Why the NHS reforms sow seeds of confusion: The Health and Social Care Act is Janus legislation that attempts to promote both competition and collaboration at the same time
It starts to seem as if all that malarkey about competition and marketisation of healthcare during the passage of the NHS bill was just a nasty dream.
These days, the coalition government simply directs our attention to the sunny uplands of integrated care. Jeremy Hunt told us that in his first month as health secretary, "the word I have heard uttered more than any other is integration". And now, incoming health minister Norman Lamb is going down a storm in NHS circles with his plan to support a series of large-scale integrated care "experiments" that could allow local health economies to devise their own payment systems and move away from the straitjacket of "payment by results".
This is all fine, but we need to take a reality check on what is happening more broadly. Amendments following the "pause" to Andrew Lansley's bill did indeed lay a range of integration duties on health and wellbeing boards, the NHS Commissioning Board, Monitor and clinical commissioning groups. It would be fair to say that these were included belatedly and under duress, and that we are still far from clear as to what they will amount in practice. And now the first NHS mandate exhorts all organisations to focus on "the whole person rather than on specific conditions", and to "ensure people experience smooth transitions between care settings".
Even in the absence of countervailing factors, this would be a tall order – the landscape of social policy is littered with the language of failed exhortation around inter-agency working. But there is one huge complication that seems to inhabit a parallel policy universe and that is the fixation in the NHS and Social Care Act with the primacy of choice and competition in healthcare. How might this confound local attempts to work more closely together?
Lots of clues can be found in the deluge of reports and consultations emanating from the centre. In its recently closed consultation paper on "securing best value for NHS patients", for example, the Department of Health makes it clear that the default setting for the NHS will be choice and competition. Proposals for local integrated care will have to meet the "indispensability test" – that "if commissioners decide to make arrangements which materially restrict competition", they will need to demonstrate three "trade-offs":
• It is "in patients' interests"
• It delivers tangible countervailing benefits such as improvements in quality or efficiency
• The benefits outweigh the disadvantages of restricting competition
The task of policing this requirement and ensuring the prevention of "anti-competitive behaviour" will fall to Monitor – the ever more powerful quango currently responsible for the authorisation of foundation trusts. Monitor is almost entirely staffed by accountants and economists, yet has been given the task of determining whether local arrangements for integrated care will improve quality or efficiency and reduce inequalities with respect to either access or outcomes. If not, they will not be permitted to proceed.
The reality is that while Monitor is fairly clear about how it will "prevent anti-competitive behaviour", it is far from clear about how it will simultaneously promote integration. At the recent annual accountability hearing before the health select committee, the chief executive of Monitor, David Bennett, was asked a series of questions about integration which he seemed unable to answer.
Barbara Keeley, for example, asked what skills Monitor has in assessing whether integration is working or not. "We will have to learn," she was told.
Sarah Wollaston asked how Monitor will work directly on integration with local health and wellbeing boards. "The truth is we have more to do to work this out," she was told.
All this confusion and uncertainty are creating integration planning blight at local level. On the one hand, the air is thick with the rhetoric of integration, but lurking in the background is the awaited regulatory guidance on choice and competition. Local councils and CCGs who wish to work closely together simply cannot work out how best to deal with this Janus legislation that simultaneously attempts to face two ways. To complicate judgments further, there is the threat of UK and EU competition law, the right to choice specified in the NHS constitution, the spread of personal budgets and the fragmenting effect of the Any Qualified Provider policy.
So which way should localities jump? Take a punt on the rhetoric and plan for an ambitious local programme of integration? Play it safe and integrate only after a process of competitive tendering for an integrated service? Wait around in the hope that a future Labour government will fulfil its pledge to "abolish markets" in the NHS? Responses will doubtless be variable but one thing is clear. If localities do nothing, then the current spread of privatisation and fragmentation will make integrated care far more difficult further down the line.
Guardian Professional.
It starts to seem as if all that malarkey about competition and marketisation of healthcare during the passage of the NHS bill was just a nasty dream.
These days, the coalition government simply directs our attention to the sunny uplands of integrated care. Jeremy Hunt told us that in his first month as health secretary, "the word I have heard uttered more than any other is integration". And now, incoming health minister Norman Lamb is going down a storm in NHS circles with his plan to support a series of large-scale integrated care "experiments" that could allow local health economies to devise their own payment systems and move away from the straitjacket of "payment by results".
This is all fine, but we need to take a reality check on what is happening more broadly. Amendments following the "pause" to Andrew Lansley's bill did indeed lay a range of integration duties on health and wellbeing boards, the NHS Commissioning Board, Monitor and clinical commissioning groups. It would be fair to say that these were included belatedly and under duress, and that we are still far from clear as to what they will amount in practice. And now the first NHS mandate exhorts all organisations to focus on "the whole person rather than on specific conditions", and to "ensure people experience smooth transitions between care settings".
Even in the absence of countervailing factors, this would be a tall order – the landscape of social policy is littered with the language of failed exhortation around inter-agency working. But there is one huge complication that seems to inhabit a parallel policy universe and that is the fixation in the NHS and Social Care Act with the primacy of choice and competition in healthcare. How might this confound local attempts to work more closely together?
Lots of clues can be found in the deluge of reports and consultations emanating from the centre. In its recently closed consultation paper on "securing best value for NHS patients", for example, the Department of Health makes it clear that the default setting for the NHS will be choice and competition. Proposals for local integrated care will have to meet the "indispensability test" – that "if commissioners decide to make arrangements which materially restrict competition", they will need to demonstrate three "trade-offs":
• It is "in patients' interests"
• It delivers tangible countervailing benefits such as improvements in quality or efficiency
• The benefits outweigh the disadvantages of restricting competition
The task of policing this requirement and ensuring the prevention of "anti-competitive behaviour" will fall to Monitor – the ever more powerful quango currently responsible for the authorisation of foundation trusts. Monitor is almost entirely staffed by accountants and economists, yet has been given the task of determining whether local arrangements for integrated care will improve quality or efficiency and reduce inequalities with respect to either access or outcomes. If not, they will not be permitted to proceed.
The reality is that while Monitor is fairly clear about how it will "prevent anti-competitive behaviour", it is far from clear about how it will simultaneously promote integration. At the recent annual accountability hearing before the health select committee, the chief executive of Monitor, David Bennett, was asked a series of questions about integration which he seemed unable to answer.
Barbara Keeley, for example, asked what skills Monitor has in assessing whether integration is working or not. "We will have to learn," she was told.
Sarah Wollaston asked how Monitor will work directly on integration with local health and wellbeing boards. "The truth is we have more to do to work this out," she was told.
All this confusion and uncertainty are creating integration planning blight at local level. On the one hand, the air is thick with the rhetoric of integration, but lurking in the background is the awaited regulatory guidance on choice and competition. Local councils and CCGs who wish to work closely together simply cannot work out how best to deal with this Janus legislation that simultaneously attempts to face two ways. To complicate judgments further, there is the threat of UK and EU competition law, the right to choice specified in the NHS constitution, the spread of personal budgets and the fragmenting effect of the Any Qualified Provider policy.
So which way should localities jump? Take a punt on the rhetoric and plan for an ambitious local programme of integration? Play it safe and integrate only after a process of competitive tendering for an integrated service? Wait around in the hope that a future Labour government will fulfil its pledge to "abolish markets" in the NHS? Responses will doubtless be variable but one thing is clear. If localities do nothing, then the current spread of privatisation and fragmentation will make integrated care far more difficult further down the line.
Guardian Professional.
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