to describe his U-Turn as a delay, not a full retreat. But the reality – as the Treasury has admitted privately for some time – is that the Universal Credit will never be wholly implemented. The pilot schemes – one of which, in Hammersmith, I have visited myself – are little more than Potemkin set-ups. Iain Duncan Smith’s Universal Credit will never be rolled out in full. The savings from switching from tax credits to Universal Credit will never materialise.

The £12bn is smaller, too, than it was this time last week. Instead of cutting £12bn from the welfare budget by 2017-8, the government will instead cut £12bn by the end of the parliament – a much smaller task.

That’s not to say that the cuts to departmental spending and welfare will be painless – far from it. Employment Support Allowance – what used to be called incapacity benefit and severe disablement benefit – will be cut down to the level of Jobseekers’ Allowance, while the government will erect further hurdles to claimants. Cuts to departmental spending will mean a further reduction in the numbers of public sector workers.  But it will be some way short of the reductions in welfare spending required to hit Osborne’s deficit reduction timetable.

So, where’s the money coming from? The answer is nowhere. What we'll instead get is five more years of the same: increasing household debt, austerity largely concentrated on the poorest, and yet more borrowing. As the last five years proved, the Conservatives don’t need to close the deficit to be re-elected. In fact, it may be that having the need to “finish the job” as a stick to beat Labour with actually helped the Tories in May. They have neither an economic imperative nor a political one to close the deficit. 

Stephen Bush is editor of the Staggers, the New Statesman’s political blog.