Creating a Fair PlayingFieldCompetition for Care ConferenceTom Youldon & Paul Dinkin20 May 2013
The Fair Playing Field Review is Monitor’sfirst major report as sector regulator23 May 2013 2Ensure public providers are well-ledMonitor’s primary duty is to protect and promote the interest of patientsby promoting the provision of health care services which is effective, efficient and economic,and maintains or improves the quality of services.Determine prices for NHS servicesPrevent anti-competitive behaviour andenable integrated careEnsure continuity of essential services
‘The playing field’Local48.3Planned elective£11.2Be.g. hip replacementsOutpatient(choice)£6.2Be.g. dermatology outpatientappointmentsGP Contracts£6.7Be.g. generalGP servicesDental£2.7Be.g. generaldental servicesPharmaceutical£1.5BOphthalmic £0.5BNationalspecialistservices£8.6Be.g. heart & lungtransplant;proton beamtherapyNationalpublic health£1.6B1%7%1%3%Community Health Services & Care in Other Settingse.g. Community Midwifery; Community physiotherapy; RespiteCare; Intermediate Care; Hospice care£10.9BSecondary Caree.g. Ambulance; A&E; Inpatient (non-elective); Outpatient (nochoice)£18.6BPrimary Care (excluding national contracts)e.g. Local Enhanced Services; Out of Hours GP services;prescribing costs£7.7BNationally decided(£39.0B)Locally decided(£46.7B)Mental Health Servicese.g. Child and Adolescent Mental Health Services,Substance Misuse£9.5B323 May 2013
‘Fair’4 Some providers have a comparativeadvantage e.g.• they are more efficient• they hire good people with skills thatallow them to succeed• they choose to invest in particularareas at risk• they have endowmentsA fair playing field is one where providers are not excluded for reasons that do not reflect their inherentqualities. A distortion:• impacts different types of providersdifferently• has a significant impact such that itmay change behaviour (i.e. generallyit weakens rivalry)• is extrinsic (e.g. corporate form andrules and cultural biases are outsideof a provider’s control)But crucially we only worried about distortions that harm patients’ interests.23 May 2013
‘The players’23 May 2013 5Public vs Private vs VCS Entrants vs incumbents
Our findings filled three buckets…61 2 3Participation Costs FlexibilityIs it more difficult for someproviders to get on to thefield?• Commissioning• Access to capital• BundlingDo some providers incuradditional financial costs?• VAT• Pensions• Cost of capital• Corporation tax• Payment systems (cherrypicking)• Education and training• Insurance• ITDo some providers faceadditional restrictions overthe way they operate?• Constraints on inputs (e.g.access to staff / facilities)• Burdens imposed byexternal requirements• Barriers to changingservices• The policy environmentand central controlCommissioning emerged asthe most important issue in thereview.23 May 2013
…as did our recommendations71 2 3Participation Costs FlexibilityEvidence and tools• Information on quality• Procurement guidance• Call for evidence on GP servicesStability and support• Longer contracts• Pricing & costing• Plans for CSUsAccountability and challenge• Monitoring choice• Transparency about contractsNo change on CTCharities access to VATrebatesRisk reflective cost ofcapitalCost reflectivereimbursementClarity about the role ofcentral bodiesAll FT public sectorPay flexibilityConsistency on FOIReview of CRS23 May 2013
We engaged widely and listened carefully23 May 2013 8“A helpful reviewwhich sets outsensible ideas toenable a range ofdifferent NHSproviders to offer thebest possible serviceto their patients on afair playing field”“A well-considered,well-balancedreport”• We are now working with partners toimplement the review’s recommendations“The governmentmustn’t wimp out orwriggle out. Wedon’t want weaselwords or lengthyconsultations. Itshould beimplemented”
Will we see more VCS entry?23 May 2013 9Need moreevidencebefore we inferfuture trendsReviewrecommendationswill help VCSOther reforms willhelp VCSVCS work notalways in thenumbersAcute growthdriven by need tocover fixed costs
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