As a result of the Health and Social Care Act, the number of private healthcare providers have been allowed to increase under the figleaf of a well reputed brand, the NHS, but now allowing maximisation of shareholder dividend for private companies. The failure in regulation of the energy utilities should be a cautionary tale regarding how the new NHS is to be regulated, especially since the rule book for the NHS, Monitor, is heavily based on the rulebook for the utilities. The dogma that competition drives quality, promoted by Julian LeGrand and others, has been totally toxic in a coherent debate, and demonstrates a fundamental lack of an understanding of how health professionals in the NHS actually function. People in the NHS are very willing to work with each other, making referrals for the general benefit of the holistic care of the patient, without having to worry about personalised budgets or financial conflicts of interest. It is disgraceful that healthcare thinktanks have been allowed to peddle a language of competition, without giving due credit to the language of collaboration, which is at the heart of much contemporary management, including notably innovation.
It has now been belatedly admitted that there need to move beyond fragmented care to an integrated approach in which patients receive high-quality co-ordinated services. There is of course a useful rôle for competition, but it has to be acknowledged that healthcare professionals all try to provide the optimal medical care for their patient in the NHS, irrespective of cost, as this is literally a life-death sector, unlike production of a widget. The implication is that competition itself need not be a barrier to collaboration provided that the risks of the wrong kind of competition are addressed. Porter and Teisberg’s argument is related to the analysis of Christensen and colleagues (Christensen et al 2009), who see the solution to the problems of health care in the United States as lying in competition between integrated systems. And when the United States coughs we of course sneeze.
In 2011, the Kings Fund produced a pamphlet entitled, “Where next for the NHS reforms? The Case for Integrated Care”. This was before the inevitable enactment of the Health and Social Care Act (2012). This pamphlet was nonetheless useful in articulating that there are many barriers to the implementation of integrated care, including organisational complexity, divisions between GPs and specialists, perverse financial incentives, and the absence of a single electronic medical record available throughout the NHS. The Kings Fund at that time argued that enhanced primary care involves an action to reduce variations in the quality of primary care and to provide additional services that help to keep people out of hospital. This required a network of primary care providers that promote and maintain continuity of care with local people and act as hubs not only for the provision of generalist care but also for access to diagnostics and chronic disease management. This was of course before a wholesale shift in the ownership and outsourcing of the functions of the NHS had taken place, and what exists now is nothing short of a mess.
It is all too easy to produce politics-based evidence for contemporary healthcare in the NHS, but it is perhaps worth taking note of disasters from abroad. Martin Painter, writing in The Australian Journal of Public Administration in 2008, was one of the first to point out the dangers of privatisising the State, discussing Vietnam and China. In Vietnam and China, decentralisation is a by-product, both by default and design, of the transition to a state-managed market economy. A dual process of horizontal and vertical decentralisation was occurring simultaneously in both the economic and political arena, with an increasingly high level of de facto political/fiscal decentralisation, much of it occurring by default as local governing units try to meet rising demand for services. This is accompanied by the marketisation and socialisation of services such as education and health. Accompanying both of these processes is a trend towards greater ‘autonomisation’ of service delivery units, including the emergence of new ‘para-state’ entities. This could be seen akin to the enthusiasm demonstrated by New Labour for the NHS Foundation Trust, and the Francis Report (2013) promises to provide useful insights into the definition of this new model army of autonomous units. Most of these decentralisation processes were recognised to be the by-product of marketisation, rather than part of a process of deliberate state restructuring in pursuit of ideals of decentralised government. The cumulative effects include a significant fragmentation of the state, a high potential for informalisation and corruption, and a growing set of performance accountability problems in the delivery of public services.
With fragmentation, in addition to a lack of coherent national policy, brings a culture of mistrust which is toxic for any organisation, let alone economic sequelae (discussed later in this article.) According to the Deloitte LLP 2010 “Ethics & Workplace Survey,” when asked what factors contributed to their plans to seek new 9-to-5 work environments, 48 percent of employees cited a “loss of trust,” 46 percent said a “lack of transparency in communications,” and 40 percent noted “unfair treatment or unethical behavior by employers.” Hospitals are among the most complex types of hierarchical social organisations. Collaboration within and across hospital departments can improve efficiency, effectiveness and the quality of services, but competition for resources, professional differences and hierarchical management practices hinder innovation. However, coordinating activities across functional and interorganisational boundaries is difficult. Conflicting goals and competition for scarce resources diminish trust and the willingness of decision makers across the value chain to work together. Several researchers have identified collaboration as a means of reducing various different types of conflict both between and within organisations, in the private sector. Importantly, the “dynamic-capabilities” approach highlights two realities that underlie a firm’s opportunity to exploit collaboration. First, the word “dynamic” implies the ability to rapidly change a firm’s resource base in response to a changing environment. Second, by definition, a capability is “the firm’s ability to integrate, build, and reconfigure internal and external competencies”. The literature consistently employs terms such as “coordinate,” “combine,” and “integrate” to describe the process of capability development. These core concepts suggest the need to work effectively across organisational boundaries. Thus, decision makers should consider the orientations and strategic conflict literatures as they seek to achieve inimitable advantage via a dynamic collaboration capability.
The aim of collaboration is to produce “synergy”, that is, outcomes that are only possible by working with others. However, effective collaborative functioning is hard to achieve, because various institutions, departments and professionals have different aims, traditions, styles of working and mandates. Overcoming differences to forge productive collaboration is a key challenge to the implementation of innovative health promotion. Collaboration is a multifaceted concept with many synonyms. One person’s ‘teamwork’ can be another person’s ‘alliance’ or ‘collaboration’. Kickbusch and Quick (1998) define health promotion partnerships as the bringing together of “a set of factors for the common goal of improving the health of populations based on mutually agreed roles and principles”. Straus (2002) sees collaboration as problem solving and consensus building. Cooperation and collaboration between organisation units is also risky, and marked by uncertainty regarding a partner’s skills, goals, and reliability, as well as the pair’s ability to work together. This can be cast as an issue of incomplete information, and the most obvious way to reduce uncertainty is to improve the information used in choosing a partner. There are two possible sources: experience and other firms. Past experiences with another unit will both improve abilities to cooperate and yield information about that firm. Successful collaboration involves common knowledge, shared routines, similar ways of thinking, and tacit knowledge, all of which can be built through repeated cooperation. In addition, it also creates trust, both in terms of motives and in terms of competencies. As a consequence, there is inertia in partnership formation, and stability in network structures: firms will, all else being equal, prefer partners with whom they have worked in the past.
A problem is that collaboration may require investment from the NHS, which is justified if the partners realise valued aims that could not have been realised by the partners working in isolation. However, it may also be that one or more partners consider at least part of their investment of time, effort and money to be wasted – resulting in antagony, which is the opposite of synergy. While some waste is perhaps inevitable (‘that meeting was a complete waste of our time!’), when the waste is judged excessive, collaboration may fall in danger of crumbling before aims are achieved. This is among the reasons that many collaborations cease functioning before they have achieved their aims. However, recent experience is that public health networks can produce economies of scale, enable shared expertise, increase capacity and support professional development across all three domains of public health – health improvement, health protection and health care. Networks potentially fit well with current moves across local government towards cross-authority collaboration. Future plans need to ensure that the work of existing public health networks is not lost. Within local government, public health networks will offer new opportunities for collaboration, including shared services, intelligence and analysis and cross-authority public health commissioning.
A lot of time inevitably has been lost in a package of unelected reforms costing around £2bn so far, and will continue to be lost if the Health and Social Care Act (2012) is repealed. However, Andy Burnham has promised to move forward by allowing existant structures to do ‘different things’. Either way, Part 3 of the Act is definitely to be reversed under Burnham’s plans, and it seems as if Burnham wants to re-engineer the NHS such that private companies do not participate in ‘economic undertakings’ in such a way that EU competition law is triggered. This, I feel, would be a valuable time for Andy Burnham to admit that, while there is a rôle for competition, there is also a value role for collaboration and solidarity, through which other organisational competencies could be embedded such that key aspects are promoted like innovation or leadership. No experience goes to waste.
