NHS Monitor: Integration is not the opposite of competition, collaboration is

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As many report:

In a speech on the future of the NHS, the Prime Minister said Monitor's ‘main duty' was to protect and promote the interests of people who use health care services.

‘Monitor will now have a new duty to support the integration of services — whether that's between primary and secondary care, mental and physical care, or health and social care,' he said.

There is a problem: integration is not the opposite of competition. Collaboration is the opposite of competition.

Integration implies a disparate selection of independent bodies have to be meshed as well as possible one with another, with at any time there being risk of one component being replaced with an alternative. Relationships will be defined contractually: trust will be low because at any time the risk of a component being rejected and a replacement being sought is high. Defensive behaviour will be prevalent, focussing on the need for survival of the constituent parts, not the behaviour of the system as a whole. The patient will have low priority in that case.

Collaboration means people working together towards a common goal. If collaboration is the target the aim is to achieve a common goal. The risk of component failure is covered by seeking high standards of behaviour universally: the result is risk can be taken to achieve that aim. The relationships are built on trust, not contract. It is maximum and not minimum performance criteria that matter.

Which model is likely to produce the best health outcomes? Clearly a collaborative one.

Now, I admit we have not got such a model now. That is the fault of governments past, both Tory and Labour. So we need reform. But not the reform we are getting, which will undoubtedly increase fragmentation in the NHS (that is its purpose) and so make integration hard and collaboration impossible.

We do instead need to create a collaborative model. This is possible. Instead of breaking the NHS up we need to re-centralise it.

Yes,  I mean that: we need to remove whole swathes of NHS management by making much larger management untis within a nationlised NHS. And, of course, we need to remove the internal market from the NHS which is designed to reduce collaboration by making all relationships within it contractual rather than collaborative.

For example, it is absurd that more  than 100 Primary Care Trusts exist. People want an NHS. They don't want a local service. Certainly there is a need for local management of issues, but the idea that the drugs available in one county (or smaller area) should differ from another is absurd. The idea that 100 or so organisations need to develop policy on identical issues as they do right now is crazy but it will get worse: if the Tories get their way this will go up to 500 or more organisations spending time on identical tasks when there are commissioning groups. They will all be duplicate effort endlessly - when the desire is for similar (or identical)  outcomes amongst the people of the UK. The postcode lottery is one of the most despised aspects of the NHS.

And the result of this absurd localism, replicated by making hospitals compete with each other as independent units, is gross inefficiency. It's glaringly obvious that the resources we have available to dedicate to the NHS are limited. The last thing we can do is duplicate tasks. So far from splitting up PCTs into smaller units now we do instead need regional management groups. In the area where I live, for example, it makes complete sense to group Norfolk, Suffolk and Cambridgeshire. It may be worthwhile adding Essex, although I suspect that would better group with Hertford and Bedfordshire. And so on.

Within these areas there is room for just one GP oversight body, allocating funds to practices on the basis of weighted social need (which would produce an outcome where areas with high need got most money - perversely the almost exact opposite of what happens now).

And within these areas there would be one ambulance service, one out of hours service, one service for mental health, one system to integrate health and social care, and as important, a group of hospitals under common control. That would have the enormous benefit of allowing coordinated concentration of high level specialisms - something which modern medicine so clearly needs and which is the exact opposite of the likely outcome of the government's plan.

Think of the savings this could achieve: one chief executive, one senior management team, one set of non-execs, one audit, one accounting consolidation, one set of admin overheads, the benefits of centralised buying resulting in serious saving.

And the end of so many petty boundary disputes between managers. The end of vast amounts of accounting between organisations that should all be working to one goal. An the opportunity to manage on the basis of something much easier to implement, and of far greater medical relevance, which is an appropriate, easily monitored and readily reviewed set of key performance indicators.

Plus the opportunity for building centres of excellence where they are needed.

That's the NHS reform we need, and it is far removed from the reform we are getting.


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