NHS: Competition

Lord Turnberg Excerpts

Monday 10th February 2014 Grand Committee

Asked by

[Lord Turnberg]

To ask Her Majesty’s Government what assessment they have made of the place and value of competition in the National Health Service.

[Lord Turnberg (Lab)]

My Lords, I am delighted to have this opportunity to debate the place and value of competition in the NHS. It is perhaps a little unfortunate that I received notice that I had secured this debate rather late last week. As a result, we have a rather select and distinguished band of noble Lords speaking today.

I want to make the case that we now have an unhealthy degree of competition, but in doing so I do not want to suggest that competition per se is necessarily a bad thing; nor do I want to get sidetracked into an ideological argument about the relative merits of free markets versus collective action. I want to try to tease out what the evidence really is for the value of competition in the NHS.

It is probably a basic human urge to compete. When I was a physician working in a hospital in Salford and when I was dean of Manchester’s medical school—here I express my interests in both—I have no hesitation in admitting that I was competitive in wanting my hospital and my medical school to be the best in the country if not in the world. It so happens that Salford Royal hospital is now lauded as being one of the most advanced in the way that it provides its services—it has obviously taken advantage of my absence to do great things.

However, when one comes to the National Health Service—that is, the national service—naked competition can become very counterproductive. We can certainly have too much of a good thing and the unhealthy degree of competition that we have now is interfering with our need for that collaboration and co-operation that are so vital for optimal patient care, to say nothing of its impact on integration as I will describe.

It is not as if we have never had competition before now; indeed, the previous Labour Government introduced the principle of opening up services to private providers. However, we took a devastating leap forward, or more accurately backward, with the health Act 2012 and the unloved Section 75, which placed a virtual obligation on commissioners to go out to tender for any and every service. It is that obligation that distinguishes it from what went before. We need to get the balance right between healthy and unhealthy competition. I shall give some of the many examples of where we have not got it right in a moment or two.

Those who promote competition in health services say that it improves patient care and efficiency, but what is the evidence for that? Does it work and, if so, in what circumstances and for what particular services? As one might expect, there have been a number of academic studies to try to tease this out and the results have been far from conclusive. The Office of Health Economics report in 2012 was very cautious and found that while some aspects were improved, others were made worse. Let us listen to those who have done the research. Dr Light wrote in the Journal of Health Politics:

“Promotion of competition is guided by political and ideological considerations and is not supported by any scientific evidence”.

Valentina Zigante and her colleagues have written:

“The ideology of competition and choice is running way ahead of the evidence that it improves efficiency, equity or quality”.

Dixon and Le Grand have said that there is,

“no evidence that the choice policy has resulted in significant changes for the patient or to patient pathways”.

However, we do not need to rely on academic studies to recognise the difficulties that we now have with the competition agenda: the problems are absolutely clear in the many day-to-day examples in the NHS. One only has to look at the gross case of Poole and Bournemouth, where everyone involved—the public, local authority, the doctors, nurses and managers—all agreed that amalgamation of the trusts’ services was essential if they were to be able to provide a safe and efficient accident and emergency service, avoid the £8 million black hole that was looming and save £14 million a year. After reportedly spending some £6 million on legal fees and gathering mountains of documentation, the whole thing was blocked by the Competition Commission. You do not need too many examples like that for managers around the country to run a mile before engaging in similar rational mergers or use of resources.

There are many other examples. Let us take the case of the CCGs in Blackpool which had found a better and cheaper way of dealing with patients with headaches than having to send them to a hospital, only to be challenged by Spire private healthcare for not sending them enough cases. The cost to the CCGs in money and time of having to sift through mountains of records to fight the case was very high and will certainly make others think twice before going down the same route. There are reports that in Bristol, the unified cancer care pathway has been put on hold, while at King’s College Hospital the plan to integrate care for the elderly with the local council has been stopped by competition law.

It is not as if this bonanza for the lawyers was not predicted. In our debate on the Section 75 regulations last April, several speakers, including myself, warned of just this sort of costly litigation. As Sir David Nicholson said to the Health Select Commons Committee recently, the NHS is getting,

“bogged down in a morass of competition law”.

Despite all the reassurances given by the noble Earl when we debated the statutory instrument last April, managers in the health service are running scared of coming up against competition law whenever they set up their contracts for services. It is hardly surprising, according to a recent survey in the Health Service Journal, that nine out of 10 chief executives are making their top priority the cutting back of competition rules, and it is not difficult to see why they feel obliged to avoid litigation when they have Monitor breathing down their necks, as well as the Office of Fair Trading backed by UK public procurement regulations and EU competition law looming above them. It is of little use to managers that the kindly David Bennett of Monitor is hinting that he will not pursue them if they take a sensible approach and do not go out to tender for anything and everything, because in practice the law is biting hard.

It is hard, too, to see how multiple contracts with a range of providers can fail to impact on the need to focus specialised services in a smaller number of hospitals or to centralise scarce facilities. These rational and laudable aims can hardly avoid being inhibited by the drive to competition. And, of course, there is the knotty issue of integrating care across the hospital/community divide, which everyone wants to see but which will be inhibited by competition for the different elements of what should be seamless care. There seems little doubt that uncontrolled competition can result in a fragmentation of services that simply frustrates the need for a strong and coherent set of services.

What can be done about it? We have to tackle the legal driver of competition law which is creating such an expensive diversion of resources and manpower away from more important work like caring for patients. It is no use saying that commissioners have the freedom given by reassurances from Monitor on the one hand when they find that they have to defend themselves from legal action taken by private providers on the other. I have only one question for the Minister. Will he help to obviate this legal quagmire into which we seem to have blundered by repealing this onerous and damaging set of regulations and starting again with a less destructive set?