Waiting list policy reset makes things worse

Health secretary Wes Streeting has said some patients’ experience of the NHS this winter makes him feel “ashamed,” and he had seen patients left crying and distressed and stuck in corridors as hospitals struggle to cope.

But his comments are less convincing coming as they did the day after Keir Starmer made a big speech that ignored the crisis in emergency services. Instead, it focused on yet another lowering of Labour’s ambitions for ‘change’ and revival of the NHS.

Despite their massive parliamentary majority and their previous promises, the Starmer government has opted to focus only on a gradual reduction of the waiting list and waiting times – by 2029 – and decided not to tackle any of the other glaring problems that are currently grabbing media headlines.

Aside from the warnings from NHS management bodies and front-line professionals of the very real problems and pressures they face right now, the political wisdom of Starmer’s approach is questionable.

Something old, something borrowed

Little of what he had to say was new: indeed much of it simply adopts the policies already implemented by the various Tory governments since 2021, especially the focus on Community Diagnostic Centres (CDCs) and surgical hubs.

The focus on delivering relatively small reductions in the waiting list in the next two years is unlikely to impress many health workers, patients, campaigners or an increasingly sceptical public concerned by very visible problems in emergency medicine, mental health and crumbling hospitals.

Moreover, the way the government is going about this is not the logical route of expanding the NHS itself – which provides the overwhelming majority of elective as well as emergency and diagnostic services – but through a new agreement with the private sector, committing to long-term contracts for treating NHS patients.

It appears that Starmer and Streeting have allowed their ideological attachment to the notion of the private sector as a “partner” of the NHS to override common sense and practicality.

Fragmenting the already under-staffed NHSD workforce into smaller scattered units is a recipe for inefficiency and chronic staff shortages, and diverting more patients with the most minor conditions to private sector providers means diverting more money and staff away from the main NHS providers which have to cope with the full spectrum of health needs.

By September last year, NHS England announced 165 CDCs were already “operational” in a variety of settings “including shopping centres, university campuses and football stadiums.”

Some of these are privately-delivered and run, or run jointly with the private sector, although precise numbers are hard to find. Last summer the Independent Healthcare Providers Network (IHPN) complained in a report that

“Despite initial thinking that the independent sector would be substantially involved, the actual numbers show that fewer than 7% of CDCs (13) have extensive independent sector involvement.”

The IHPN explains more fully how limited the private sector role has been: “Of the 203 CDCs, we understand that, to date, only 13 are (or due to be) run by an independent sector provider, with a further 26 having meaningful sector involvement. In addition, a proportion of the “new” CDCs that are run by an independent sector provider are “rebranded” existing services that predate the CDC programme. There are a larger proportion of CDCs which have some independent sector involvement, but they tend to be providing mobile diagnostic capacity alone.”

The IHPN notes that the CDC programme, alongside other hospital investment, originally aimed to increase diagnostic capacity by a further 9 million a year (35%), hoping to increase overall capacity to approximately 35 million tests per annum.

So far the latest figures show NHS delivery increased by over 30% from 23.5m in the 12 months to November 2019 to 30.6m in the 12 months to November 2024. The private sector role remains at best marginal.

However the requirement that a CDC “must be located away from other acute hospital services on a separate site” raises real questions over the availability and affordability of the staff required to deliver the services required, which include as a minimum CT, MRI, Ultrasound and Xray – for which radiographers and radiologists are needed.

In November the Royal College of Radiologists warned of “a stark 31% shortfall in clinical radiologists” (the consultants who read the images), while the Society of Radiographers (SoR) who take the images reports:

“a chronic shortage of radiographers – the average vacancy rate for radiography is 15 per cent, which means that some departments’ vacancy rates are much higher. A recent survey of our members revealed that 83 per cent could only fill their departmental roster with regular overtime shifts, because of staff shortages.”

Lack of radiographers means MRI and CT scanners stand idle for parts of the week. The SoR points out that:

“In 2020, the Richards Report into diagnostic services for NHS England stated that staffing CDCs would require an additional 4,000 radiographers. However, while the new CDCs came with a budget for equipment, there was no additional budget for staffing.”

In some cases the less stressful elective caseload of CDCs might even prove more attractive than pressurised hospital environments and wind up drawing vital staff away from hospitals. The SoR notes: “CDCs have therefore had to draw on the existing radiography workforce to fill posts – leaving hospital acute departments chronically understaffed as a result.”

The staffing issues will not be made any easier by Starmer’s insistence that the CDCs will be expected to open for 12 hours a day seven days a week “wherever possible.”

Moreover, the usefulness of these new centres, further fragmenting the NHS workforce, is not immediately obvious: the HSJ has reported only 10% of CT and MRIs are done in CDCs, and progress in rolling them out has been “slower than hoped.”

Private sector role

Lowdown readers will be aware that our new year overview article published three days earlier had noted “the much lower profile Streeting has recently given to his mantra in opposition about greater involvement of the private sector as the key to reducing NHS waiting lists.” Obviously, that silence has now been broken by Starmer’s statement.

The plan is focused on the controversial, costly and counterproductive increase in the use of the private sector rather than investing in expanding NHS capacity.

A new agreement has been made with the so-called “independent sector,” which turns out to be increasingly dependent upon NHS contracts and, of course, on NHS-trained staff.

The DHSC press release notes that the new agreement will:

• “work on aligning NHS and independent sector digital systems around a national set of standards so patients can more easily see appointments and results on the NHS App”
• “encourage longer-term contractual relationships to be established, enabling further independent sector investment in NHS capacity,” and
• “work together to grow and develop the elective workforce, including ensuring training occurs consistently in the independent sector.”

While the impact of the NHS App changes remains uncertain, especially given the uneven distribution of the private sector capacity, and its concentration in more prosperous areas, the prospect of the NHS signing up to long-term contracts in order to get the private sector to build new, private sector capacity and guarantee their profits is obviously a major step backwards.

The danger is that the NHS would become permanently dependent upon private sector provision of an even larger share of elective work, with depleted NHS resources and a fragmented workforce attempting to cope with the entire burden of more complex elective work along with all of the emergencies, maternity, paediatric services and the vast majority of chronic ill health.

Similarly the agreement to allow the private sector to play a role in the training of doctors seems certain to distort that training (since the majority of private hospitals are small-scale (averaging 50 beds) and with a completely atypical caseload. It is clearly aimed at creating the illusion of a single “elective workforce”.

Going further than the Tories

However, the new Agreement with the private sector is even more worrying. It proposes to go much further than the Tory government’s 2022 Health and Care Act by committing to include the private sector in local NHS planning and decision-making – something Tory ministers were willing to rule out. It states:

“Independent providers are an important part of NHS systems and should be involved in planning local services. This includes planning services based on knowledge of available local capacity and commissioning services from a range of providers, both NHS and independent, across the whole care pathway. …” (2.1)

It goes on to agree that:

“The independent sector and NHS will work together closely to enable further independent sector capital investment to support future growth in NHS diagnostic and elective capacity, building on the successful collaboration on community diagnostic centres.” (2.3)

The agreement also includes an impossible requirement: that the private sector expand its activity without requiring more of the same qualified staff required to keep NHS services running:

“Independent providers should ensure that capacity offered to the NHS provides additionality to system capacity and is capable of being staffed without having a material impact on the existing local NHS workforce.” (5.3)

The agreement pretends that this can be resolved through amending NHS training programmes and “training opportunities” in the private sector:

“NHS England will establish plans with national and local professional NHS trainee programmes to provide them with access to training within the independent sector. Independent providers will provide access for training opportunities where appropriate and required in line with the NHS Standard Contract.”

This will not be enough to prevent a further loss of crucial staff from the NHS to private providers if their caseload is increased as planned.

And the whole plan is a high-stakes gamble: as the Commons Public Accounts Committee found in its March 2023 report Managing NHS backlogs and waiting times in England  there are real doubts as to whether – especially in the absence of any additional funding –  the use of private providers will genuinely increase the numbers treated, or merely displace treatment from the NHS to the private sector.

Delighted private providers

David Hare, Chief Executive of the Independent Healthcare Providers Network (IHPN) is obviously delighted that:

“This new agreement is a clear statement from government, the NHS and independent sector that independent providers are a critical part of the NHS’s long-term recovery and renewal,”

and that the new agreement “supports the [private] sector to invest in, and deliver, an even wider choice of high quality services to NHS patients to bring waiting times down.”

He also claims that all services will be “delivered free at the point of use and paid for at NHS prices.”

But even as he said this the Health Service Journal revealed that NHS England is to carry out “a wide-ranging review of how elective care is paid for,” noting that system leaders want to use “pricing changes to incentivise providers to clear backlogs in the most troubled specialties, such as gynaecology and ENT….”

So “NHS prices” could well wind up being higher – as an extra benefit to profit-seeking private providers, while the NHS budget remains unchanged, meaning any increase for some treatments would mean cutbacks elsewhere.

Other problems

There are other problems with the new Labour policy, which is almost indistinguishable from the previous Tory policy. It gives no indication of the costs involved, the timescale for increasing the number of appointments taken on by the private sector, or the length of contracts required to secure the private sector investment in expanded private sector capacity. It is a real pig in a poke: we don’t know what the NHS would receive or how much it would cost.

It also appears that the proposed ‘review’ would also continue the bad old tradition of heaping rewards and ‘freedoms’ on the most successful trusts, while those which are struggling the most to cope are penalised or simply left behind. Far from offering any real alternatives for patients living near struggling hospitals, these plans are likely to widen the ‘postcode’ inequalities in timely access to treatment.

The Starmer government has, as widely feared, dragged us ‘back to the future’, reviving one of the least successful and most wasteful policies pioneered by New Labour in the 2000s. But Starmer’s big speech has answered none of the arguments why turning to the private sector is a big and costly mistake.

The Lowdown, NHS Confederation, NHS Providers and many others have pointed out the private sector is only geared up to treat the least complex elective cases, so diverting already inadequate NHS funds to make greater use of these services would leave many on the waiting list with more demanding needs waiting even longer for limited NHS capacity to become available.

The proposal for the private sector to take an additional one million appointments on top of the five million or so appointments and treatments it is currently providing each year represents a 20 per cent increase.  Increasing by this much would represent a massive expansion in patient numbers compared with recent years, which have seen a 14% leap from 4.4 million in 2022 to 5 million in 2023, but a more modest projected 4.7% increase to 5.26m in 2024. We don’t know how long such a major expansion might take.

While no financial details have been revealed, the Guardian analysis speculates that if the amount spent on private providers is increased proportionally from the latest total (£12.3 billion in 2023/24) it could add up to an extra £2.5 billion flowing out of the NHS into the private sector.

But this would mean a staggering average cost of £2,500 for every appointment. The latest private sector data shows at least two-thirds of the NHS-funded patient caseload is for outpatient appointments, which should cost nothing like as much, with inpatient treatment averaging 15,000 per week (780,000 per year).

Making things worse

While this news is all good for the private sector, which can be guaranteed the caseload to fill up its empty beds and spare clinic sessions, the removal of funding on anything approaching this scale will massively worsen the financial plight of NHS trusts, many of which are already deep in the red.

In short, the Starmer/Streeting plan seems set to make things worse for much of the NHS and make precious little difference to the waiting times and even less impact on the growing public perception that the NHS is continuing to decline.

The focus on cutting waiting lists through private providers will undermine other core aspects of the NHS:

• It does nothing to tackle – and by diverting staff and funding could even delay – the more complex cases on the waiting list, which only the NHS is equipped to treat
• The manifesto focus on improving cancer care (and specific pledge to double the number of cancer scanners) appears to have been dropped
• The expansion of diagnostics, if not linked with the expansion of clinical capacity to deliver treatment, could even make the situation worse for some patients
• The new plan does nothing for the beleaguered emergency services
• Nor does it address the massive gaps emerging in mental health care
• The focus on securing private finance to expand elective care leaves unresolved the running sore of the growing £13.8 billion bill for NHS backlog maintenance and the need to rebuild the worst-affected hospitals built with defective RAAC concrete

The end result, even if the plan succeeds in its immediate aims, will be a stronger private sector at the expense of a weaker NHS. That was certainly not in the manifesto.