A barrage of publicity surrounded the publication last week of the long-awaited report of Rishi Sunak’s 17-strong “taskforce” on elective recovery, which was set up last December.
There was no surprise that its focus was on ways of maximising the use of private hospitals and on getting private providers to run new Community Diagnostic Centres (CDC).
A quarter of the 17 places on the taskforce were taken up by representatives of the private sector: (Independent Healthcare Provider Network (IHPN) boss David Hare, Dr Paul Manning, chief medical officer of US-owned Circle Healthcare, owner of the UK’s largest chain of private hospitals, Darsjak Shah from private eye health firm Newmedica, and Medefer CEO Dr Bahman Nedjat-Shokouhi).
In addition to minister Will Quince the taskforce also included two right wing government advisors, Robert Ede from neoliberal think tank Policy Exchange and Bill Morgan, founding partner from PR and lobbying firm Evoke Incisive Health whose clients have included the IHPN, the now-defunct Virgin Care – which sued the NHS over a lost contract, and private mental health provider Cygnet – owner of two hospitals exposed by a BBC Panorama investigation and by CQC inspectors.
With this substantial lobby group on board, many of us were braced for some dramatic proposals. Even more so when it was launched at a Downing Street summit which aimed “to ‘turbo-charge’ use of the private sector to help clear record waiting lists, as pressures on the NHS grew.
But in the event the taskforce has produced a fairly limited set of proposals, most of which are even less adventurous than the proposals to expand and effectively create a new NHS-funded private sector outlined by New Labour ministers in Tony Blair’s and Gordon Brown’s governments from 2003 onwards.
Sadly Labour’s shadow health secretary Wes Streeting showed again he has learned and forgotten nothing from those costly experiments, which paid private providers an average of 11% above the NHS rate for each patient treated. He picked up where New Labour had left off … and criticised the Sunak government’s slowness in resorting to private hospitals!
Promoting the report, health minister Maria Caulfield shocked and confused the Daily Mirror and some campaigners by inaccurately claiming on Sky News that the government is spending “about £19 billion a year” on private providers (which, if true, would represent a near-doubling of almost £11bn (£10.85bn) spent on “independent sector providers” in 2021/22). She also claimed that although £19bn “sounds like a huge amount, it’s actually only 8% of the NHS budget”: but for £19bn to be just 8% of the budget, the budget would have to be a massive £237 billion – almost 50% higher than NHS England’s actual budget of £167bn for 2023/24.
Caulfield seems to have been following in recent Tory ministerial tradition by just making up figures and relying on the (seemingly unlimited) ignorance of interviewers to allow them to go unchallenged.
In reality the striking thing about the taskforce report is that unlike New Labour’s plans to sponsor the growth of new “independent sector treatment centres,” backed by increased funding, the taskforce plan is backed by no extra funding at all: it is simply diverting more existing NHS funds into contracts with the private sector.
The main headlines on the report were grabbed by the announcement of 13 new “community diagnostic centres” (CDCs), eight of which are to be run by the private sector.
Five of these in the South West (on permanent sites in Redruth, Bristol, Torbay, Yeovil and Weston Super Mare) are to be run by one company, InHealth, which hit headlines back in 2019 when they landed a controversial 7-year contract to provider PET scan services in Oxfordshire against the opposition of local clinicians and politicians. It’s not clear which firms will run the other three CDCs in Southend, Northampton and Birmingham.
The five new NHS-run CDCs will be in Hornchurch, Skegness, Lincoln, Nottingham, and Stoke-on-Trent. In total, the new CDCs will deliver over 742,000 additional tests, checks and scans a year.
Apparently NHS England has so far approved over 50 schemes with independent sector involvement, including fully independent sector-led CDCs, joint service delivery models and CDCs that have made use of independent sector-delivered mobile diagnostic facilities.
However no financial details of the initial investment or running costs, or other details of the size, scope and staffing requirements of CDCs are given, except we are told the five new NHS-run CDCs are to be funded from the £2.3bn pot announced back in the 2021 Spending Review.
And while the attention of the news media and campaigners focused on the newly-announced CDCs, few if any reporters have been asking how big or expensive these units will be. The report’s ‘case study’ on CDCs states:
“Currently over 200 Independent Sector Providers (ISPs) provide over 10,000 diagnostic procedures per week to the NHS”.
That means they are tiny. Each ISP averages just 50 tests/procedures per week: and the whole private sector contribution over a year is the equivalent to slightly more than the 479,000 diagnostic tests and procedures the NHS delivers every day.
The government has further muddied the water in assessing the scope and scale of existing, new and planned CDCs by publishing only a monthly cumulative total of procedures carried out since July 2021, and not giving the relevant number of CDCs in service month by month. However these figures do allow us to calculate that the 114 CDCs that have already come on stream delivered an average of around 240,000 procedures per month over the year to May 2023, and a total of 2.8 million in the year to April 2023.
From all the evidence so far it seems clear that unless the new and future CDCs are much bigger than the CDCs opened so far, adding 13 more CDCs, which are expected to provide 742,000 additional scans, tests and checks each year, is going to make only a minimal inroad into the delays and increasing numbers of patients waiting for diagnostic tests.
The government’s declared ambition is to roll out 160 CDCs across the country by 2025 to increase capacity by 9 million tests, checks and scans a year, with the programme “backed by” the same £2.3 billion of diagnostics investment. So far the annual total of tests increased by 10.3% in the year from April 2022, to 18.8m per year. But to increase by 9 million would require a further 38% increase (7.2m) – a massive target – well beyond the scope of the remaining 43 that have not yet been announced.
A King’s Fund Briefing warned last autumn that there may not be enough skilled staff to run both the new centres and pre-existing facilities: “Moreover, without a diagnostic workforce strategy, staff shortages and skills gaps may undermine the additional community capacity that the centres are aiming to create.”
The problem is all the greater because the one thing the private sector, with its focus on profit, is consistently worse at than the NHS is recruiting and retaining staff. This was behind the collapse of community health service contracts and the ignominious failure and premature abandonment of the privatisation of management of Hinchingbrooke Hospital.
After 13 years of real terms cuts in funding, the NHS lacks capital for buildings or equipment. So the possibility of renting some facilities from the private sector might make some sense as a short-term expedient. But getting the private sector to staff and run the services – inevitably recruiting staff from the same shallow pool the NHS relies upon – makes no sense at all.
In July last year, the Royal College of Radiologists raised concerns about staffing levels, highlighting that their 2021 Workforce Census had identified a shortfall of 30% (1453) clinical radiologist consultants and 17% (163) clinical oncology consultants in England. The Society of Radiographers (the staff who take the X-rays and administer radiotherapy) which has been engaged in strike action over pay, is also concerned at staff shortages, and there is a chronic shortage of scientific staff.
Deputy chief executive at NHS Providers, Saffron Cordery, while accepting the increased reliance on the private sector, has also warned that an increase in diagnostic capacity has to be matched by increased capacity across the health and care system to deliver the treatments patients need once diagnosed. This is lacking.
She also urged the government to give the NHS “the capital funding it needs now and in the longer term to expand its own diagnostics capacity amid a backdrop of growing patient demand.”
Given their prominence in the news, it may be surprising that the CDCs are not even the main event in the skimpy, repetitive 10-page taskforce report . Much of its focus is on ways of using so-called “patient choice” to persuade more patients to choose private hospitals or clinics for their elective treatment.
As the report’s introduction (signed by Minister Will Quince, NHS England director Sir Jim Mackey … and IHPN boss David Hare) puts it, the hope is to: “speed up the treatment of patients by championing their right to choose where and when they are treated. Our expectation is that these measures will quickly play a key role in increasing the use of independent sector capacity …”
The taskforce proposes various measures to crank up the pressure on patients and their GPs to choose private providers, who we know are desperate to fill large numbers of empty beds as the cost of living crisis and high costs of private care limit the numbers able to afford to ‘self-pay’ – even as the waiting list soars to 7.5m. The private sector has said it has capacity to do an extra 30% of the work it was doing for the NHS before the pandemic.
It calls for improvements to the online electronic referral system, and for all patients needing elective care to be offered a shortlist of a minimum of 5 providers (“where clinically appropriate”). This is almost identical to controversial New Labour proposals almost 20 years ago.
NHS England is also apparently developing a new patient-initiated Digital Mutual Aid System (DMAS) that will enable patients to request to move provider:
“From the end of October 2023, all patients who have waited more than 40 weeks without having had their first outpatient appointment will be able to initiate a request to transfer to another provider.”
There will be a “patient-facing comms campaign” starting from August 2023 to “ensure patients know about their right to choose and how to exercise it,” and DHSC, with NHS England support, will “update the NHS Choice Framework to help patients understand the choices available to them in the NHS.”
Nowhere is there any recognition of the limited size and scope of private hospitals, which mean that if too many NHS patients are persuaded to choose them they too will inevitably begin to build a waiting list and delay treatment.
The taskforce repeatedly reiterates the claim that the backlog was “caused by the pandemic,” although all the evidence points to a chronic shortfall in NHS capacity as a result of 13 years of under-funding.
It looks to remove “obstacles to new providers offering healthcare services,” and reinstate what was then called the “payment by results” (cost per case) system of funding that was introduced by New Labour in the mid 2000s to facilitate the diversion of funds from NHS to private providers.
The new proposal is for: “a return to paying according to the amount of elective activity delivered to allow integrated care boards (ICBs) to move elective activity across providers, including to independent sector providers.”
New guidance has just been issued by NHS England “ensuring commissioners operate in compliance with their obligations in line with current legislation,” while aiming “to revise patient choice legislation and establish the Provider Selection Regime (PSR) in 2023,” – all to make it easier to refer patients to private providers and harder not to:
“the PSR will be a new regulatory regime to govern the procurement of healthcare services in England. This is intended to improve avenues for providers who are suitably qualified to deliver clinical services.”
Ominously, the taskforce also seeks to establish a new so-called ‘independent panel,’ which will “review compliance with patient choice and PSR requirements”: effectively acting as enforcers to badger commissioners, GPs and trusts that fall short of the expected level of referrals to private providers.
The NHS workforce plan is effectively redefined as a plan to ensure “the NHS and independent sector has access to a sustainable workforce”. And in what could be an important move towards the further exploitation of junior doctors, there is a proposal to extend the limited amount of “training” of junior doctors in private hospitals which have contracts for a substantial volume of NHS patients.
This is one reason NHS England are developing the ‘NHS Digital Staff Passport’, which will go live in December 2023 – a verified virtual record of a doctor’s training and occupational health records – “reducing the administrative burden of moving between providers.”
In addition the ‘doctors in training’ group, which for some reason comprises the IHPN, NHS England and the Royal Colleges “will continue to ensure barriers to junior doctor movement are minimised.”
The NHS has also just started publishing regular data on independent sector use “showing the independent sector’s contribution to tackling the backlog.” Despite all the evidence that their aim is to divert the least complex elective patients from the NHS to private providers, the taskforce report claims:
“This [data] will also help to ensure that independent sector activity is additional rather than displaced NHS activity.”
In fact the data so far underlines what a minor and insignificant role the private sector has played in delivering patient care. They show that in the year to April 4 2023, private hospitals treated just 105,000 NHS-funded elective in-patients and 650,000 day cases, and delivered 665,000 diagnostic tests and procedures.
By contrast England’s NHS in the most recent statistics (2021-22) treated 7.9 million elective in-patients, 6.8 million day cases, 6.2 million in-patient emergencies and 17million diagnostic tests.
IHPN boss David Hare, in an article on the 75th Anniversary of the NHS tried to justify a greater role for the private sector. But he admitted (as the Lowdown has shown from ICB Board papers) many NHS managers, facing tight financial constraints, have been looking for ways to reduce rather than increase their reliance on the private sector:
“IHPN recently conducted a survey among our members, looking at engagement with the NHS planning process for 2023/24. 60% of respondents reported being asked by their local NHS to do the same or less activity as in 2022/23.”
He goes on: “I understand the reasons. Of course it’s understandable that NHS trusts – themselves under extraordinary financial pressures – want to retain work. However, we also need to ask – with 7.4m people on the waiting list – and with more than 300,000 people having waited more than a year – are we pulling out all the stops? Are we doing everything we possibly can?”
Mr Hare, of course, wants us to ignore the costs and consequences of NHS reliance on private hospitals:
- the small scale and limited scope of private hospitals (average size 45 beds);
- the fact they can handle only the least complex cases – limiting the numbers of NHS patients for whom their hospitals are “clinically appropriate”, and leaving the NHS with reduced resources to deal with the most complex, costly and difficult cases;
- the fact that private hospitals can only expand their work by recruiting staff from the same inadequate pool of qualified staff as the NHS;
- and the fact that diverting all the least complex cases (and the funding for them) to the private sector dislocates the training of doctors, which is the responsibility of the NHS, and requires a varied case mix to equip tomorrow’s specialists to deal with the full range of the NHS caseload.
In other words using apparently “empty” or “spare” capacity from the private sector not only lines the pockets of their shareholders, but comes at a heavy price to the NHS.
The most logical and efficient way to expand capacity in health care in England is to expand the NHS, not divert vital resources, staff and funding, into small-scale, profit-seeking private businesses.
While the government may be able to push through the proposed changes in legislation before the next election, and make use of the desperate shortages of capacity they have created by years of underfunding to effectively force more referrals to private hospitals, this blatant move to undermine the NHS and boost the private sector should be a major focus of the election campaign, along with the dire consequences of 13 years of austerity funding and neglect.
Any incoming government committed to the values of the NHS should commit to reversing such changes, and properly funding the NHS instead of diverting funds and staff to prop up a parasitic alternative.
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