This discussion paper was presented to the the Socialist Health Association Central Council November 2013 but not considered.   It is not agreed policy. This is a revised version.

This set of principles is founded on the presumption that the SoS has ultimate powers of direction over providers of NHS services and that Part 3 of the H&SC Act is repealed.

There should be no support or any form of incentive for privately provided care, through tax allowances or any form of subsidy.  There must be strong professional guidance about the circumstances when non NHS provided health care options should be offered and proper independent expert advice available to all care users on their rights and options (including, where appropriate, advocacy).

Private Medical Practice

The NHS should continue to be a provider of privately funded health care where this can bring benefits to the NHS.  There must however be proper guidance over separation of accounting to ensure transparency.

All Trusts must report in their accounts the level of income and expenditure from private patient activity in a prescribed manner which would cover income through Joint Ventures and similar organisational devises.  The calculation of expenditure on private patients must include a contribution for the NHS costs in training the staff involved and the finance costs of the equipment used. In addition, the “profit” derived from treating private patients must be greater than the “surplus” which would have arisen from treating NHS patients with similar conditions.
Any plans by an NHS provider to significantly change the level of private patient activity must be consulted upon and supported by appropriate HWBs and (if there is one) the Governing Body.

Private Provision of NHS Funded Healthcare

Healthcare must remain a predominantly publicly delivered service, and the public provision of social care should be strongly supported.  All providers of care must comply with minimum standards around workforce terms and conditions, training, development and supervision as well as quality standards.

Commissioners/planners should review all care services on a regular basis and include in that consideration proper engagement with service users.  Reviews should be published.  Where they are satisfied that the service provided is appropriate they should support it (preferred provider).  Any proposed change to care services should be examined also for its wider impact on other services – a whole system test.

Where a service from the current provider cannot be improved to the required quality standard or where a new service is required which is currently not provided then competitive procurement including private providers may be used. Organising a new service through supporting development of current NHS providers would also have to be considered.

Commissioners and the HWB must ensure that all providers of NHS care have public and patient involvement embedded in their governance.

It is unlikely that any service will be procured using a contracting arrangement unless:-

  • the service is largely independent of other services
  • the quality requirement can be properly specified in a legal contract
  • there are already a number of recognised providers of such a service.

The national procurement regime (as permitted under EU Public Procurement Directive) for care services should ensure that there is no compulsory competitive tendering (old EU Part B services).

There should be a test of suitability applied to prospective private care providers applied through continuing registration conditions or through contracting.  Major changes in capitation (for example) could enable contracts to be terminated.

The relationship between commissioners/planners and public providers should be through “NHS Contracts” which are not legally enforceable but rather subject to arbitration.

Where a public body has a legal contract with a private provider that contract must ensure full openness and transparency – with no “commercial confidentiality” outside the actual procurement process.  FoI would apply to such providers. Contracts and procurement requirements should specify ability to ensure continuity of care (which might include some financial bond being required) and knowledge of local conditions and services and populations would be an essential condition.

The price paid for services to any non public providers should be the same or consistent with the price that would have been paid to a public provider for the same service.

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  1. Shibley says:

    Any government wishing to stop private sector involvement in healthcare will run the risk of offending EU ‘restraint of trade’ legislation, now that the health market has been set up by successive governments.

    1. Richard B says:

      Opinions on this vary – yet to see any definite position. Its not the EU that is the problem its the pro-competition Tories/LDs.

  2. Didn’t the SHA just spend a year deciding its policy on this? Where exactly is the impetus to revisit this policy coming from?

    1. Richard B says:

      Policy is always developing. We had an extensive and very interesting email exchange amongst members which I have tried to summarise. Its not policy unless CC says it is.

  3. The most relevant policy should be to charge the private sector the maximum possible, to discourage private patients within the NHS, then create a framework of legally binding open information, with penalties for falsely declaring such information.

    When we had State industries suppliers to those industries were impelled to abide by government legislation to provide the same working conditions for their employees as state employees and more.

    Time to revisit that kind of legislation.

    I do not accept that EU legislation is sacrosanct, isn’t it funny how Britain is so keen to abide by the letter of EU law but other member states pick and choose what they do.

    Secondly, the EU has broken it’s contract with the people of Europe and are forcing unnecessary economic measures on the weakest members of the union. It is now time to challenge the ideology driving the insanity that is destroying the very fabric of European society. Now is not the time to bow to corporate corruption but to expose it.

    1. Richard B says:

      I think we are reasonabaly confident that EU legisaltion does not prevent a future Labour government implementing the policies we are advocating – if implemented intelligently. The most recent EU Procurement Directive actually weakens the regulatory framework around healthcare provision.

  4. Richard Grimes says:

    “It is accepted that the NHS is a provider of private health care and that this brings benefits to NHS patients.”

    This is not a given. Trusts that treat private patients must be able to prove that there is a profit from the business (few do, because they cannot). This means factoring into the costs of NHS investments like MRI machines and the training of staff. (In any other business, the costs of a service passed on to the customer will include contributions to the costs of items like training and capital assets.) If you only include operational costs like staff hours and drugs then you are accepting that the NHS should subsidise the treatment of private patients, which is not acceptable.

    Remove this sentence, it is not correct and it adds nothing to the policy.

    “NHS Trusts must report in their accounts the level of income and expenditure from private patient activity in a prescribed manner.”

    Indeed, but we must go further. Before they are allowed to treat private patients, Trusts must prove that they will make a bigger profit from the private patient than the surplus they will make on an equivalent NHS patient. In almost all cases the latter will be true. NHS trusts only make a profit on private patients in the few cases of the large London specialist trusts. If the trust will make a bigger surplus on the NHS patient then the trust is failing in its financial governance.

    After the first sentence of this paragraph add: “The calculation of expenditure on private patients must include a contribution for the NHS costs in training the staff involved and the finance costs of the equipment used.” Add to the end of this paragraph the following “The HWB must ensure that treating private patients will deliver a profit that is greater than the surplus for treating NHS patients with similar conditions.”

    “Where a public body has a legal contract with a private provider”

    Add to the end of this paragraph: “Commissioners and the HWB must ensure that all providers of NHS care have public and patient involvement in the governance of the provider that delivers the service.” Private providers must not be allowed to exclude public and patient involvement in how they deliver their care.

  5. Richard B says:

    Good points – can you make the suggested amendments and send to me please.
    The issue of interest is your first point. Are we saying we would like to remove all private patient activity but it is too difficult/expensive/disruptive or are we accepting that there can under some controlled circumstances actually be some benefit to the NHS. Some CC members have argued for the latter, some want total separation.

    1. Richard Grimes says:

      I think we can accept that we do not want an overt two tier system: car parking spaces reserved for private patients and their visitors; signs pointing to the plush corridor for private patients, tatty corridor for NHS patients; clinics with a fast track for private patients, private patients pushed in front of NHS patients in the queue for the MRI or CT scanner, an NHS patient at the end of their life dying on the ward because the single room is being used by someone who’s paid for it, etc. All of these overt two tier effects must be avoided. Indeed, it is a responsibility of Governors in the HSCA to prevent this from happening (s164(3) says private work must not “to any significant extent interfere” with treatment of NHS patients).

      This means that there has to be a separation of private and NHS patients. Separate private patient units, separate entrances to facilities, and in some cases totally separate hospitals (which kinda negates the whole reason for people choosing to be a private patient at an NHS hospital – they do not get the benefit of the extra expertise the NHS has which the private sector does not have). This separation does not come without a cost, we have to make sure that this cost is put upon the private patients and does not affect NHS patients.

      I also think we must look carefully at Joint Ventures. These must not be allowed to circumvent any rules imposed on private treatment (as was the case with the old private patient income cap). All patients of a joint venture must be treated as private patients of the trust when it comes to any caps or restrictions.

      The opinion that “under some controlled circumstances [private patients can] actually be some benefit to the NHS” is at best a bit fanciful. The *only* argument that they are “beneficial” is if they contribute to the surplus of the trust, and consequently the surplus is spent on improving services for NHS patients. Trusts are understandably coy about proving this, and that suggests to me that they do not.

      I have no objection to people self-paying for their care – everyone is allowed to waste their own money in whatever way they choose – my opinion is that the principle purpose of an NHS organisation is to provide care for NHS patients and they should not be distracted by providing 5 star hotel services for a handful of patients. I also have qualms about people employed to be an NHS employee are allowed to moonlight in the private sector. In any other organisation “working for a competitor” would be a sackable offence, in the NHS it has been allowed to happen for decades, but worse, it is now actively encouraged. It is bad enough that a consultant is allowed to run their private practice (as a “competitor” to the NHS) in a private hospital outside of their contracted hours, but by allowing a consultant to run their private practice in an NHS hospital (as is the case of private patients in an NHS trust) we are legitimising this moonlighting.

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