Although it is not SHA policy many of us are drawn to the idea of a publicly owned, publicly provided and publicly accountable NHS (3Ps).  We have tried many times to persuade those who are in favour of this to set out what it actually means, how we would be able to make the transition from the NHS of today (or 2015), and what the impact would be; how long it would take, what it would cost, what governance would be necessary and how funds would flow.  We need to understand what the 3Ps NHS would be like, compare it with what we have now and work out the implications of the transition.

Our understanding is that this 3Ps model must mean all premises and facilities used for NHS services are owned by the NHS and all those who provide services to the NHS are employees.  Private provision would be permitted but strictly separate and private providers of healthcare would be regulated and have to deposit a bond to reimburse the NHS for any NHS costs their “customers” incurred.  Hospitals and GPs would be either private or NHS but not both.  GPs would be NHS employees along with the practice staff.

There would be no commissioning; NHS services would be funded directly from the centre presumably based on current expenditure uplifted periodically for inflation. GPs would retain their gate keeping role but patients would be referred to a specific NHS setting.  Planning, performance management (of the system) and quality assurance would be through a top down management structure, presumably with regional and local nodes, and all senior executives would be appointed.  There would be no non-executive directors and no direct involvement of patients or public.  Social care would remain separate.

The variation around this could include having local health boards – with elected/appointed members which would be funded by formula.  This brings an element of commissioning back.  Also providers (especially) hospitals could have a degree of autonomy with their own management boards with some elected and some appointed directors.  Public health, community and primary care could also have separate governance structures and funding but again this brings back commission and the C/P split in some form.  We could also find a role for some variation on Community Health Councils.

There are many possibilities and it would be helpful if one of the advocates of 3Ps could write a paper with some proposals and some information.

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  1. neil wood says:

    ‘Hospitals and GPs would be either private or NHS but not both.’

    This would cut off NHS hospitals from a valuable source of direct funding. I have always maintained that the likes of BUPA & PPP should never have got a foothold in this country on the basis that private patients should be treated in private wards in NHS hospitals with the profits on the revenues raised going to improving facilities for NHS patients. Unfortunately in the 70’s the unions argued that NHS resources were being used for private patients and the private units of NHS hospitals were closed down. However this failed to increase activity on behalf of NHS patients as hospital revenues were reduced in real terms. Hospitals like the Royal Free and GOSH are shining examples of how the private and public sector can co-exist for the benefit of all.

    Furthermore the Foundation Trusts legislation allows for the DoH to directly control the level of private vs NHS activity in FT hospitals which is scrutinised by Monitor. In practice this tends to be raised during Conservative and lowered during Labour administrations.but not to a point where it impacts either on NHS patient activity or threatens the financial stability of the hospital.

    1. Irwin says:

      Many would agree but what we are hoping is that those who argue for the 3Ps model set out what it actually means.

  2. Martin Rathfelder says:

    The abolition of NHS pay beds is a good example of a reform which had the opposite effect from what was intended. We need to think carefully about any attempt to disturb the balance provision in the NHS.
    The balance between primary care, which is mostly private now and secondary which is largely public is going to change because of technical developments, whatever government is in power.

    1. neil wood says:

      I do not agree that primary care Providers are mostly private. Many provider services were merged in Foundation Trusts when they were unbundled from PCT’s and others set up as Social or Community Enterprises. In fact the regulations were changed to allow Provider staff to move to Enterprise models and still stay in the NHS pension scheme (one of the best pension schemes in Europe) in order to encourage take-up of this option.

  3. SHA must be congratulated for a good start in establishing a basic fundamental principles – (Three P’s) of Public Health Delivery, which I think must mean all Dr’s and Surgeries should be direct employees of the NHS-and Hospital Trust Boards would again be employee’s of the NHS… where I differ is the management structure, which I see and containing a basic weakness, because all the evidence we have is, that State CEO’s see themselves as a super ” Special Management Breed” that needs huge rewards way above what is reasonable, with incentives, PBR and all that rubbish, in this process bringing into the NHS, all the worst aspects of Modern Capitalist management into the NHS, which we must all reject this hostile and clearly “Ideologically Orientated to the free market system values” into the NHS, with very bad consequences for delivering basic Healthcare Services to millions of people.

    Somehow, they all adopt “superman egotistical attitudes ,where their breed of management has to be rewarded and all these boards become top heavy with these parasites who aare all trained or slung out in these “Business Ideologically attitudes” not least to say they’re above both Clinical Public Accountability- or even mere G.P’s who they clearly despise !

    I do agree that we cannot have a three tier system of care which is, in my view, what is developing now, & Hospitals must be either Private or Public. What is clear to me is that its planned that we have the Rich Bourgeois of all the world now descending on the UK for healthcare. As USA foreign Policy has been incompatible all round, hence they see UK as a good alternative-and the Tories want to get their pals in Surgery etc Consultants, etc to wreck the state system.
    Basically they’ll keep the NHS doing its basic third rate stuff, get a secondary system in place, based on Insurance Groups Prudential/Virgin/ BHA/BUPA/ and a ” First Class International Top Class Luxury” at £500 a day in hospital bracket. That’s the plan as I see it with the constant break up and downgrading of the NHS happening through C.C.G’s where BS/BV- will force out basic services of hospitals and more and more of the Hospital will be kept,maintained &run at Public Costs, but most of the Hospital services the profitable parts will be run by profit making private companies or services contracted on a two/three year contract to deliver at a price.
    That’s happening locally (South West London)where a Local Care Centre run by a consortia of two large Surgeries,both in the Virgin Health take over a local hospita-l and Virgin will de-facto run it, they will obviously outsource on the BSBV principle, as much of the time as they can, and who’s to stop it ? So we, the patients, etc, wont have hardly any NHS employees or services at this NHS Hospital, yet we the Taxpayers will fund it and pay the costs on PFI of re-development. Hence “doubly robbed by the Merchant banks and by the Non NHS contractors.” Very smart Business Plan where none of the Capital Set up costs, running Costs, etc, are borne by the Entrepreneurs, but by us the people.. they get all the profits we get all the costs… and no public accountability no public challenge, no ongoing public interference- as its Private ?

    1. neil wood says:

      ‘Basically they’ll keep the NHS doing its basic third rate stuff …..’ this is such rubbish , whilst the administration in our hospitals often leaves a lot to be desired especially in regard to patients discharge , patient after patient testify to the excellence of surgical and medical teams. The reason why we have a major problem regarding treating ‘baby boomers ‘ is because of the high quality of treatment in the NHS has kept so many alive to pensionable age.

  4. Is it official SHA policy that GPs are no different to large private companies?

    It is not a position I share.

    It may or may not be desirable to make GPs salaried employees – until recently I would have said it was, however I currently see some risks in that approach – it is GPs very independence that appears to be making them an outspoken threat / scapegoat number one for Hunt, at present.

    Even if that were not the case, I am not sure that those fighting strongest against NHS privatisation currently see making GPs salaried staff, as a priority. I would say it seems far more important to remove the destructive influence of the large corporates from our health service and restore greater political accountability to it. Eliding GPs and corporations seems to obscure more than it reveals.

    1. Irwin says:

      The article has nothing to do with SHA policy. It is intended that those who support 3Ps can set out what they think that means – how it applies to GP Practices is a good example. At present we have the strap line but no real details; the article just offered some suggestions. Feel free to set out your views.
      The SHA needs to explore the issue further but the current view is that the “small business” model for GP Practices should be phased out over a period with more salaried GPs instead – but this is open to discussion.

      1. neil wood says:

        Can’t see GP Partners voting for a £50k salary drop.

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