References to unfettered markets might be missing in the revised health and social care bill, but competition will still play a significant role in the reformed NHS
The dust had barely settled on the long-awaited report from the Future Forum before the government issued its response. At first blush, it seemed as though there had been a spectacular climb-down.
The ‘pause’ in the progress of the health and social care bill appeared to be a rewind: the secretary of state was back in charge of the NHS, Monitor’s wings appeared severely clipped and GP commissioning consortia morphed into multi-specialty clinical groups with lay members and newly accountable to health and wellbeing boards.
However, a closer look reveals a rather more subtle set of changes that alter the tone rather more than they do the substance of the reforms. This is nowhere more evident than with regard to competition policy, the lightning rod for much of the most vocal opposition.
Certainly there has been a stepping back from the bullish pro-competition rhetoric that imbued previous government policy statements. There have also been a number of changes to the proposed competition architecture.
Price competition is dead for the foreseeable future. Monitor will no longer promote competition so much as police specific abuses of competition. Monitor will also have fewer powers to challenge commissioners who might be soft-pedalling on competition and will no longer be able to require providers to open up their facilities for use by competitors.
However, it would be quite wrong to see the government’s response as a denial of the competition creed. The Principles and Rules of Cooperation and Competition (the code of practice that kick started the march to competition under the previous government) will not only remain, but will gain a statutory footing. The Cooperation and Competition Panel will survive, being lodged within the new Monitor.
Moreover, the ‘any qualified provider regime’, the subject of so much debate and – in some quarters – concern, will be implemented from April next year (although it will initially focus on community services in addition to current hospital services already subject to choice). As recommended by the Future Forum, the secretary of state will enshrine the duty of the NHS to deliver choice through a new ‘choice mandate’, presenting further opportunities for competition, if appropriate.
Overall, the Future Forum itself took a measured view of competition. Most crucially perhaps, they saw a role for competition in driving up the quality of care as long as it was well-regulated.
Significantly, the National Commissioning Board and Monitor will be responsible for identifying how services should be ‘bundled’ and how tariffs for integrated services might be developed. This opens up the prospect of competition between providers of integrated care.
It, in effect, allows incentivised providers to compete to deliver the ongoing management of long-term conditions, rather than stand-alone treatments. This could be the Holy Grail that reconciles proponents of both competition and integration.
The move away from placing too much faith in unfettered markets – overestimating the real value of competition – is welcomed. However, while the political war over the NHS looks set to continue in Parliament, it is hard not to conclude that competition has survived this particular battle relatively unscathed.
Dr Richard Lewis is a partner at Ernst & Young. He spent a decade working within the NHS, most recently as an executive director of a large health authority in London
