Looking out to compete, looking out to co-operate

There are three reasons for linking them:

• co-operation and competition both oblige chief executives – backed by the force of law, if necessary – to look out beyond their own organisations.
• they both need to be regulated by an external organisation to ensure trust boards take them into account.
• if competition and co-operation are separated in the running of an organisation – if, for example, a trust board spends a year pursuing competition with no thought of co-operation with external organisations – that trust will not thrive.

More has been written about competition than co-operation – and indeed there is a very strong set of competition law policies and practices from other sectors that health care organisations can learn from; so here I would like to concentrate on co-operation.

The injunction to co-operate will lead to different behaviours from commissioners than from providers. Commissioners have a responsibility to create a climate of relationships where co-operation is encouraged both between providers and between providers and commissioners. In other market places organisations recognise that they will sometimes get the best deal for their customers not by pitting everyone against everyone else but by creating teams of organisations to provide services together.

The way in which commissioners behave can facilitate or hinder this co-operation. Much of the current culture of public service contracting is imbued with secrecy and seems to discourage discussion between commissioners and providers or between providers. Organisations obviously need some time to construct their own team and their own bid. But before and after this period the contracting process could be much more open, and commissioners could encourage much greater co-operation between different providers rather than simply relating to single providers.

This enhanced co-operation will be particularly important for health providers over the next few years because patients and the public are set to become increasingly empowered. At the moment services tend to be organised around the needs of the provider. This often makes the patient experience difficult and causes bureaucratic and medical mishaps in the many handovers from provider to provider.

In the last few years services in many other sectors have begun to organise themselves around the needs of their customers rather than themselves. As this starts to happen in health care, providers will either learn to co-operate with each other and construct patient pathways across different organisations or they will stick to their non co-operative boundaries. If current providers fail to improve their services through co-operation, they will lose out to providers who are prepared to organise themselves differently and thereby create better experiences for patients.

For example, emergency care and urgent care have been institutionally separated, with no co-operation between A&E, out-of-hours services, GP services and community health services; this separation has created millions of day-to-day problems for patients every year. These services need to recognise that their value and their resources are being squandered because they do not work together.

Strong commissioners will contract for a seamless service, and institutions will have to learn how to deliver that service co-operatively or give way to others who are prepared do so.

The area in which failure to co-operate loses the most value for the patient – and which receives 70 per cent of the NHS budget – is long-term conditions. The imminent squeeze on resources will bring the greatest pressure for seamless co-operation to be introduced for these conditions. As co-operation will bring about radical change in service delivery, it will not be a simple thing for care providers to achieve. Some parts of organisations will resist the changes that will come through co-operation and that will make co-operation itself difficult for institutions to deliver. That is why the injunction to co-operate comes from outside institutions and why its implementation will be the subject of investigations and recommendations by the Co-operation and Competition Panel.

When the panel was created early in 2009, most people believed that the most contentious areas of its work would relate to competition. I suspect that its more important role will be to remind people and organisations how much improvements to patients’ pathways depend on the changes that are driven by co-operation.