• Francesca Frosini, Anna Dixon, and Ruth Robertson.
• The King's Fund, London, UK. f.frosini@kingsfund.org.uk
• J Health Serv Res Policy. 2012 Jan 1; 17 Suppl 1: 16-22.

ObjectiveTo analyse how competition is experienced and characterized by NHS and independent sector acute care providers in the English National Health Service (NHS).MethodsSemi-structured interviews with 49 senior staff in 15 NHS trusts and independent sector providers between November 2008 and April 2009, in England.ResultsThe market was predominantly defined based on geographical proximity. Competition was mainly on the periphery of catchment areas but markets were differentiated based on the scope and type of services. Niche providers, specialist hospitals and tertiary centres did not directly compete with district general hospital-type providers. Competitors were increasingly primary and community care providers, while there was little perceived threat from the private sector. There were many examples of how different providers (both NHS and independent sector) were co-operating and collaborating. Patients and general practitioners (GPs) appeared to be loyal to local providers.ConclusionThe providers' view of the market and the relevance of historical relationships and loyalties suggest fine grained variations in competition which is consistent with a relational rather than structural approach to competition. Also the evidence on embeddedness of relationships implies that collaboration might be a strong lever for quality improvement locally. Finally, some of the agreements found might be deemed in breach of the rules of competition but they may well be in the interests of patients and taxpayers, with implications for regulation in publicly funded health care systems.

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