The must-read stories and debate in health policy and leadership.

The case for competition

The debate over competition and its benefits for the NHS and healthcare have raged since the 1990s and beyond. Following the disastrous reforms pursued by Andrew Lansley and David Cameron between 2010 and 2013; under Simon Stevens and Jeremy Hunt policy swung decisively in favour of collaboration and integration.

So confident, seemingly, are Mr Stevens and NHS Improvement’s Ian Dalton in their view that the NHS long-term plan last month advocated removing the role of the Competition and Markets Authority in NHS provider merger and acquisition. This will require legislation but it is clear the regulators see the CMA as an unnecessary barrier to improvement.

Enter stage left a detailed study by the CMA examining the fundamental question of whether competition helps, or hinders, the level of harm in the NHS.

The study has much to commend it. It considers a range of typical harms such as falls, pressure ulcers and blood clots, and looks at activity covering 60 per cent of hospital admissions, rather than only narrow types of procedures. The authors controlled for a range of factors that might influence harm and mortality.

However, while the mechanics of the study are impressive, the final conclusions seem a leap too far. According to the authors, a merger resulting in a monopoly could increase mortality by 550 per cent and harm rates by 182 per cent. As Nigel Edwards of the Nuffield Trust told HSJ, this appears an overextension of the findings and ignores many other factors at play.

Meanwhile, the timing of the report – so soon after NHS England advocated chopping the CMA’s role from mergers – is interesting to say the least.

Should NHS England/Improvement pursue more mergers and an agenda of integration of providers - as many anticipate - this paper could indicate that the CMA may not be willing to go quietly; and could use this paper to justify further interventions in the cause of patient safety.

A complex problem

The row over mortality and culture at the cardiac surgery unit at St George’s Hospital has been high profile. But, at the most recent meeting of the trust’s board last Thursday, there were welcome signs of improvement.

The board walk around visits saw the chief executive, medical director and a non-exec take a trip to the unit. They observed a unit that seemed less fractious under its new associate medical director than it has done previously.

However, a very large review of mortality at the unit has yet to conclude. The department still receives support from two neighbouring teaching trusts while also being overseen by an NHS Improvement-mandated panel led by Sir Andrew Cash.

There were indications that referrals to the busy tertiary centre were dropping before the trust officially discontinued complex work there in September. Although it is now inching back to accepting more complex work, there has been a substantial financial hit.

Roughly half of the decline in its year-end forecast deficit (£11m of a £22m deterioration) has come from lost income and increased costs as a result of less complex work coming to Tooting.

St George’s receives this work from outside its local south west London boroughs, so if there is a bailout necessary for the trust (or indeed the wider south west London patch), then it seems a little unfair if it has to be covered locally.

It would also be interesting to know what income the trust expects from this service line in the coming years: ie, will complex work ever return there?