NHS for Sale: Myths, Lies & Deception (26 page)

Of course there are other ways of privatising secondary care apart from handing a hospital, its assets and a guaranteed revenue stream to a private company. One of the central planks of the HSC Act was the raising of the cap on the non-NHS income that foundation trusts could generate, including from private patients. The private patient income cap (PPI) was originally a sop from Tony Blair to prevent a backbench rebellion over the foundation trust legislation. It was based on the proportion of income from private sources at the time of becoming a foundation trust and had traditionally been very low – typically 2 per cent, apart from a few specialist hospitals, mainly based in London and with an international reputation.
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From October 2012 this figure was dramatically raised to 49 per cent for foundation trusts. While a few commentators were happy that it would give ‘enterprise’ in the NHS ‘a freer rein’
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the majority saw it as a major step forward in the privatisation programme
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and a threat to an equitable NHS. The raising of the cap came against a background of financial problems for NHS hospitals – static budgets, reduced tariff prices for treatments and efforts by CCGs to save money by diverting patients away from hospital care. By the beginning of 2014 most foundation trusts were in deficit, with 66 (80 per cent) ending the most recent quarter with a combined deficit of £212m, the first deficit in the foundation trust sector’s
history. In September 2014
The Guardian
reported that another 33 NHS hospital trusts expect to end 2014-15 with a combined deficit of £563m.
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Meanwhile bed numbers have been cut, and in April 2014 an OECD study reported that only Sweden had fewer hospital beds per capita than the UK.
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The result has been longer waiting lists
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and thus an increased incentive for patients who can afford it to seek private treatment. At the same time the dire financial straits of most hospitals means trusts are under pressure to raise money by allocating more NHS beds to private patients. This has happened most noticeably in those trusts which were already established centres of expertise, such as the Royal Brompton and UCH, which both significantly increased their private patient income by 37 per cent and 39 per cent respectively in 2013/2014. Foundation trusts are meant to re-invest any such profits in NHS care, but Dr Evan Harris in an article for
The Guardian
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noted that Moorfields Eye hospital had used its private patient profits to set up a branch in Dubai, where NHS patients are presumably unlikely to be found in the waiting room.

Ironically, at the same time that financial pressures are forcing the NHS to increase the number of hospital beds occupied by private patients, the government has also cut hospital bed numbers to the point where hospitals are having to buy extra capacity for NHS patients from private hospitals at inflated prices. In January 2014
The Guardian
reported that Dame Barbara Hakin, deputy CEO of NHS England, was in discussions with private companies with a view to them providing ‘spare capacity’ in the event of a winter crisis (a revival of Alan Milburn’s extravagantly expensive ‘concordat’ with private hospitals to treat NHS patients at up to 40 per cent above the standard NHS cost).
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Using the private sector
to bail out a struggling NHS is not unheard of for elective work, but this was an alarming development. The NHS Confederation reported that urgent and emergency care was on such a knife edge that ‘hospitals may not be able to handle a sudden spike in demand’.
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A DoH spokeswoman unhelpfully said ‘we’ve increased the NHS budget in real terms but the NHS must also become more efficient if it is to meet the rapid rise in demand while ensuring compassionate care for all’. Professor John Appleby summed it up more truthfully when he said that hospitals could no longer ‘maintain the quality of services and balance the books’.
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Once again the private sector was being proposed as the solution to NHS woes resulting from government mismanagement. The private sector was of course very eager to help out because their own income from patients with private insurance has been falling.
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They are only too happy to plug the gap with NHS contracts and fill some of their many otherwise empty beds.

Recently two other moves towards privatisation have appeared on the secondary care scene – mutualisation and ‘self-funded’ patients. Mutualisation has been touted by politicians and think tanks as a solution to the problems of the English NHS. It proposes that NHS providers be taken out of state ownership and managed by their employees, citing ‘increased employee engagement’ as one of the benefits. John Lewis and Arup are trotted as the enduring success stories but the list usually stops there.

Professor Martin McKee, in a recent
BMJ
article,
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cites the many companies that did not fare well after mutualisation, including Northern Rock, Bradford and Bingley and the
Automobile Association, ‘whose reputation plummeted after its new private equity owners cut costs, increased its debt and eventually walked away with £2bn profit’. He goes on to express concern that ‘the journey to mutualisation … could simply be the first step towards being swallowed up by a major corporation’, a not unreasonable suspicion given the government’s record, and wants to know how we ensure that these fledgling organisations remain mutual, and do not fall into the hands of asset-stripping private companies, based abroad where they are protected from demands for accountability and taxes. He points out that while mutuals have played a role in health care in countries like Germany this is because there are legal safeguards in place to stop corporate takeover, while similar organisations in England would enjoy no such protection. Mutualisation looks like yet another privatising policy wrapped up in cosy language and it must be regarded with a high degree of suspicion until and unless the safeguards McKee describes are put in place.

At about the same time that mutualisation was being enthusiastically promoted by the likes of Tory MP Francis Maude
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news emerged of a new concept: ‘self-funding’. In July 2013 a
BMJ
article
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noted that a new category of private patient – the euphemistically named ‘self-funding patient’ – was being introduced at an increasing number of hospitals. These patients pay for their treatment – in NHS facilities or in private facilities delivering NHS care – at a rate based on NHS costs, which are typically considerably lower than those charged by private hospitals. Procedures available on this basis include imaging, ophthalmology services, and some surgical procedures such as hernia repair and arthroscopy that are now subject to ‘restrictions’ by CCGs and/or for which there are long waiting lists. As waiting lists get longer and
more strictures are placed on what the NHS can provide the options available to self-funded patients naturally increase to fill the gap.

Those operating the scheme claim it allows ‘patients to access restricted treatments at a cheaper rate than the private sector’ but behind the spurious justifications it is, as John Appleby of the King’s Fund has pointed out, ‘paying privately to get some healthcare provided by the NHS. It is a private scheme.’
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More importantly it blurs the boundaries between the NHS and the private sector, creating yet again the conditions for a two tier NHS in which it is inevitable that those who can pay will either queue jump through buying access to the service or will get treatments that aren’t available to those who can’t pay, or both.

Private provider Care UK is quite unabashed about it. A leaflet sent to GPs and patients, offering self-funding at four of its eleven NHS funded treatment centres, says: ‘If you require treatment but cannot access it through the NHS you may choose to opt for Self Pay. This way you’ll benefit from prompt medical care at a time that’s right for you – and with Care UK it may cost less than you imagine.’ Nick Hopkinson, a London consultant chest physician voiced the concerns of many when he said that he feared this would lead to queue jumping and an inferior service for those who couldn’t pay, and that once ‘the private providers have integrated themselves into NHS provision they’ll be in a position to offer people their premium service as well’.
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It’s not hard to see how insurance companies will step up to offer cover for those who would like to be ‘self-funding’ when the need arises, thus exacerbating this fundamental break with the concept of equity, one of the founding principles of the NHS.

Private companies are increasingly taking advantage of the fact that the boundaries between private and public are becoming more blurred. In another
BMJ
article
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Margaret McCartney describes the private company Better as.one
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which guarantees ‘medical peace of mind’ for £300 a year. For this relatively modest sum you the subscriber are entitled to an urgent triage by a consultant as soon as ‘you have a condition that concerns you’. Thereafter you can be referred back to the NHS for tests and treatment which the company will help you access ‘as quickly as possible’. As McCartney points out the offer of a ‘fast track to treatment on the NHS’ not only undermines the purpose of primary care as a gatekeeper but also means that the NHS pays to ‘sort out non-evidence-based interventions that began in the private sector’. And once again patients who can’t afford to pay to bypass the system will find themselves in the queue behind those who can.

The introduction of compulsory competitive tendering has led to more contracts going to the private sector for the reasons described earlier in the chapter. This is happening in primary care, secondary care and in community services, and as the contracts become larger and more complex they increasingly span the boundaries between all three.

Many only woke up to the shape of things to come when, in 2012, Virgin Care was awarded a £650m contract to run NHS community health services in Surrey. The contract included community nursing, health visiting, physiotherapy, diabetes treatment and renal care, prison health care and sexual health services.
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Losers in the bidding process were Central Surrey Health, the government’s flagship social enterprise mutual,
and a local NHS foundation trust, both of whom presumably had a little more clinical experience than Virgin. Virgin Care had recently taken over Assura Medical and went on to bid successfully for a number of other contracts. NHS campaigners remain particularly incensed at Richard Branson’s forays into the NHS and have managed to temporarily close a number of Virgin shops with street protests.
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Further large contracts have since appeared, including, in 2013, an £800m contract to run integrated adult and older peoples services in Cambridgeshire which again includes acute and community services, and is set to run well into the next parliament. It met with much resistance from local campaigners
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and was eventually (eighteen months later) awarded to an NHS consortium, with an estimated minimum £1m
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spent on the procurement process – taxpayers’ money that would surely have been better spent on patients than lawyers and accountants.
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The final straw for many came with the announcement that four CCGs in Staffordshire were putting together a contract worth £1.2bn for cancer services and end of life care.
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The cancer care contract, worth £687m, is set to run for ten years and has attracted the attention of a number of private companies, who are being advised by Macmillan Cancer Support charity.
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It is ironic that the CCGs involved say that they want a ‘more joined up system’ for their patients, given that it is largely the coalition’s reforms that have led to the fragmentation of traditional patient pathways – another classic example of running down the NHS and looking to the
private sector for the answer. The plan to contract out these services has triggered an impressive scale of opposition, with thousands signing petitions and hundreds attending public meetings and protests – a level of public engagement seldom seen before in campaigns against privatisation.

Paul Evans, director of the NHS Support Federation, commented: ‘The most sensitive areas of NHS care are being opened to the private sector. This shows there is no limit to the willingness of the government to replace NHS services with those from profit-driven companies.’

Dr Clive Peedell, co-leader of the National Health Action Party and a cancer specialist, was concerned:

[T]here are already national shortages of professionals involved in cancer management. Contracts with non-NHS providers will take many of these highly trained staff away from the established NHS services, where the full range of cancer services are delivered to a regional population.
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He also noted that the project is being driven by the Strategic Project Team (SPT) – a shadowy part of NHS England with a history as ‘arch privatisers’. The SPT – consisting mostly of management consultants rather than permanent NHS employees – have been involved in most of the ‘groundbreaking’ NHS privatisations to date.
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As in Staffordshire, the Coastal West Sussex Commissioning Group also cited concerns about joined up care when it handed a contract for orthopaedic work worth £235m to BUPA in September 2014.
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It later emerged that the majority of the group who awarded the contract were unable to vote because of ‘conflicts of interest’ i.e. they presumably stood to gain financially.
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The CCGs Declaration of Interest Register
makes interesting reading and was criticised for not being up to date at the time of awarding the contract.
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According to the
Chichester Observer
the contract meant that local hospitals would no longer be responsible for orthopaedic services, although a ‘local NHS spokesperson’ disingenuously claimed that patient choice would not be affected (unless of course they chose to go to their local hospital). It is of course tempting to ask what will happen if the private provider decides to terminate the contract (as has happened previously, see
Chapter 8
) at which point the orthopaedic departments in the local hospitals will presumably have been disbanded and there will be no services at all to choose from.
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