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
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Will the House of Lords block Brexit?

Process, and a desire to say "I told you so" will be the real battle lines. 

It’s the people versus the peers, at least as far as some overly-excited Brexiteers are concerned. The bill to trigger Article 50 starts its passage through the House of Lords today, and with it, a row about the unelected chamber and how it ought to behave as far as Brexit is concerned.

This week will, largely, be sound and fury. More peers have signed up to speak than since Tony Blair got rid of the bulk of hereditary peers, triggering a 200-peer long queue of parliamentarians there to rage against the dying of the light, before, inevitably, the Commons prevailed over the Lords.

And to be frank, the same is ultimately going to happen with Article 50. From former SDPers, now either Labour peers or Liberal Democrat peers, who risked their careers over Europe, to the last of the impeccably pro-European Conservatives, to committed Labour and Liberal politicians, there are a number of pro-Europeans who will want to make their voices heard before bowing to the inevitable. Others, too, will want to have their “I told you so” on record should it all go belly-up.

The real battle starts next week, when the bill enters committee stage, and it is then that peers will hope to extract concessions from the government, either through defeat in the Lords or the threat of defeat in the Lords. Opposition peers will aim to secure concessions on the process of the talks, rather than to frustrate the exit.

But there are some areas where the government may be forced to give way. The Lords will seek to codify the government’s promise of a vote on the deal and to enshrine greater parliamentary scrutiny of the process, which is hard to argue against, and the government may concede that quarterly statements to the House on the process of Brexit are a price worth paying, and will, in any case, be a concession they end up making further down the line anyway.

But the big prize is the rights of EU citizens already resident here.  The Lords has the advantage of having the overwhelming majority of the public – and the promises of every senior Leaver during the referendum campaign – behind them on that issue. When the unelected chamber faces down the elected, they like to have the weight of public opinion behind them so this is a well-chosen battleground.

But as Alex Barker explains in today’s FT, the rights of citizens aren’t as easy to guarantee as they look. Do pensions count? What about the children of EU citizens? What about access to social security and health? Rights that are easy to protect in the UK are more fraught in Spain, for instance. What about a British expat, working in, say, Italy, married to an Italian, who divorces, but wishes to remain in Italy afterwards? There is general agreement on all sides that the rights of Brits living in the rest of the EU and citizens of the EU27 living here need to be respected and guaranteed. But that even areas of broad agreement are the subject of fraught negotiation shows why those “I told you sos”  may come in handy sooner than we think.

Stephen Bush is special correspondent at the New Statesman. His daily briefing, Morning Call, provides a quick and essential guide to British politics.