Panel debate on competition

Competition in healthcare has long been a controversial subject. While some see it as an essential driver of quality, innovation and value for money, others regard it as a threat to the founding principles of the NHS.

Some people saw competition as counter-productive because they thought it could undermine collaboration and service coordination across the pathway of care, Programme Director at NHS South of England, Murray Cochrane, told delegates. ‘I don’t subscribe to that view, but it’s a concern that needs to be addressed.’

There were areas where integration worked well, he said, with hospitals working very effectively with community services, and avoiding unnecessary hospital admissions was vital for the health service’s long-term sustainability. This was an area where the private sector could play a key role in helping to drive and support new technology, he said.

‘Patients value the ability to be able to choose provider,’ said Director of the Co-operation and Competition Panel (CCP), Catherine Davies, offering a regulatory perspective. However, the public sometimes had difficulty understanding that there were variations of care within the public sector itself, she stressed. ‘You don’t need everybody choosing a hospital. You just need a critical mass of patients in order to drive up quality.’ Hospitals were unaware whether patients had chosen that particular hospital or had been referred by their GP, she added, and they were also increasingly responding to the initiatives of neighbouring hospitals, ‘exactly as organisations respond to competitive pressure in other sectors’.

There were, however, issues around the range and type of choice, said Director of the NHS Partners Network, David Worskett. ‘We tend to see it as choice between providers, but we haven’t really got sufficient provider plurality. We need a more sophisticated approach, one that includes types of treatment,’ he said, as there could be a tendency in the ‘paternalistic’ NHS to underestimate the ‘savviness of patients’.

Murray Cochrane agreed that choice was not just about provider. ‘It’s also about how people experience, and are included in, their care – it’s more a practical issue than an ideological one.’ Many patients also ultimately deferred to their GP, he pointed out. ‘That’s where the choice ends up being made.’ It was right that this happened, however, said David Worskett, as the information was often complex. ‘It’s right as long as doctors aren’t biased in some way or loaded down with ideological baggage.’

More trusts that seemed unable to achieve Foundation Trust status alone were merging with other organisations, delegates heard. However, finding a ‘new and bigger home for an organisation’ was not necessarily the answer if there were issues to be addressed, warned Catherine Davies. The CCP tried to ensure a back-up plan for mergers that failed to meet the needs of patients, she said, and it worked with commissioners to make sure that quality indicators were in place to match those that would have existed had the two organisations still been in competition.

Mergers could simply be a way of ‘ducking or deferring difficult questions and decisions’, said David Worskett. ‘Many, many mergers – even the ones that look good on paper – don’t work, because they haven’t been thought through or the skills aren’t there.’ On the question of whether greater private sector involvement was preferable, there was a ‘very strong case’, he told the seminar. ‘If it’s not working out in the public sector, let’s see if the private sector can do better. That third party engagement can often be the catalyst for improvement.’

Regulation was now a very complex area, delegates heard, with CCP, Monitor, the Office of Fair Trading and the NHS Commissioning Board all playing a role, and it was essential that the guidance issued was joined up, stressed Catherine Davies. ‘I hope the Department of Health and Monitor have learned from the terrible example of the establishment of the Care Quality Commission (CQC),’ said David Worskett. ‘I think lessons have been learned in terms of not establishing undoable remits for a large regulator from the outset.’

Monitor needed to ensure that a level playing field and a managed market were in place, he added, and warned of inevitable tension between the organisation and the National Commissioning Board. ‘I don’t think that tension will always be productive.’ More attention also needed to be paid to Health and Wellbeing Boards, he said, as they could be key players in integrating health and social care.

The new commissioning landscape also meant that GPs and clinical commissioning groups would face real challenges, the seminar was told. ‘GPs have been launched into this, and, at best, 10% are keen,’ said Murray Cochrane. ‘GPs are going to be key players in the future, and they’re going to need a lot of support and skills.’ 

‘Monitor needs to make the case for competition, but I find that drawing analogies with other parts of the economy can often alienate people in the health service, because they feel that health is special,’ said Catherine Davies. The evidence that competition worked needed to be built up, however, stressed David Worskett. ‘Every sector will say that it’s special – you just need to battle on.’

The landscape had changed significantly even within the last few months, with the passing of the Health and Social Care Act 2012, delegates heard. ‘As the money has become tighter, people are more willing to come forward and say, “We need to challenge this procurement” or challenge the way things are run,’ said Catherine Davies.

However the controversy over the Act also meant that the issue of competition, in policy terms, had perhaps ‘gone backwards’, she warned. ‘Everybody used it as an opportunity to get on their soapbox and give their views about competition, whether they were relevant to the debate or not. But I really believe that if you get the incentives right, you’ll produce services that patients want.’