Dr Phil Hammond, broadcaster and sessional GP in Bristol

Are you looking forward
to 'integrition'?

Can you have competition and integration in the NHS at the same time? It’s an interesting question, and the success of the Health and Social Care Bill rests on the answer. First you have to come up with a new word. Labour tried to reassure us that we could have cooperation and competition side by side in healthcare using the term ‘coopetition’. Now, we have the equally exciting prospect of ‘integrition’.

All healthcare systems, from socialist Scotland to competitive Kaiser, are trying to join up health services to stop patients falling through the cracks. Kaiser Permanente, the California-based ‘integrated managed-care consortium’, is ahead of the curve on this. Patients are treated as close to home as possible, any emergency admission is viewed as a failure, and the IT system is so joined up that your eye surgeon will tell you if you’re due a cervical smear.

Kaiser has the advantage over the NHS of not having to take on every patient or the responsibility for research and training, but its key message is clear—integration is impossible without leadership from clinicians and IT that breaks down the barriers between institutions. Intriguingly, the most successful American integrated care organisations were developed originally without much in the way of competition. Only when they’d figured it out did they take their products to the market.

The challenge for integration in the NHS is not just getting the IT right and winning the hearts and minds of clinical staff to work together in primary, secondary, and social care. We may also have to design and develop integrated services in competition with big multinational companies that have been doing it for years, and have the expertise and resources to pay all the legal bills. Say you’ve sat down with patients, relatives, and colleagues and designed a wonderful evidence-based integrated care pathway for people with dementia. It’s taken hours of effort and put bags on the bags you already have under your eyes working as a full-time GP. You’ve even worked out an ingenious plan to split the savings between all of the providers and still have enough to reinvest in improving the service. Then your lawyer phones to say you may have to put the whole pathway out to competitive tender.

So you spend your one weekend off a month reading up on European Union (EU) competition law. Articles 101 and 102 of the EU treaty are supposed to prevent agreements between businesses that cause harm to consumers, and prevent businesses that have significant market power from acting in a way that harms consumers. How much of it will apply to the NHS after the Bill goes through may only be discovered in the courts. Then there’s EU procurement law, which sets out rules for how public bodies can procure services from third parties. There is currently no requirement to tender all NHS services competitively, but some GPs have complained that they were forced to put their precious pathways out to tender under Labour and it seems that this might become more common after the Bill goes through.

A lot is riding on Monitor, which has been given statutory control of the Government’s ‘principles and rules for cooperation and competition’. The Competition and Cooperation Panel will also be merged into Monitor, and it will have concurrent powers with the Office of Fair Trading (OFT). This will mean that if a case were to be brought against part of the NHS under the Competition Act, it is likely that it would be dealt with by Monitor rather than by the OFT.

The bottom line is that if you’re getting into commissioning, you’d better get on well with Monitor. It has a duty to prevent anti-competitive behaviour but if the competition rules get in the way of procuring integrated services that benefit patients, then Monitor has the power to remove the barrier. So if you want to know what ‘integrition’ is, ask Monitor. Nicely.G


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