The (£ paywalled) Times has reported that one of the outcomes of Rishi Sunak’s controversial taskforce on boosting NHS contracts with private hospitals will be a new push to persuade patients to use the NHS app to “book private healthcare.”
Of course the right for elective patients with sufficiently minor conditions to “choose” their elective provider, including private hospitals working on the NHS tariff, is not new. It was established back in the mid 2000s by Tony Blair’s government.
Even then the notion of “choice” was deceptive, since most patients needing healthcare preferred to be able to access prompt, safe treatment in their local NHS hospital, which was not the kind of choice New Labour was promoting. Recent Health Foundation polling confirms that local NHS care is still the preferred option for most people.
New Labour wound up resorting to threats to in their efforts to push patients in to unwanted, newly-established “independent sector treatment centres” which had been established by the Department of Health over the heads of local commissioners, and which many patients preferred not to use.
What is new is today’s heavy focus on using the NHS app which, since Covid, large numbers of patients now have on their phones, as a means to increase use of private hospitals.
There were no apps available in the 2000s: and Blair government’s costly experiments with use of private providers took place in the context of a decade of rapid real terms increases in NHS spending, which was always the decisive factor in expanding NHS capacity and reducing waiting lists.
By contrast Sunak’s latest efforts to steer more patients and funds into the private sector comes after 13 years of real terms cuts in NHS funding, and at a time when up to 20% of the reduced number of NHS front line general and acute beds are tied up with Covid patients (3,550 on May 17) and patients who are medically fit but cannot be discharged for lack of social care and community health services.
Given this lack of NHS capacity Tory ministers who have run down the NHS to this level now seem to believe that encouraging more patients to choose private providers will somehow reduce the record 7.3 million-strong waiting list. It seems from his recent statements that Labour’s Keir Starmer also believes the same, and the policy is now cited by the right wing press and the Independent Healthcare Providers Network as a “cross party consensus”.
Flawed plans
But it won’t work. The evidence from NHS experience, and from recent similar moves in Canada (see box – below) is that this approach does not deliver. Even the Times’s Chris Smyth points out that
“The evidence that choice itself makes a difference to waiting lists is largely inconclusive. Patients have been sceptical, asking why they should be expected to shop around when they just want a good local hospital.”
Richard Murray, CEO of the King’s Fund also raised concerns, telling the Times: “Patients having a choice over where they are treated is a good thing, but I don’t think this is the thing that is going to turn the dial on waiting lists.”
A recent Health Foundation report has also warned that use of the private sector can only have a “limited impact” on tackling things like NHS backlog, and cannot solve other issues such as the spate of different workforce-related challenges and general underfunding.
Nor of course is the private sector any help to NHS trusts dealing with continued delays in treating the most serious emergency cases.
The Health Foundation report is focused on private sector provision of NHS-funded ophthalmic and orthopaedic care, which have seen the greatest growth in independent provider activity. It notes that the overall number of NHS-funded treatments has only just recovered to pre-pandemic levels.
‘Independent Sector Providers’ (ISPs) delivered 8.7% of these treatments – a 1% increase from before COVID-19. But the private sector share of ophthalmic care procedures almost doubled to nearly four in 10 (38.6%) in February 2022 compared with 23% before the pandemic. The report explains:
“This suggests the delivery of cataract procedures is both highly amenable to scaling, and attractive to ISPs – which isn’t true of other procedures we’ve explored through this analysis.”
In many areas cataract referrals are direct from high street opticians, and several Integrated Care Boards are now concerned that this has led to them overspending on tight budgets.
The report also notes the increased share of orthopaedic operations carried out in the private sector to almost a third (31.2%) of inpatient orthopaedic care in February 2022, up from around a quarter (26.8%) before the pandemic.
However even the Times report trumpeting Rishi Sunak’s latest effort to increase the use of private providers notes that “the private sector performs about 140,000 procedures a month paid for by the NHS out a total of 1.5 million [i.e. 9.3%]. There are questions about how far this can be scaled up.”
This is especially true given the limited size of private hospitals (average size 40 beds) and the limited facilities available, which means they cannot take on more complex cases – all of which wind up waiting for the limited number of available NHS beds.
The NHS Confederation in December pointed out some of the gaps and weaknesses in private sector provision, noting that both the NHS and private sector “are recruiting from the same pool” of qualified staff, so any growth of the private sector inevitably undermines the NHS. It went on:
“the independent sector will not have the capabilities, workforce or capital to take on the cases which are more complex in nature and acuity.
“The NHS will likely be left with the more complex and costly procedures to carry out because of the expertise and infrastructure needed. People on waiting lists, many of whom have been waiting several months, have deteriorated in their health and will need more complex care than they did when they first joined the waiting list. Due to this, these patients will not have the choice to use the independent sector, and this further complexity of care means health inequalities worsen.”
NHS Providers also warned:
“Trusts have mixed views about the use of the independent sector in tackling the waiting list. Firstly, private sector provision is not uniform across the country and therefore access to the independent sector isn’t always available. There is a concern that a reliance on the independent sector could further widen health inequalities as independent sector provision is more likely to be present in affluent areas. […]
“The role of the independent sector is limited … Independent sector provision largely covers high volume, low complexity cases as most independent sector providers do not have intensive care capacity. Therefore, independent sector provision can only really accommodate low risk patients.”
There is also a financial cost, since money paid to the private sector cannot be used to develop NHS resources, and flows out of the NHS, often lining pockets of shareholders here and overseas.
Only recently the Health Service Journal reported private sector bosses calling for an increase in the rates they are paid for treating NHS patients, and threatening to “turn away” from NHS work if they don’t get a big enough increase – which would destroy the argument that private provision costs the NHS no extra money.
Even without any preferential tariff increase for private providers the recent Health Foundation report warns:
“ISP activity is ultimately funded from an NHS budget already stretched by high inflation and other cost pressures. Against a backdrop of an imperative for ICSs to cut costs and deliver financial balance, it may be challenging for the NHS to fund a substantial increase in ISP activity even where genuinely additional capacity to treat more patients is present.”
In evidence to the Commons Public Accounts Committee (PAC) last December, the Health Foundation also questioned how much of the activity delivered by private providers is genuinely additional, rather than simply privatised delivery of services that NHS hospitals could have done. The PAC itself clearly agreed, and decided to write to NHS England, calling on it to write to it to explain
“the extent to which these initiatives [purchasing care from private providers] have so far generated genuinely additional activity, rather than simply displacing activity elsewhere in the NHS.”
The latest reported proposals from Rishi Sunak raise another question: just how much capacity is currently unused in the private sector?
There have been claims from the Independent Healthcare Providers Network and the Private Healthcare Information Network that business is booming, with individual firms claiming phones ringing off the hook.
But if they really were that busy with paying customers, why would the private hospitals be so eager to turn away potential private punters and take NHS patients instead?
In fact the private sector’s hype about soaring numbers of self-pay patients (a large percentage increase on a very small number) and the grossly inflated claims about the growth in private GP services conceal a stagnant market for private health care, that has barely recovered to pre-pandemic levels of activity, and has yet to make any of the expected gains from the huge growth of NHS waiting lists.
The message for some time from the private sector has been that they have received far fewer NHS patients than they expected from the generous 4-year £2.5bn per year framework contract that was signed with NHS England in 2020 as a means to enable the NHS to reduce waiting lists after the peak of the Covid pandemic.
Labour politicians in particular have pinned their hopes on tapping into unused capacity in private hospitals, with Wes Streeting delighting private bosses with his assertion that “Labour would use the spare capacity in the private sector to get patients seen faster … If the Conservatives had got their skates on, almost 300,000 patients could have been treated, off the waiting list, and back to living their lives to the full.”
Last December the Telegraph reported private sector sources themselves arguing how much of their capacity is under-used. The obvious reason is that people who might consider going private can’t afford the hefty charges.
That’s why private health bosses have been appealing for the NHS to fork out the money to fill these empty beds, claiming “The network’s estimates suggest private hospitals have enough spare capacity to carry out around 30 per cent more NHS-funded activity than they were allocated before the pandemic.”
Private beds may indeed be empty, but with large numbers of NHS trusts carrying eight-figure deficits from last year, and battling to keep services intact as Integrated Care Boards seek endless “savings,” it’s not likely that many NHS bosses will be too keen to funnel more cash into the greedy hands of the not-so-independent sector.
Harsh lessons from Alberta for British politicians: privatising surgery brings reduction in services and longer queues
An important new report has exposed the sorry failure of policy in Alberta in Canada, where the right wing provincial government in 2020 announced it would spend $400 million outsourcing surgical services to for-profit facilities, and committed to doubling the number of outsourced surgeries over three years, from 15 per cent to 30 per cent of total surgeries province-wide. This seems to closely resemble the “cross party consensus” policy proposed in England … but goes far further than New Labour’s experiments in 2005-2010.
“Three years later the report has found that Alberta has among the worst performance in reducing surgical wait times in Canada. The province has prioritized for-profit surgical delivery rather than system improvement, leaving nearly 30 per cent of public sector operating room capacity unused.
Contrary to government claims that outsourcing to for-profit facilities increases provincial surgical capacity, data suggest that the expansion of the private sector’s ‘chartered surgical facilities’ (CSFs) has diverted resources away from public hospitals and, in turn, reduced provincial surgical volumes.
Investor-owned surgical facilities have been expanding through substantial contracts with the government. Between 2018-2019 and 2021-2022, surgical volumes in chartered surgical facilities increased by 48 per cent while surgical activity in public hospitals declined by 12 per cent.
Surgical outsourcing has come at the expense of public hospitals and undermined efforts to reduce surgical wait times over the long term, especially for patients requiring complex surgeries only performed in the public system.
The report, Failing to Deliver, also shows the disproportionate private sector focus on quick and simple cataract surgery, leading to an improved province-wide performance under the Alberta Surgical Initiative, while performance has fallen back for more complex hip and knee replacement surgery, and the province’s total surgical activity declined in the first three years of the ASI.
And it highlights more generalised problems with contracting out surgical services: in a period of growing staffing shortage the private sector is able to offer incentives such as reduced workloads, less complex patients, and higher pay to attract workers from the public system. As a result, surgical activity in public hospitals has declined while for-profit facilities focus on lower-complexity procedures, destabilizing the public hospital system.
“Over time, entrenching for-profit providers also reduces the public system’s ability to negotiate prices with private providers.”
It also argues that when surgical care is provided by a for-profit facility, medical decision-making is much more susceptible to conflict of interest, potentially leading to inappropriate surgeries and diagnostic testing – and diverting resources from patients with greater levels of need.
And, as British researchers have pointed out, evidence shows that private, for-profit health-care delivery is generally less safe and provides lower-quality care than public sector care where the profit motive is excluded.
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