Local services are being sacrificed on the altar of competition.

Why does anyone think we can integrate health and social care when we can’t even integrate healthcare itself? This week’s case of the “unmitigated disaster” in Nottingham illustrates the point.

GPs and hospital doctors in that city were put in an “adversarial position” to each other, and so the local hospital dermatology service was destroyed, according to an independent review. Dermatology in Nottingham was sacrificed on the altar of competition. The local Clinical Commissioning Group (CCG) decided to transfer elective dermatology services from the Nottingham University Hospital NHS Trust to the private provider Circle, ignoring the views of their colleagues in secondary care.

So an excellent hospital service was throttled. The hospital lost 9 out of its 11 dermatology consultants (only three of whom went to the private firm, and only one of whom stayed there), the rest going elsewhere in the NHS; the hospital lost its emergency dermatology services to Leicester, and they lost most of their postgraduate training and clinical research to other centres. Medical students have been transferred to Derby.

But you can’t blame the local commissioning GPs, who have been forced to put services out to tender and who are under pressure to accept the cheapest deal. We are now seeing the disastrous (and completely predictable) outcome of introduction of the internal market into the NHS by Ken Clarke and Margaret Thatcher in 1990.

The history of the last 25 years of the NHS, since the ghastly named “purchaser-provider split” was introduced, has been the story of the steady dis-integration of primary and secondary care. The whole aim of the Clarke reforms was to put the two medical groups, GPs and hospital doctors, on the opposite sides of the fence—GPs were the purchasers; hospitals the providers.

The blue print was this: all the “providers,” or what normal people call “hospitals,” were meant to compete against each other for contracts from the GP fundholders (or district health authorities where local GPs did not opt for fundholding), which would miraculously bring down prices and increase efficiency.

We all know how well commercial competition works in the NHS. You only have to look at the wonderful job locum agencies are doing today in driving down the cost of locum doctors and nurses.

In the years following the 1990 act, no politicians have had the courage to say that the “internal market” was a mistake. And the Lansley “reforms” moved that market 50 paces further on. Now the blueprint is leading to its logical conclusion.

The NHS is gradually being parcelled up into neat little commercial units, which can be run by companies such as Circle, Care UK, Virgin Health, and so on. But when one of these “nice little earners” is removed from a hospital, the knock-on effect is devastating. Meanwhile services that can’t be bundled up into commercially viable units are being starved of cash. It is a tragedy.

Annabel Ferriman is the senior news editor, The BMJ.