Do actions speak louder than words on competition?

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'What we are doing, through amendments to the legislation, is to make it absolutely clear that integration around the needs of the patient trumps other issues, including the application of competition rules'.

So said Andrew Lansley last month in response to some challenging questions from the Health Select Committee about whether the amendments to the re-committed Health and Social Care Bill really amount to a significant shift in the role that competition will play in the health system.

It is true that the Bill no longer includes 'promoting competition, where appropriate' within Monitor's main duties. Instead, Monitor must focus on preventing anti-competitive behaviour in the provision of services, 'which is against the interests of people who use such services'. The regulator must also act with a view to enabling integration of services where this would improve quality or efficiency, or reduce inequalities in access or service-related health outcomes. The NHS Commissioning Board and clinical commissioning groups are also to be tasked with 'securing' integration where it would bring those benefits.

So far, so good. But is there something of a mismatch between rhetoric and reality here?

The government has announced that it plans to not only keep the Principles and Rules for Co-operation and Competition but to give them a new power by enshrining them in law. And, the Co-operation and Competition Panel (CCP) will no longer be an advisory body, but a decision-making body situated in Monitor, whose powers for preventing anti-competitive behaviour remain relatively unscathed by the latest amendments.

If the Co-operation and Competition Panel's latest report on the operation of the 'any qualified provider' policy in elective care is anything to go by, we can expect the new Monitor to place a lot more emphasis on competition than on co-operation.

The CCP report contains some very confident – and evidence-light – statements about the benefits to be secured from choice and competition, if only those naughty commissioners would play ball. The authors believe willingness to support the policy will improve with time as its benefits are 'more widely demonstrated, understood and accepted' and 'with the ongoing enforcement of the Principles and Rules and other relevant provisions'. One recommendation is that authorisation of new clinical commissioning groups ought to be contingent on their abiding by the principles.

The not-very-deeply-buried subtext here is: you are going to learn to like this! And you will have to like it in an increasing number of service areas: last month the Department of Health announced that the 'any qualified provider' policy (in which a diverse range of providers compete for the custom of NHS patients), would be extended into community and mental health services.

Here at the Fund, we have argued for a nuanced approach that promotes competition where it will benefit patients, but places collaboration and integration at the heart of the system. However, the tone of both the CCP report and the Department of Health guidance jars with the post-pause rhetoric on the role competition should have in driving the new system. This casts doubt on whether the amendments to the Bill will really translate into a more nuanced approach that supports the use of co-operation as well as competition, recognising that each may be appropriate in particular circumstances.

To be fair on the Co-operation and Competition Panel, their work is guided by the principles, nine of which relate to choice and competition, and just one of which refers to co-operation. Unless the balance of the principles is changed, we will surely see the new powers of Monitor drive more competition in the NHS.

This blog also appeared on the British Medical Journal website.


Bernard Kat

Comment date
09 August 2011
Competition focuses the attention of the competitors on their own needs for survival and success. The needs of service users / service recipients are not perceived in their own right but become just another vehicle through which potential competitors can try to outshine each other. Surely runs counter to achievinh quality of care in health services?

James Bunt

Gordian Management
Comment date
10 August 2011
One thing I am not clear about; who is advising the Health Secretary on the development of policy here? I am all in favour of the best provider regardless of background but the mismatch on integration seems to be being ignored. If DH is not listening to Kings Fund, Service Tsars or even established IS providers and BMA then who are they listening to?

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