Choice and competition in healthcare

We have worked extensively with healthcare providers, private and public, assisting them with their mergers and acquisitions, carrying out evaluation of the effectiveness of their programmes and initiatives and providing input into their strategic decisions.

We have been at the forefront of thinking about choice and competition in healthcare from its early days over a decade ago to the present day. We have advised on the development of the policy framework and helped a large number of trusts and private providers navigate the new regime.

<3% of locally-commissioned healthcare services involved competition between providers.

Use of a competitive tender or local AQP. Source: Monitor’s Fair Playing Field report

We have advised on most of the acute hospital mergers and acquisitions that the UK competition authorities have considered.  This involves advice about how the authorities are likely to view the case, the impacts of the merger on competition and the benefits of the proposed changes.  We have also advised widely on organisational changes (joint ventures, service transfers between providers, acquisition of community providers and others) that may fall within the legal scope of the competition authorities.  This includes work on provider failure and special administration, as well as the role of competition authorities in those cases. We remain interested in the evolution of the competition framework and contribute to the debate.

We recognise that there are many different forms of choice and competition which have different impacts in different parts of the service.  Understanding the nuances helps to think through strategic issues as well as the appropriate analysis of a particular change.

80% of patients would like more choice over where they are treated.

Survey of 5000 people on behalf of the Department of Health in 2011, cited in Monitor’s Fair Playing Field report

We also advise trusts and other healthcare providers on how to use market intelligence to their best advantage, to understand better the market within which they are operating. This can be done in the context of service reviews, an acquisition or as part of an internal strategic review. We also help trusts assess the efficiency of their services, including the value for money associated with existing or planned initiatives and service reconfigurations.

We support health commissioners in their understanding of the impact of service change on patients and providers, future demands on the local healthcare economy and provider economics.

In London, we contributed to major commissioner-led reviews of services.  This work involved extensive modelling of the impact of change, assessment of patient wellbeing resulting from service reconfiguration and impact of the reconfiguration of highly specialist services.

Elsewhere, we helped commissioners understand the need for changes in care provision for long-term conditions through extensive modelling of future demand. On the national level, we analysed the drivers of A&E demand for NHS England among other projects.

We have worked on service reconfigurations across Europe. For instance, in France, we have recently advised the Government on the reconfiguration and consolidation of maternity services, the creation of local hospitals (so called “proximity” hospitals) and a major reconfiguration of teaching hospitals in Paris.

Read more on our competition work.

Q&A with Nick Woolley

Why are many hospital trusts considering mergers?

There are many reasons why trusts consider merging. Most trusts are under unprecedented financial pressure. Some trusts believe that they may be able to take out some overheads through a merger with another trust while others hope that they may turn their fortune around by joining up with a more successful trust. Some trusts want to future-proof their services and ensure that they have the right scale to deliver specialist services, achieve more resilient clinical rotas or to support their A&E. Other trusts hope that integration along the patient pathway will allow them to address the problem of ageing population and the challenges of managing long-term conditions.

Why do hospital mergers need approval from competition authorities?

Healthcare competition regulators, the Competition and Markets Authority (CMA) and Monitor, are responsible for ensuring that mergers and acquisitions in the healthcare sector do not reduce patient choice and if they do that this reduction in choice is outweighed by patient benefits arising from the consolidation. So what do healthcare providers considering merger need to do? They need to take competition rules seriously. The CMA and Monitor have the power to stop healthcare transaction on competition grounds. This would generally happen late in the preparation process once considerable resources have been spent on the transaction. However, there is no need to be unduly concerned, a merger or acquisition that is good for patients should get approved. The key to success is to be well prepared for the approval process.

Are mergers the only competition issue that healthcare providers need to worry about?

No. Trust to trust mergers have been the most prominent examples of the application of competition rules, but these rules apply more widely. They also apply to service tendering and agreements between providers. A recent CMA investigation into eye surgeons’ membership organisations shows that a common commercial practice within the medical profession can fall foul of the rules.

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