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.