One of the most serious affects of outsourcing in the NHS that has been observed is a decline in quality of care and safety issues. Quality and safety are linked and have been found to decline for a number of reasons, often related to the need for a private company to make a profit from a contract with the NHS. These are some examples
A decline in quality has been associated with the outsourcing of GP contracts to private companies. The most recent example is of the Sutherland Lodge practice in Chelmsford, Essex, which was taken over by Virgin in July 2016 after the previous partners handed back their contracts following £400,000 funding cuts to their contract. Prior to the takeover, the practice was rated outstanding, but in May 2018 the Care Quality Commission (CQC) rated the surgery inadequate overall. The rating is based on an inspection carried out in December 2017 just 18 months after Virgin Care took over the practice. Virgin Care also received more money for the contract than the previous GPs.
Under Virgin Care the CQC rated Sutherland Lodge inadequate on four of the five key measures – the safe, effective, responsive and well-led categories – and rated it “requires improvement” in the “caring” category. The practice has been placed in special measures and if improvements are not made within six months Virgin Care could be stripped of the 10-year Alternative Provider Medical Services (APMS) contract it was awarded to run Sutherland Lodge.
There are also concerns over the way Virgin runs another GP practice in Essex; in October 2017 Nicholas Challen made an official complaint to NHS England about the treatment of his father prior to his death. He told the local newspaper that in his view “Virgin are running the surgery as a standalone profit centre, and cutting corners to make the numbers work rather than a public service, fit for purpose.” In February 2014, the CQC criticised Virgin Care over its use of non-medically trained receptionists to assess patients in its Croydon Urgent Care centre. CQC inspectors found the centre was in breach of four basic standards of care.
In April 2015, two surveys were published which indicated that private providers deliver poorer GP and out-of-hours GP services. Researchers at Imperial College London found that private sector and other alternative providers of GP services to the NHS do not do as well as traditional GP practices.
The research found that these providers perform worse than typical surgeries on 15 of 17 key indicators – such as patient satisfaction, diabetes control and keeping patients out of hospital. In the second study, researchers at the University of Exeter Medical School, found that private providers of out-of-hours GP services deliver poorer care than NHS alternatives. The findings were based on 900,000 responses to the 2012/13 GP Patient Survey: NHS providers scored highest on timeliness, patient confidence in doctors, and overall care experience.
Mental Health Services
This sector has seen a number of scandals surrounding safety breaches in non-NHS facilities taking NHS patients. It is also a sector where it is evident that making a profit is paramount to the detriment of the patients’ care and safety.
In November 2018, The Times published a damning article exposing the companies and charities that make millions by providing substandard mental health services to NHS patients. The article included one case where the directors of a psychiatric hospital that was found to provide substandard care by the CQC, had paid almost £25 million into a secretive trust in Belize. The article noted that the company had received £26.3 million for services over 18 months in 2016-17 from NHS contracts.
Another case highlighted by The Times investigation was the charity St Andrews Healthcare which paid its chief executive, Gil Baldwin, £496,000 before he left in 2017, and 76 employees salaries of more than £100,000. The charity’s facilities included a private hospital where a 17-year-old girl was locked in a cell-like room with only a mattress and chair and passed meals through a hatch in the door. Three psychiatric services run by the charity, and its overall services, had been judged in need of improvement by the CQC.
In November 2017, the CQC published a report on independent residential rehabilitation units treating drug and alcohol addiction. The report concluded that people are being put at risk of harm by many of these services.
The CQC’s investigation found that nearly three-quarters of private clinics were failing to hit regulatory standards of care. The CQC inspected 68 independent services providing residential detoxification services over the last two years.
Over the last two years, the CQC has required 49 providers to make improvements because they had breached regulations of the Health and Social Care Act 2012 and failed to meet fundamental standards of care.
In addition, the CQC took enforcement action against eight providers and 41 providers breached two or more regulations and 25 breached three or more.
Hospitals run by the Huntercombe Group have received particularly critical reports after inspections by the CQC. In 2016, its hospital in Stafford was placed in special measures and told to urgently improve in 24 areas. In September 2017, Watcombe Hall, was closed indefinitely after the local NHS hospital raised concerns about the number of young patients being admitted from the unit suffering from malnutrition and dehydration. In December 2018, an inspection by the CQC of the company’s hospital in Norwich found serious concerns. The CQC took immediate action to protect those using the service, including enforcement action to remove the registration for the hospital. The Huntercombe Group then closed the service and the children and adolescents had to be found places elsewhere.
In July 2018, a mental health unit run by The Priory, one of the UK’s leading private mental health services companies, in North London was found to be ‘inadequate’ for safety by the CQC. It outlined particular concerns about the child and adolescent wards, including the presence of ligature points in child and adolescent ward bedrooms which had led to serious incidents including a child dying after hanging themselves with a bed sheet. Other safety issues were inadequate staffing levels and staff that did not understand what constituted restraint, a slow response to emergency alarms and call buttons and a lack of leadership.
In 2017, three sites run by the private provider Cygnet received highly critical ratings from the CQC. By February 2018, the company had had to close most of its beds in the south east and admissions to the two CAMHS wards at its Godden Green unit near Sevenoaks, were restricted to just eight, down from 24, and the CQC took enforcement action. It issued three warning notices and fixed penalty notices for failing to make “required notifications” of patient safety incidents.
Long-term care, including care homes and home care, is dominated by private companies. Over the years there have been numerous reports of safety issues in care homes and home care. The most notorious being the Winterbourne View case exposed by Panorama in 2011. In November 2018, an investigation by The Guardian found that “some of the country’s worst care homes are owned by companies that have made a total profit of £113m despite some of the vulnerable people they are supposed to look after being neglected.” CQC reports into the homes list various failings in care and safety issues.
The first case that really highlighted the problem with quality when NHS services are outsourced was that of Hinchingbrooke hospital, the running of which was outsourced to private company Circle in 2012. The contract hit the headlines in January 2015, when after only two years of a ten year contract, Circle announced that it was pulling out. The announcement came just before the publication of a damning report on the hospital from the Care Quality Commission (CQC): the CQC raised serious concerns about care quality, management and culture at the hospital.
The CQC found a catalogue of serious failings at the hospital that put patients in danger and delayed pain relief. The hospital was put in to special measures, the first time the CQC has had to do this. Circle cited financial considerations when announcing its withdrawal, but conceded that the report had also been a factor in its announcement.
Circle was also the private provider involved in the privatisation of Nottingham’s dermatology service, which in June 2015, was described by an independent report as “an unmitigated disaster”.
Private hospitals are being increasingly used to perform operations paid for by the NHS; around 500,000 per year. However, the safety and quality of care that patients receive is not always adequate, according to an investigation by the Centre for Health and the Public Interest (CHPI).
In its report, CHPI addresses some of the systemic patient safety issues in private hospitals. These include:
- Post-operative care in private hospitals is usually carried out by inexperienced junior doctors who are working excessively long hours;
- The consultant who carries out the surgery and who is responsible for the patient is permitted to be off-site;
- Nature of this post-operative care has been cited as a factor in a number of patient deaths;
- Lack of intensive care facilities means if something goes wrong then patients have to be transferred back to NHS hospitals, which in itself is very dangerous;
- Data on patient safety in private hospitals is poor and they aren’t required to make this information public in the same way as NHS hospitals are.
In another report, the CHPI also documents the safety issues in private hospitals following the scandal whereby surgeon Ian Paterson wounded 500 women who underwent unnecessary breast surgery in private hospitals. They conclude that until the private hospitals have full liability for the patients under their care, then there will be no guarantee of safety.
The CQC produced its own report in April 2018 prompted by the scandal of the surgeon Ian Paterson. The CQC’s conclusion included that the informal arrangements between surgeons and doctors and private hospitals is a “major concern” which could put patients at risk and that there was “substantial variation in the quality and effectiveness of governance arrangements and a number of examples of poor practice”.
The CQC warned: “There is a real danger that poor practices are not picked up or challenged in the way they should be. This can have a significant impact on the safety of services, in particular where familiarisation and subsequent informality in processes may mean that systematic and robust safety procedures are not sufficiently in place to protect patients from harm.”
There have been issues with care and safety in private hospitals for some years; in June 2013, the NHS temporarily stopped referrals to BMI Healthcare’s Mount Alvernia hospital, in Surrey, following a CQC report which found serious failings on patient consent, care, cleanliness, staffing levels and service quality monitoring. The report noted some staff had told inspectors breaches had been caused by initiatives designed to “save money” or for “logistical and financial reasons”.
Then in 2014, there were two cases of problems with quality and safety in the area of cataract operations, a routine operation frequently outsourced to the private sector. In Somerset, dozens of people were left with impaired vision, pain and discomfort after undergoing operations provided by the private healthcare company Vanguard Healthcare under contract with Musgrove Park Hospital, Taunton. The hospital’s contract with Vanguard Healthcare was terminated four days after 30 patients, most elderly and some frail, reported complications, including blurred vision, pain and swelling.
In a very similar set up in Devon, 19 NHS patients had the outcome of their cataract surgery reviewed after at least two had problems with their eyes following operations at a private hospital. The problems emerged on the first day of operations conducted under a contract to perform cataract operations between the NHS’s South Devon Healthcare Foundation trust, which runs Torbay hospital, and Mount Stuart hospital, owned by Ramsay Healthcare.
Diagnostics and support services
A number of support services in the NHS are outsourced to private companies, this includes hospital maintenance and a large amount of administration, such as letters for cancer screening programmes. All this work is vital for the smooth-running of the NHS and for patient safety and when it goes wrong then patient safety can suffer. One of the most notorious contracts with a private company is the primary care support services contract, which was awarded to Capita.
Capita took over the coordination of primary care support services in September 2015. However, since the contract began there has been an never-ending series of problems – ranging from things as mundane as surgeries running out of prescription pads and syringes to far more serious problems with the secure transfer of patient notes around the country, with notes going missing or delivered to the wrong surgery, and women being dropped from the cervical cancer screening programme. The most recent issue, which surfaced in mid 2018, was that Capita had failed to send out nearly 50,000 letters as part of the cervical cancer screening programme and although the company discovered this issue in August 2018, it neglected to inform NHS England of the issue for two months.
Finally, in May 2018 the National Audit Office (NAO) produced a report on the contract noting that patients had been “put at serious risk of harm” due to Capita’s failures. The report noted how both parties grossly underestimated the size and complexity of the task and the risks involved. The NAO report was particularly critical of NHS England and its inability to control Capita’s “aggressive” programme of office closures and redundancies, even when it became clear “it was having a harmful impact on service delivery”. In response NHS England highlighted the £60 million the contract had saved; the NAO report noted that the extent of harm to patients will not be known for some time to come.
Another notable case of falling quality of care is that of Serco in Cornwall. The quality of care provided by Serco under a contract to provide out-of-hours care was reported to have fallen “unacceptably short” of essential standards of quality and safety by the Government Public Accounts Committee. The problems came to light after whistleblowers contacted the media.
A review by the Care Quality Commission in March 2013 found GPs were working double shifts of up to 13 hours due to staff shortages. The following month Serco admitted it had found evidence that their staff had altered performance records. Eventually in December 2013 Kernow Commissioning Group reached an agreement with Serco to cut short its contract, which finished early in May 2015.
The contract was dogged with controversy – Serco had to admit that some of its staff had falsified data to make the company’s performance appear better than it was and whistleblowers had raised concerns about poor staffing levels. In 2013, Serco unsuccessfully tried to sub-contract the work to Devon Doctors, the GP consortium that had failed to win the original bid; Serco had won the bid as it was cheaper.
There have been numerous incidences where patient care and safety have been put at risk by private ambulance companies. For an overview see our page Contract failures in the ambulance service.
See further reading for more information on problems in the private sector.