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Competition is killing the NHS, for no good reason but ideology Competition is killing the NHS, for no good reason but ideology
(6 days later)
It came too late. "We are bogged down in a morass of competition law. We have competition lawyers all over the place telling us what to do, causing enormous difficulty." So said Sir David Nicholson, departing head of NHS England, to the health select committee, excoriating what has been done to the NHS. David Cameron's pledge of "no more tiresome, meddlesome, top-down restructures" may have been wiped off the internet, but few will forget.It came too late. "We are bogged down in a morass of competition law. We have competition lawyers all over the place telling us what to do, causing enormous difficulty." So said Sir David Nicholson, departing head of NHS England, to the health select committee, excoriating what has been done to the NHS. David Cameron's pledge of "no more tiresome, meddlesome, top-down restructures" may have been wiped off the internet, but few will forget.
Nicholson could have stopped Cameron's Health and Social Care Act had he and other NHS leaders dared speak out as it struggled through parliament, hanging on exactly this point – infecting the NHS with competition law. It's too late, now the NHS has tendered out three-quarters of new contracts to competition, according to Pulse magazine. Headlines focus on the gathering storm in A&E, bed shortages, waiting times and rationing (one eye only for cataracts). Less visible, but equally disruptive, is section 75's competition clause.Nicholson could have stopped Cameron's Health and Social Care Act had he and other NHS leaders dared speak out as it struggled through parliament, hanging on exactly this point – infecting the NHS with competition law. It's too late, now the NHS has tendered out three-quarters of new contracts to competition, according to Pulse magazine. Headlines focus on the gathering storm in A&E, bed shortages, waiting times and rationing (one eye only for cataracts). Less visible, but equally disruptive, is section 75's competition clause.
Here's what's happening: two Blackpool commissioning groups (CCGs) are stunned at being referred to Monitor's competition arm for failing to send enough patients to Spire private hospital. Spire accuses the CCGs of telling GPs to use the NHS Blackpool hospital instead. Dr Amanda Doyle, head of one CCG, "strongly refutes" and "deeply resents" the charge. She says Spire has fewer referrals for good reasons: a faster, cheaper pathway for headache care has diverted patients away from Spire's neurology consultants, so GPs treat people in the community, ordering CT scans, avoiding costly hospital visits. GPs have been trained to give joint injections and make referrals to physiotherapy without hospital appointments, so Spire lost orthopaedic work. "Spire went direct to Monitor, without talking to us," Doyle says. The cost will be huge for her small group: she's had to hire an administrator to collect thousands of documents, tracking every referral from every GP for years. "This has shocked me. I didn't think it possible."Here's what's happening: two Blackpool commissioning groups (CCGs) are stunned at being referred to Monitor's competition arm for failing to send enough patients to Spire private hospital. Spire accuses the CCGs of telling GPs to use the NHS Blackpool hospital instead. Dr Amanda Doyle, head of one CCG, "strongly refutes" and "deeply resents" the charge. She says Spire has fewer referrals for good reasons: a faster, cheaper pathway for headache care has diverted patients away from Spire's neurology consultants, so GPs treat people in the community, ordering CT scans, avoiding costly hospital visits. GPs have been trained to give joint injections and make referrals to physiotherapy without hospital appointments, so Spire lost orthopaedic work. "Spire went direct to Monitor, without talking to us," Doyle says. The cost will be huge for her small group: she's had to hire an administrator to collect thousands of documents, tracking every referral from every GP for years. "This has shocked me. I didn't think it possible."
She's not alone. The final judgment by Monitor, the Office of Fair Trading and the Competition Commission forbidding Bournemouth and Poole hospitals from merging has stunned the NHS. Poole's CEO told a meeting it cost them more than £6m in lawyers and paperwork; without merger his trust will have an £8m-a-year deficit. Tony Spotswood, CEO of Royal Bournemouth, says: "The merger would have saved £14m a year, with great benefits to patients. A single A&E would offer 24-hour, seven-day-a-week consultants," but that's scrapped, along with a new maternity centre. Several specialisms only viable when shared will go, sending patients far away. Unified cardiology would give 24-hour consultant cover, but not now. Poole and Bournemouth, 10 miles apart with no other competitor in sight, have been forced to give the Competition Commission an undertaking not to try any backdoor co-operation. Bournemouth's motto is "Putting patients first", but priority goes to competition ideology.She's not alone. The final judgment by Monitor, the Office of Fair Trading and the Competition Commission forbidding Bournemouth and Poole hospitals from merging has stunned the NHS. Poole's CEO told a meeting it cost them more than £6m in lawyers and paperwork; without merger his trust will have an £8m-a-year deficit. Tony Spotswood, CEO of Royal Bournemouth, says: "The merger would have saved £14m a year, with great benefits to patients. A single A&E would offer 24-hour, seven-day-a-week consultants," but that's scrapped, along with a new maternity centre. Several specialisms only viable when shared will go, sending patients far away. Unified cardiology would give 24-hour consultant cover, but not now. Poole and Bournemouth, 10 miles apart with no other competitor in sight, have been forced to give the Competition Commission an undertaking not to try any backdoor co-operation. Bournemouth's motto is "Putting patients first", but priority goes to competition ideology.
Jeremy Hunt strives to airbrush out the past three Andrew Lansley years and the £3bn cost of the Health and Social Care Act. He tries to blame any fault on Andy Burnham's previous era, a ruse unlikely to see him through the unfolding turmoil. Wriggling in front of the Commons health committee, he hinted the act might be revisited to soften the disastrous section 75. But the government has privately ruled it out as too politically embarrassing to reopen the floodgates of that controversy. They hope Monitor, and the Competition Commission, will be more sensitive to the NHS in future, but without rescinding section 75, no one can stop the likes of Spire using their legal competition rights.Jeremy Hunt strives to airbrush out the past three Andrew Lansley years and the £3bn cost of the Health and Social Care Act. He tries to blame any fault on Andy Burnham's previous era, a ruse unlikely to see him through the unfolding turmoil. Wriggling in front of the Commons health committee, he hinted the act might be revisited to soften the disastrous section 75. But the government has privately ruled it out as too politically embarrassing to reopen the floodgates of that controversy. They hope Monitor, and the Competition Commission, will be more sensitive to the NHS in future, but without rescinding section 75, no one can stop the likes of Spire using their legal competition rights.
Chris Ham of the King's Fund thinktank says: "It's only becoming apparent now what it means to expose the NHS to red in tooth and claw competition law." He cites two Bristol trusts trying to create a unified cancer pathway, which has cut cancer deaths elsewhere. But the OFT has stopped them, ordering them to compete. London's King's College hospital wants to integrate community older people's services with the local council, as universally recommended, but competition law stopped it. Guy's, St Thomas's, King's and the Maudsley want to combine south London mental health services, but may be blocked. The OFT slapped down some NHS hospitals for agreeing tariffs for private patient units. Chris Ham of the King's Fund thinktank says: "It's only becoming apparent now what it means to expose the NHS to red in tooth and claw competition law." He cites two Bristol trusts trying to create a unified cancer pathway, which has cut cancer deaths elsewhere. But Monitor has asked them to compete. London's King's College hospital wants to integrate community older people's services with the local council, as universally recommended, but competition law stopped it. Guy's, St Thomas's, King's and the Maudsley want to combine south London mental health services, but may be blocked. The OFT slapped down some NHS hospitals for agreeing tariffs for private patient units.
Cameron is ordering the NHS to use the private sector, but it's no cheaper. St Andrew's, a private mental health service, paid its CEO £650,000 – until Third Sector magazine reported it. Nuffield Health pays its CEO £840,000. A curiosity in private hospitals is that many are technically charities, in the same way Eton is a charity, gaining tax privileges for the privileged. NHS top salaries have risen steeply under this government, which inherited 290 very senior managers earning over £200,000 but has increased their number to 500. Perhaps that's what it takes to find those willing to run this chaotic, high-risk new system.Cameron is ordering the NHS to use the private sector, but it's no cheaper. St Andrew's, a private mental health service, paid its CEO £650,000 – until Third Sector magazine reported it. Nuffield Health pays its CEO £840,000. A curiosity in private hospitals is that many are technically charities, in the same way Eton is a charity, gaining tax privileges for the privileged. NHS top salaries have risen steeply under this government, which inherited 290 very senior managers earning over £200,000 but has increased their number to 500. Perhaps that's what it takes to find those willing to run this chaotic, high-risk new system.
A leading competition lawyer at Clifford Chance tells me he acts for eight other NHS trusts planning to collaborate or merge various services – but they have been stopped in their tracks by the Bournemouth/Poole decision. Sir Bruce Keogh's call for A&E rationalisations may often trip over section 75 competition law too. Monitor, which supervises foundation trusts, is reportedly "at war" internally due to its two conflicting duties – to force competition yet ensure the financial viability of trusts. Now it will see Poole at risk of going bust because of its own competition duty.A leading competition lawyer at Clifford Chance tells me he acts for eight other NHS trusts planning to collaborate or merge various services – but they have been stopped in their tracks by the Bournemouth/Poole decision. Sir Bruce Keogh's call for A&E rationalisations may often trip over section 75 competition law too. Monitor, which supervises foundation trusts, is reportedly "at war" internally due to its two conflicting duties – to force competition yet ensure the financial viability of trusts. Now it will see Poole at risk of going bust because of its own competition duty.
Monitor, the OFT and the Competition Commission may be overwhelmed with cases, each requiring billions of bytes of data going back years. Poole had to collect half a billion documents in evidence, with mega fees and hours of lawyers and administrators – all for what? To stop the integrations and rationalisations that a hard-pressed NHS needs. This is precisely what was warned, and what Lord David Owen made such impassioned, forensic speeches about in the Lords. This was the point over which Shirley Williams caved in during the bill's notorious "pause", when her party might have stopped it.Monitor, the OFT and the Competition Commission may be overwhelmed with cases, each requiring billions of bytes of data going back years. Poole had to collect half a billion documents in evidence, with mega fees and hours of lawyers and administrators – all for what? To stop the integrations and rationalisations that a hard-pressed NHS needs. This is precisely what was warned, and what Lord David Owen made such impassioned, forensic speeches about in the Lords. This was the point over which Shirley Williams caved in during the bill's notorious "pause", when her party might have stopped it.
One lesson for the NHS – why did so few speak out? Even now, with the NHS perched on a cliff edge, most of those I speak to in senior positions ask not to be quoted, so what hope for whistleblowers lower down the chain? One of the pledges Computer Weekly found wiped off the internet was this Cameron promise of "near-total transparency of the political and governing elite". The NHS needs that honesty now.One lesson for the NHS – why did so few speak out? Even now, with the NHS perched on a cliff edge, most of those I speak to in senior positions ask not to be quoted, so what hope for whistleblowers lower down the chain? One of the pledges Computer Weekly found wiped off the internet was this Cameron promise of "near-total transparency of the political and governing elite". The NHS needs that honesty now.
• This article was amended on 20 November 2013. An earlier version said the Office of Fair Trading had stopped two Bristol trusts from merging. It was Monitor which considered the case but stopped short of recommending that the trusts reverse the configuration.
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