Competition is unwelcome in the NHS – but “collaboration” that strips hospital services from whole areas and increases health inequalities is no solution

Competition has no place in the NHS. But neither do the government’s plans for Accountable Care – now rebranded as Integrated Care to avoid the connotations of the USA’s Medicare/Medicaid system.

If you agree, BY MIDNIGHT ON FRIDAY 22 FEBRUARY, please scroll right down this page to the comments box and add your name to this response to Polly Toynbee’s Comment Is Free article on the NHS. We will then send the response (with signatures) to the Comment is Free editor, with a request for them to publish it.

Polly Toynbee is half-right in her Guardian Comment Is Free article on the NHS (“The NHS lives by co-operation. The privatisers are still trying to wreck it” – Feb 12th, 2019). But we question her judgement in cheerleading for the government’s NHS Long Term Plan and its mission to dismantle the NHS into 44 Integrated Care Systems, under the rubric of replacing competition with collaboration.

Like Ms Toynbee, we have no truck with the Coalition government’s 2012 Health and Social Care Act, which imposed widespread competitive tendering on the NHS. We have been campaigning for years to remove contracting, through restoring the NHS as a fully publicly funded, provided and managed service, through the NHS Reinstatement Bill.

Polly Toynbee says that any such legislation is impossible because “this paralysed government dares not reopen the Lansley catastrophe in parliament”. But the Secretary of State Matt Hancock recently told the House of Commons Health and Social Care Committee that NHS England has made proposals on changes to the law and:

“The Dept of Health is open to potentially making government time available for a bill.”

Simon Stevens added that NHS England will put forward proposals in February for legislation to enable Integrated Care Providers to work jointly with Clinical Commissioning Groups on planning and funding – as well as providing – a whole range of NHS and social care services for their areas.

This would be done through a contract designed to “manage demand”, based on the USA’s Accountable Care Organisation contract which has led to denials of care and cherrypicking patients who are cheapest to treat and likely to have the best outcomes.

But Polly Toynbee apparently sees this cost-cutting exercise as creating “collaborative, joint NHS and social care structures locally, not competing but cooperating.”

This spin distracts from the fact that the Accountable/Integrated Care model is – like the Lansley “catastrophe” it aims to replace – built on NHS cuts proposals that the global management consultancy company McKinsey produced for the New Labour government after bankers crashed the global economy.

These are some key features of the new cuts-driven “collaborative” model of the NHS.

  • Cuts and centralisation of District General Hospitals – including the downgrade or closure of at least 23 full blue light A&E departments that we’re aware of.
  • Bed closures in many community hospitals.
  • Moving hospital services into new primary care networks serving 30K-50K patients that each shares a “locality hub” serving up to around 180k patients – a massive and unevidenced change to primary and community health services.
  • Restricting patients’ access to GPs – who will mostly only see high cost patients with complex conditions. New grades of less qualified staff will see everyone else.
  • Pushing much of the work of health and social care onto patients themselves, their families, friends and voluntary sector organisations.
  • Large scale behaviour change schemes targeted at patients suffering from or deemed to be at risk of non-communicable illnesses (eg obesity, diabetes, anxiety, depression, heart and respiratory problems) – regardless that their causes are largely social, economic and environmental injustice and deregulated corporations.
  • Remote digital monitoring of people’s bodily functions through wearable technology – with pretty horrendous privacy and civil liberties implications (discussed by Shoshana Zuboff in her Surveillance Capitalism book).

Polly Toynbee sees correlation/causation statistical problems in the Competition and Markets Authority’s report. We do too.

But Polly Toynbee seems to throw out the Competition and Markets Authority data with the interpretation bathwater – ignoring the likely damage to patient safety from the hospitals cuts and centralisation that are key features of Simon Stevens’ “collaborative” Integrated Care Systems and Integrated Care Providers.

The Competition and Markets Authority’s analysis of data found that more hospitals within a certain distance correlates with lower harm rates. If there are 3 or more hospitals, there are fewer harms than if 1 or 2.

Like Polly Toynbee, we think that the absence of competition is unlikely to be the cause of increased mortality and harms such as ulcers and blood clots in areas where hospitals merge or where there is only one hospital. There are too many confounding factors for this to be a reasonable deduction.

Rather, the Competition and Markets Authority data could perhaps be more realistically explained as the result of running down District General Hospitals by centralising and cutting services. That always involves staffing cuts and bed cuts, which would explain the worsening quality of care. It also involves greater distance for patients to travel to hospital – both by ambulance in emergencies, and for family and friends to visit.

So are patients suffering higher morbidity and mortality due to delays in reaching treatment where services are more sparse? This phenomenon can be shown directly from the data for A&E, where the first hour after an accident/sudden onset serious of serious illness is known as the “golden hour”.Some data is here.

Hospital mergers can damage your health

Ms. Toynbee’s advocacy of Simon Stevens’ plan for “closer collaboration” between NHS organisations goes really wrong when she celebrates the recent ruling that the two struggling Dorset hospitals in Bournemouth and Poole can merge to share services.

Dorset Clinical Commissioning Group has been put in a position where running a full-service hospital in Bournemouth and a full-service hospital in Poole (half an hour to the west) is beyond its means. With the result that Poole Hospital is now threatened with shutting down its Maternity, Paediatric, A&E and Trauma services.

That could be dressed up as a victory over the “competition dogmatists” in the CMA who wanted Bournemouth and Poole Hospitals to compete with each other. But it doesn’t look like any kind of victory to the thousands of Dorset residents who have crowdfunded a judicial review against losing vital A&E and other key services from Poole Hospital so that they can be centralised at the more distant, less accessible Bournemouth hospital.

Dorset County Council’s Health Scrutiny Committee, supported by the Borough of Poole Health and Social Care Overview and Scrutiny Committee, has referred the proposal to the Secretary of State for Health on the grounds that it is not fit for the public.

Ms Toynbee also misrepresents the effects of the merger of Ipswich and Colchester hospitals as entirely positive. According to Support the NHS Colchester, there’ll be an A&E as well as maternity at each hospital, but other units will be shared out. People will have to travel from quite rural areas, with little affordable public transport. There’s no plan in place to deal with patient – or staff – access.

Polly Toynbee has got the wrong end of Simon Stevens’ stick. Competition is unwelcome in the NHS – so is “collaboration” that strips hospital services from whole areas and increases health inequalities.

Update 24.10.2022 Study confirms that hospital mergers damage quality of clinical care

A study of published a few days ago reports that hospital mergers have “immediate and persistent negative effects” on clinical quality. The paper, KIller Deals? The impact of hospital mergers on clinical quality, examined hospital mergers in the English NHS between 2006 (when the New Labour government introduced hospital choice) and 2015. It found that,

“[O]n average a merger increased the likelihood of death by 0.4 percentage points and the likelihood of readmission by 0.9 percentage points.”

Over the study’s sample period, 159 NHS hospitals were involved in mergers, comprising 13 transactions.

On this basis, the study calculated that clinical effects of the mergers on the patient population amounted to approximately 98 additional deaths and 218 additional readmissions a year.


  1. Staff and patients know what has happened to NHS services.
    The NHS must be fully publicly owned and run, and services should not be cut where there will be an impact on the population which has already paid for them.
    ‘Irresponsible scaremongering’ says Colchester’s property solicitor MP, Sir Will Quince Of Buckinghamshire.
    Unison, NMC and other unions pushed through a ‘Meaningful Pay Rise For All Staff’ last year.
    HCPC spent £70,000 from registration fees on lunches over 5 years then hiked the fees by 18%.
    BMA appears to be rolling over to let everything happen as planned.
    It’s clear that it’s a gravy train funded by the many for the few, and just about every body which exists to protect staff and the public is not acting in their interests. So it’s down to the people to take this on ourselves and fight to the end.


  2. We live in East Devon and have been subject to these changes, and despite a well organised campaign and some strong independent local political support, the Tory MPs at local level drove the system through and even when at the Scrutiny Committee level, it was still driven through despite not demonstrating a clear costed argument to provide care in peoples homes, the carbon footprint that having several specialists calling on people in their home cannot be good and many of these patients are remote with no internet connection and much is being driven online. We have lost nearly all our local hospitals in all areas of Devon, and many other facilities such as Maternity, this has put a massive increase on the demand in the main hospitals and with the shortage of staff to provide home health care this massively complicates the issue.

    Liked by 1 person

  3. We should return to the principle of NHS health care free at the point of need, not the simplest-work – for – the-most – money contracts


  4. It has long been the Conservative aim to privatise the NHS. Simin Stevens was headhunted to turn our publicly funded service into a private insurance based business that puts profit for shareholders above patient care. Polly Toynbee needs to do more research. The NHS is on a knife edge now and all effort is needed to counteract Tory spin.

    Liked by 1 person

  5. The NHS is for the health of the people of this country and not for private profit SAYNO to any type of privatisation within the NHS no matter what fancy name it is given by this Tory government and it’s cronies
    Maureen Idle Leeds Hospital alert


  6. I find it sad that people like Polly cannot see the simple basic strategy of the Govt’s attitude to the NHS. Starve it, run it down and make the alternatives look good. Put straightforward ‘bread and butter work into the private sector but paid for by the NHS and make a lot of people happy whilst abandoning others and propagate the idea that ‘private’ is quick, efficient, professional while leaving our hospitals in dire straits. Some things will work and make people feel well they are right. They are choosing where to put the money, where to take it from and are destroying our NHS with a stick and carrot system and a bullying culture that unless people really understand what is going on will like the environment be past the point of no return if we cannot halt it. People at the top of the pile will get richer but in the long term there is only loss for society and quality of life. Forget what might be good and bad a lot of people are working very hard despite all that is thrown at them to make things work, they are improving areas their innovative ideas are being taken on and act as a smoke screen. This is political ideology at work the model is the American healthcare system and we do not want it here.


  7. I am a retired GP. The govt have very carefully dressed up the changes it is making in the NHS to make them sound positive. But they are really aimed at reducing the quality of the service and chopping it up ready for americanising it and limiting budgets spent on people. Also, the amount spent on the NHS is way too small to keep up with medical inflation etc.


  8. It’s time to acknowledge the Tories’ planned destruction of our NHS and end it now. There is no place for greed and competition in health care.


  9. I hope the Guardian will publish this article and perhaps Polly would like to meet with Steve, Jennie and some of the others who have done so much to expose the enormous theft that is taking place.


  10. It is well known that the Chief Executive of NHS England (NHSE), Simon Stevens, was a senior-vice president at the massive US health insurance company UnitedHealth. He is said to have had responsibilities for lobbying both to water down ObamaCare, and to push for health to be included in the controversial TTIP transnational ‘trade’ deal. What is less well known is that the ‘Five Year Forward View’ of October 2014, is drawn directly from the World Economic Forum’s (WEF) diagnosis of the healthcare crisis, and also reproduces the Forum’s prescription for supply-side change and the various levers available to policy makers (1). The WEF has been described as the “the most comprehensive planning body of the transnational capitalist class”, where “concepts of control are debated, and if need be, adjusted on a world scale”, and whose aim is “enhancing competition to the full and eliminating whatever niches remain protected from the full discipline of capital”. Public healthcare systems are evidently notable ‘niches’ in this sense (1). Similarly, David Prior, Chair of NHSE, is founder of two free schools (underlining his commitment to encouraging the private sector into public services) and has questioned the premise of a tax funded NHS, advocating more competition to ‘drive up standards of care’ and more entrants into the market from private-sector companies (2). The ten year ‘plan’ for the NHS appears full of good ideas but remains totally unfeasible given the lack of funding, the unaddressed crisis in social care and the fact of nearly 110,000 staff vacancies. Tellingly, the Board of NHSE appeared simply nonplussed when the manpower issue was raised by a nurse who was brave enough to ask ‘why is the king wearing no clothes?’ right at the end of one of their recent meetings (3). Perhaps structural reorganisation is the main point of the long term plan, with unaccountable Integrated Care Systems now being steamrollered through as the future model for the health and care system in each footprint area? Far from being transformative however, ICS are a rebranding of US Health Maintenance Organisations and represent an institutionalised expression of ‘managed care’, aimed at containing costs whilst ensuring profits and disciplining the workforce (4). Self-congratulatory neoliberal ‘group think’ (3) must not be considered the way to deliver better services for patients or to ensure a long term future for an NHS where founding principles should still guide planning. The national leadership see things through a neo-liberal prism, a world view that is entirely comfortable with an increase in the role of the private sector in the economy and society engineered by promoting privatisation, austerity, deregulation, and reduction in government spending. There are none so blind as those who do not wish to see.
    1. Player S. The Truth about Sustainability and Transformation Plans.
    4. Player S. ‘Accountable care’ – the American import that’s the last thing England’s NHS needs.


  11. After years and yeas of hard work please save our NHS for the people who need it, Bevin would be turning in his grave if he could see what is happening to his NHS!!!!!!!


  12. The NHS should be reinstated to be publicly funded, publicly provided and should provide the full range of medications and treatments universally to all free at the point of delivery and regardless of wealth, status or address and postcode. A modern civilised democracy which is 6th richest country in the world would and should provide this to all. The NHS should not be run on a profit making basis, nor on a competitive model and should not be provided by private profiteers. The responsibility for the health of the nation should be restored to the government and the Secretary of State for Health so that government can be rightly held to account for failing to ensure a good standard of universal public health and can be forced to put into place services which are fit for purpose and properly funded and staffed. Ill health is not a business opportunity. Reinstate Our NHS


  13. Wish I had got this earlier – hundreds of NHS workers would sign it. We must overcome those working behind the scenes to privatise services, because they will benefit, in kick-backs or vested interest.

    Liked by 1 person

  14. A country can be judged on the way it looks after it’s sick and disabled, the UK has led the way since the NHS came into being, it’s worth cannot be measured a healthy populace is a happy one than work to pay it’s way. The govts have committed the unthinkable by deliberately and by stealth starving the NHS of funding over a number of years. Six yrs ago they decided to step up the pace to realise full privatisation, to do that they engineered a scandal, they invented hundreds of needless avoidable deaths and patients drinking from invisible vases. They made people afraid, they played on those fears, divide and conquer in the name of greed! The results have been clear to see, patients being sent around counties being forced to wait to see GPs and consultants, forced to use the services of Babylon, high risk births taking place at roadsides and babies dying. No one should ever put a price on the health of a fellow human being but this is what is happening, if you can’t pay you face the delay, you can’t pay you suffer!


  15. Centralisation of services and rationing of care is making a nonsense of the “universal service” our NHS claims to provide. We need no wasteful markets, nor “Integrated Care Systems” designed as a cover for privatisation, but rather fully publicly owned, fully tax funded health and social care, run democratically by health workers and patients.
    On behalf of Cumbria Health Campaigns Together.


  16. I couldn’t agree more with this response to Polly Toynbee’s article. It’s a crying shame that Polly cannot see beyond the ‘line’ promoted by Simon Stevens. It’s frustrating that Polly knows full well that outsourcing public services is a disaster (this article from March last year, but seems unable to join up the dots and understand that Integrated Provider Contracts are designed to do exactly that – package the NHS in England into 44 separate outsourcing packages.


  17. This is so depressing, worrying and outrageous. I agree with everyone’s comments. Who would want to go along with this nightmare !


  18. I agree with so many of these comments. We must not allow the NHS to be recreated as a brand, used as a front for privatisation.


  19. Being a disabled person with a series of complicated, long term conditions, needing a range of health care providers’ support over 15 years, I have been a witness to how the NHS has changed Some changes, in administration for instance, have been for the good, but the closing of local hospitals and A&Es, increasing waiting times is not good. Neither is the outsourcing of services like physiotherapy. In house, you get to know the same physiotherapists over the years, who know your conditions. Outsourcing removes this. It is the same for many other services. We need to keep as much of the NHS out of private hands as possible to keep it coherent and complete


  20. The tories and their hand-picked apparatchiks in charge of the NHS have found over the years that there is far too much vocal public affection for a publicly owned and run NHS, free at the point of delivery, for them to privatise it directly or openly. But it’s very clear that privatisation remains their aim. This so-called “collaboration” strategy is just one of several methods they have applied to steadily run down the scope and quality of services provided by the NHS by stealth, in preparation for a disguised privatisation.
    In the era of Brexit, this seems to be flying under the radar and attracting much less attention and opposition than might otherwise be the case if people’s attention wasn’t distracted elsewhere. It’s very important that we bring it out more into the glare of public scrutiny.

    Liked by 1 person

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