Category Archives: Private Medicine

The impact on NHS finances and NHS patient care

When the Health and Social Care Act was passed in 2012 the treatment of private patients was expected to become a significant source of NHS hospital trust income. While this has not happened on the scale that some observers foresaw, the continuing squeeze on NHS funding could lead to the treatment of private patients becoming more important, with a potentially significant impact on the availability of care for NHS patients.

  1. This report sets out the findings resulting from interviews with 17 hospital staff carried out in 2016, published research findings, official publications, LaingBuisson’s market surveys, and Freedom of Information requests to all 153 acute hospital trusts in England.

  2. The report describes the scale and distribution of private patient treatment in NHS hospitals. It discusses two issues: whether the treatment of private patients generates additional income for NHS hospital trusts, and whether treating patients privately in NHS hospitals risks disadvantaging NHS patients.

Why do private patients want to be treated at an NHS hospital rather than a private hospital?

  1. A primary reason for patients wanting to pay for treatment at an NHS hospital rather than a private hospital is that higher-risk or more complex cases cannot be safely treated in a private hospital if, as is typically the case, it has no on-site specialist teams or intensive care beds. Even patients who are eligible for NHS treatment may elect to be treated as private patients in order to have their choice of consultant, for example, or to be treated more quickly, or to have a private room.

  2. Another reason, which is particularly relevant to self-paying patients (as opposed to those with private health insurance), is that the price charged for treatment in an NHS hospital’s dedicated Private Patient Unit or PPU is reported to be often up to a third less than in a neighbouring private hospital. Some private patients may also think that the quality of care in an NHS hospital will be higher, thanks to having on-site multispecialty teams of clinicians and offering more assurance of safety, although these advantages have not been widely appreciated in the past.

What drives the NHS’s interest in treating private patients?

6. The Health and Social Care Act 2012 raised the limit on the share of total trust income that NHS hospital trusts may receive from private patients to 49%, and since then NHS hospitals have been encouraged to see private patients as a significant potential source of income. In 2015-16, four years on from the passage of the Act, the total income that the NHS generates from private patients had increased from £511m to £596m – a 16% increase in nominal terms and a 12% increase in real terms (at 2012/13 prices) .

Table 1. Private patients treated in NHS hospitals in England: number, share of total Finished Consultant Episodes, and income generated (UK data).

private patient numbers

Sources: Finished Consultant Episode data from NHS Digital 2011, 2012, 2013, 2014, 2015, 2016; income data for UK from LaingBuisson 2016

  1. Despite this increase in the income generated from private patients, the percentage of NHS activity which is dedicated to treating private patients has remained very small. Only 0.5% of all Finished Consultant Episodes in NHS hospitals are for private patients and this percentage has not changed substantially since the Health and Social Care Act became law. In 2013, NHS hospitals’ share of the total income earned from the treatment of all private patients in England was little over 8%.

  2. During interviews, some healthcare professionals suggested that in addition to generating revenue from private patients, NHS hospitals might encourage the treatment of private patients to support consultants who want to treat private patients and sometimes need to treat them in the NHS hospital where they work – whether because a patient is too high-risk or has a condition too complex to be treated at a local private hospital, or because the hospital has facilities that are not otherwise available, or for other reasons. Some clinicians interviewed also thought that treating private patients adds status to a hospital and enables it to attract high-quality staff, in particular consultants.

9. The amount of income generated from private patients by the NHS varies greatly between NHS hospitals. A small number of NHS hospitals in London earn a significant income from private patients, and many others have invested in private patient beds or dedicated private patient units (PPUs) in an attempt to boost this source of revenue. By June 2016, the number of PPUs had risen from 84 in 2014 to 91, though with a slightly reduced total number of beds – 1,142, down from 1,155 in 2013.

  1. LaingBuisson  estimate that in 2016, besides 1,143 dedicated beds in PPUs, another 1,500 NHS beds in NHS hospitals in England were used to treat private patients about ten percent of the time. Taken together this means that approximately 1% of the NHS’s roughly 131,000 beds were set aside for, or used by, private patients at any given time – equivalent to the number of beds in two average-sized NHS hospitals. While small, the number of NHS beds not available for NHS patients should be seen in the context of total NHS bed numbers having fallen significantly over the past 30 years, and being markedly fewer per head of population than in comparable European countries. With overnight bed occupancy rates peaking at 95% (or even more) in the winter months, the loss of capacity for treating NHS-funded patients is potentially a significant issue, as pointed out by the Kings Fund. It should also be seen in the context of the planned further reduction in the number of hospital beds set out in the Sustainability and Transformation Plans due for implementation in 2018.

  2. The distribution of income from private patients is very concentrated. The ten PPUs with the greatest private patient income are all in London, thanks to the concentration of more affluent people in London and southeast England, and because London is the destination of choice for private patients from outside the EU. Between them, these ten PPUs account for 58.7% of the total private patient income received by NHS hospitals in 2015/16. Some hospitals in Greater Manchester and Cheshire, however, have also seen some growth in income from private patients in 2015/16.

  3. Around a third of NHS hospital trusts reported no income from private patients in 2015/16; excluding these, the median hospital trust income for that year from private patients was only £769,000 (calculated from Foundation Trust Accounts and NHS Trust Accounts). A further third reported private patient income over £1m; thus private patient income in the NHS is highly concentrated amongst a small number of NHS hospitals.

Table 2 shows the top ten hospital foundation trusts in terms of the share of total income derived from private patients.

top 10 trusts private income

  1. Foundation trusts have seen greater growth in private practice than nonfoundation trusts . Non-foundation trusts which are struggling to meet NHS financial and other targets are less likely to be able to treat private patients, since Department of Health guidance states that private practice must not adversely affect the ability of a hospital to meet the needs of NHS patients. As one consultant at a trust in the south-east of England put it, “When we are struggling to meet the NHS targets there is no place for private patients…. There is a massive bed crisis, a bad situation, we can’t manage. So there are no private patients at all. It is not banned, but there simply is no room.”

Is the treatment of private patients in NHS hospitals profitable?

  1. While income from the treatment of private patients is known with reasonable accuracy, it is only possible to tell whether it represents a net gain to the NHS if the costs of the treatment are also known, and this is frequently not the case. Sally Gainsbury’s 2008 study, based on Freedom of Information requests to 182 acute hospital trusts in England, found that some trusts were losing money on some procedures for private patients. Many hospitals admitted that they could not calculate the cost of treatment of private patients, and only thirteen provided data. According to that study, out of the 4,142 patients for whom data were provided, thirty percent (1,238) were charged less than the cost of their treatment, and four percent were charged less than the NHS tariff. The total profit made from the treatment of the other 2,904 patients outweighed the losses made, but some trusts probably made losses overall on their treatment of private patients.

  2. Given the importance attached by NHS England to the treatment of private patients, echoed on many NHS hospital trust websites, it seemed important to try to find out how far the situation reported by Gainsbury in 2009 had changed – how far the £596m revenue that NHS hospitals in England earned from treating private patients in 2015/16 represents a net gain for the NHS. One hundred and fourteen out of 153 trusts responded to an FOI request to provide figures for the annual number of finished consultant episodes for private patients, and the income and expenditure relating to them.

  3. Most of the 114 trusts that responded reported earning some income from treating private patients, but 73 of these were unable to report their expenditure on doing so, in most cases due to not measuring or not recording it.

  4. The figures provided by 9 trusts, however, indicate that each of them made a loss on the treatment of private patients in some or all of the years from 2010/11 to 2015/16. Overall 4 of these 9 hospital trusts made significant losses between 2010 and 2016, with one, Frimley Health NHS Foundation Trust, making a loss of £18m over the six-year period.

Table 3. Profits and Losses (in pounds sterling) made by some NHS hospitals from treating private patients (losses shown in red)

Loss making trusts

  1. The reasons why trusts do not measure or record costs are numerous, but interviews with hospital doctors made it clear that recording the procedures performed for private patients separately is burdensome and seldom done systematically, even when hospitals have guidance in place for clinicians on the requirement to do it. Some trusts were only able to give the combined cost of patients from overseas whose care is paid for by their home country’s healthcare systems, through reciprocal arrangements with the UK, and those who pay for their own treatment or are covered by insurance.

  2. Some of the money due from private patients is never received. Table 4, drawn from Foundation Trust accounts, shows the scale of debts written off for the ten NHS Foundation Trusts with the largest bad debts, ranging from Guy’s Hospital, which wrote off £407,000 in 2015/16, to Aintree which lost £53,000. This represents on average 3% of the income received from private patients for these ten hospital trusts with bad debts. According to the accounts of Foundation Trusts the total value of bad debts written off for all private patients treated at NHS Foundation Trust hospitals was £1.77m in 2014/15 and £1.81m in 2015/16.

Table 4. Largest bad debts and claims abandoned in relation to private patients

NHS bad debts

How do NHS Trusts determine how much to charge private patients?

  1. Failure to set prices for treating private patients which reflect the cost of delivering the care may also explain why some hospitals were making a loss from their private patients. Despite the substantial income which is generated by treating private patients, there is no standard price-setting approach across the NHS.

  2. Of the 114 NHS acute hospital trusts that responded to an FOI request, 78 provided information about their methodologies for setting the prices charged to private patients. As Table 5 shows, 22% of the responding trusts did not have a standard procedure for setting private patient charges, and of trusts that did have a standard procedure, most based their prices on either (a) a calculation of the costs of the treatment, (b) NHS tariffs, (c) insurance company or market prices, or (d) a combination of these. Six trusts stated that they add a mark-up to the national tariff (the price per procedure, such as a hip operation, which is set centrally by Monitor and NHS England). Of these, four disclosed their percentage mark-up, which varied from 20% to 50%.

Table 5. Approaches to price setting

Price setting

  1. Table 6 shows the resulting variation in the prices set for a range of procedures by four hospitals, reflecting these differences of approach. The variations are strikingly wide, although this may be partly accounted for by different ways in which interventions are coded or bundled together (for example, some trusts charge a separate price for the contrast injection that is given before some MRI scans). It is also notable that for two interventions the price charged to private patients is below the NHS tariff. As noted above, some prices may be set low, and even below the cost of the intervention, in order to compete in the local private healthcare market, or to attract or retain consultants. To the extent that  this approach plays a significant role in price-setting, however, the treatment of private patients seems unlikely to add to a trust’s net revenues.

Table 6: Examples of prices charged for private patient treatments (in £s) in four NHS hospitals (differences from the national tariff shown in brackets)

Prices

  1. Setting tariffs in such a way as to attract private patients while also making a profit is obviously a commercial skill which NHS hospitals have not historically needed. A study published in the Health Service Journal in 2012 found that many PPUs charged 50% less than private hospitals for comparable services.

  2. To conclude, it is not possible to say whether the NHS benefits financially from devoting resources to the treatment of private patients. Given that these resources are significant and that NHS hospitals are running large
    deficits and are under pressure to make risky economies, this is an issue that needs urgent clarification. When NHS income from private patients is predicted to grow by 6% a year till 2020 it is important to determine whether this would represent a net financial gain.

Does the treatment of private patients adversely affect NHS patients?

  1. The NHS Code of Practice for Private Patients states that “provision of services for private patients should not prejudice the interests of NHS patients or disrupt NHS services”, and “NHS commitments should take precedence over private work”. In theory, therefore, private patient care should not impact on the availability of beds or other resources for the treatment of NHS patients.

  2. This principle appears to be compromised in practice in various ways. For example, junior doctors who were interviewed said that “clerking” (taking notes on) private patients admitted without adequate notes tended to take time away from attending to NHS patients. Others said that private patients – and NHS patients who had previously been private patients of the admitting consultant, and so were already known to them – tended to get more attention from the consultant, and therefore also from the junior doctors in the consultant’s team, than NHS patients. Two nurses who were interviewed, however, said that when private patients were admitted to the NHS wards they worked on, nurses often did not know which patients were private and therefore did not treat them differently.

  3. It seems unlikely that NHS patients are significantly disadvantaged in terms of receiving consultations and care from health professionals, so long as the number of private patients relative to NHS patients is small and the pressure of work permits all patients to receive appropriate attention from all the staff. If NHS funding per patient continues to fall, however, and the ratio of private to NHS patients increases, a pattern of different levels of treatment could potentially emerge in some hospitals.

  4. A more measurable disadvantage may flow from the treatment of private patients making NHS patients wait longer. A major reason why patients choose private treatment over NHS treatment is to be treated speedily. If they are treated in an NHS hospital, and especially if the treatment requires theatre time, treating them quickly is only possible if NHS patients wait longer, as several consultants who were interviewed acknowledged.

  5. It appears that to give proper effect to the Code of Practice for Private Patients a rule is needed to the effect that faster treatment cannot be obtained by being a private patient in an NHS hospital unless the hospital can demonstrate that it provides additional facilities, staff and beds, over and above those needed to treat NHS patients and corresponding to the number of private patients who will be receiving such faster treatment.

  6. A particularly invidious challenge to the principle of priority for NHS patients is that that a patient may “jump the queue” by paying for the first part of their care and receiving an earlier diagnosis and/or initiation of treatment,
    and then transfer to NHS funding. Regulations state that patients moving from private to NHS funding should face the same waiting times, access to medications and standard of care as any other NHS patient; and NHS guidelines state that “patients referred for an NHS service following a private consultation or private treatment should join any NHS waiting list at the same point as if the consultation or treatment were an NHS service. Their priority on the waiting list should be determined by the same criteria applied to other NHS patients”.

  7. This means that if a patient chooses to transfer from private care to NHS care before receiving treatment there should be an assessment of the patient’s clinical priority. The interpretation of this rule in practice may leave room for queue-jumping, however. For example, while one trust’s guidelines state that the assessment should be carried out by the clinical director of the department, another trust says the assessment should be done by the consultant looking after the patient’s care, and that he or she should only “consider discharging” the patient and putting them on the appropriate NHS waiting list. The latter guidance does not explicitly bar the consultant from placing their formerly private patient on the waiting list ahead of other NHS patients with similar or even higher clinical needs. To avoid this, all trust guidelines should require the assessment to be made by the clinical director of the department or an alternative independent consultant.

Conclusion

  1. Information provided by NHS acute hospital trusts, published reports and health professionals working in the NHS suggests that increasing the provision of private healthcare within the NHS may pose risks to the use of NHS funds and the care of NHS patients. Procedures for acceptance, treatment and charging of private patients are not standardised and frequently not transparent, with some trusts stating that commercial confidentiality prevents them from providing such information. To ensure adherence to the values of the NHS, including equity of access and quality of care, and to ensure financial sustainability, NHS hospital trusts should be required to measure, record and report the costs of, and income from, the treatment of private patients.

This was first published on the Centre for Health and the Public Interest  site, where there is a version with footnotes and references.

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Reforming private hospitals in England after the Ian Paterson scandal

Executive summary

  1. This report sets out a series of recommendations to reform the private hospital sector in England following the Ian Paterson scandal which left over 500 hundred women who underwent unnecessary breast surgery in two private hospitals maimed and injured.

  2. As we have shown in two previous reports, there are a number of systemic patient safety risks which are specific to the private hospital sector. The reaction by both the regulator the Care Quality Commission and the private hospital sector to the Ian Paterson scandal highlights the extent to which those risks remain and will continue to do so unless extensive reforms are introduced.

  3. Based on an extensive review of the CQC inspection reports of 177 private hospitals in England this report provides evidence which identifies the
    characteristics of the private hospital business model which make it susceptible to exploitation by ill-meaning or incompetent surgeons.

  4. The report shows that these systemic risks stem from one central flaw. Unlike any other type of hospital the vast majority of private hospitals seek to transfer the risk and the liability for something going wrong to the NHS or other companies.

  5. The refusal by private hospital companies to accept full responsibility for what happens in their facilities means that patients will always be at risk. Or put another way there can be no guarantee of patient safety in private hospitals without full liability.

  6. Further, the regulatory regime which covers private hospitals does nothing to address this central weakness and has in most cases ignored or overlooked the extent to which patients have been put at risk.

  7. The report makes the following 5 recommendations to reform the private hospital model in order to make them truly safe for patients and to avoid a repetition of the Ian Paterson case.

  8. First, private hospital companies should directly employ the surgeons and anaesthetists who work at their hospital facilities and should take on responsibility for monitoring their activities and appraising their performance. The failure by the private hospitals to accept the liability for the actions of Ian Paterson was not an isolated case, but is central to how the private hospital business model operates. Allowing hundreds of NHS trained and employed surgeons to carry out operations in small private hospitals, but without having a direct contract of employment with them, prevents the private hospital from being able to effectively monitor their performance.

  9. Further, if private hospitals are not liable for the activities of the surgeons operating in them, they have no incentive to monitor their performance and activities.

  10. In addition, this report shows that in hundreds of cases the failure by private hospital businesses to directly employ surgeons means that it is entirely possible that a surgeon will not have performed an operation in a given private hospital for over a year but would be allowed to do so tomorrow. This poses direct risks to patients as the surgeon is unlikely to be familiar with the hospitals procedures, facilities and staff.

  11. This report also shows that those hospitals with the highest number of surgeons who are granted the right to practise within a hospital tend to have above average rates of adverse incidents for patients. It also shows that some private hospital businesses allow surgeons to be 45 minutes away from the hospital after they have carried out an operation and so are not on site to deal with any post-operative complications. This has been found to be a key factor in the avoidable deaths of patients at private hospitals and is contrary to the Royal College of Surgeons Standards on Unscheduled Surgical Care, which require consultants to be no more than 30
    minutes away. Despite this risk the regulator of the private hospital sector permits this practice to occur.

  12. Second, private hospitals will not be truly safe unless they have adequate facilities to deal with those situations where a patient’s life becomes endangered following an operation and where the hazardous transfer of patients to NHS hospitals ceases. Currently, the great majority of private hospitals transfer patients to the NHS when complications post-surgery arise. We estimate in this report that this reliance on NHS hospitals could have cost as much as around £250m over the course of the last three years, with no evidence that private hospital businesses have paid anything to cover these costs. Whilst the safety net for private hospitals provided by
    the NHS saves lives, its existence is an impediment to a true patient safety culture in private hospitals. If the private hospital business does not have to deal with the consequences of post operative complications it has no incentive to prevent things from going wrong in the first place.

  13. Third, private hospital businesses must end their reliance on a single junior doctor (a Resident Medical Officer), working extreme shift patterns, to provide post-operative care for patients. This report shows that most private hospitals have only one junior doctor in charge, irrespective of the number of patients in the hospital, with some being responsible for up to 96 beds. In addition, the current working patterns of these junior doctors are incompatible with the European Working Time Directive with many doctors working shifts of 24 hours a day (168 hours per week) for one or two weeks at a time.

  14. Instead of relying on an outside agency to employ these doctors – which again allows the private hospital business to seek to avoid liability if they are not properly trained or vetted – the hospitals should employ them directly. There is no good clinical reason why the current Resident Medical Officer model should continue to be used to provide post-operative care to patients in private hospitals.

  15. Fourth, as we have stated before, private hospitals should be required to adhere to the same reporting requirements as NHS hospitals in order to enhance the possibility that the risk of harm to patients can be more easily detected. This report shows again that the notification of adverse patient safety incidents (such as unplanned patient transfers or readmission rates) to the CQC is haphazard, and the quality of the data is unreliable – currently only 63% of private hospitals registered provide regular returns to the CQC as they are not mandated to do so by law.

  16. What data is available shows that there is a huge variability in the occurrence of patient safety incidents across private hospitals but that despite this the CQC does not have the ability to determine where potentially dangerous practices are occurring. Instead where patient transfer rates are 4 or 5 times the national average the CQC has deemed these to be of no concern and has often rated these hospitals as ‘good’ or ‘outstanding.’

  17. The private hospital companies have argued that the data which they have been required by the Competition and Markets Authority to provide to the Private Hospital Information Network (PHIN) address the concerns about data transparency. However, despite the misconception that this data contains patient safety information it is of limited value. It is also information which has yet to be fully collected and published by private hospitals, despite this now being a legal requirement. The organisation which has been set up to publish and validate this data is funded by and governed by representatives from the private hospital businesses.

  18. Fifth – The legislation governing private hospitals should be amended to make clear that all those who are registered with the CQC should be fully liable for all the services which are provided within it, including the actions of surgeons and other healthcare professionals. The Health and Social Care Act 2008 sets out requirements for private hospitals to ensure that they employ properly trained and competent surgeons and other healthcare professionals. However, the difficulties that the victims of Ian Paterson have had in gaining compensation and redress for the harm caused to them shows that this legislation is either unclear or inadequate.
    The fact that the requirements of the existing legislation have not been properly enforced by the CQC raises the question whether the Paterson scandal could have been prevented had the regulator intervened at the time. A simple amendment to the Health Service Safety Investigations Bill currently before Parliament could easily rectify this issue.

  19. Finally this is an issue for the NHS as much as for private funded patients. The risks posed by the current private hospital model do not only affect patients who are funding their treatment themselves or through private insurance. The analysis set out in this report shows that almost half of all inpatients treated in private hospitals are funded by the NHS, as are a third of outpatients. There are now 82 private hospitals in England where the majority of patients are funded by the NHS. This puts the NHS and the Department of Health in a very strong position to require changes to the private hospital business model in order to ensure the safety of NHS patients.

Key facts about private hospitals in England

  • 500 + – the number of women on whom Ian Paterson carried out unnecessary breast surgery in two private hospitals.
  • £250m – the estimated cost to the NHS of treating patients who have been transferred from private hospitals.
  • 45% – the percentage of inpatients in private hospitals who are funded directly by the NHS.
  • 32% – the percentage of outpatients in private hospitals who are funded directly by the NHS.
  • 82 – the number of private hospitals where more than 50% of patients are funded directly the NHS.
  • 104 – the number of patients who died following a transfer from a private hospital to an NHS hospital.
  • 168 hours – the typical weekly shift of a junior doctor a Resident Medical Officer in a private hospital.
  • 32 – the average number of beds for which a single Resident Medical Officer is responsible in a private hospital.
  • 868 – the number of consultants who have the right to practise at the Harley Street Clinic, a hospital with 100 beds.
  • 45 minutes – The duration, in travelling time, which a consultant is allowed to be away from a number of registered private hospitals in the event of their patient becoming unwell.

Read the full report at the CHPI website

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We are so used to the attacks on the NHS from the Daily Mail that we forget that it can be merciless to private medicine too. A critical article by Lois Rogers for the Mail’s on-line edition on June 12th provoked a defensive response from the Association of Independent Healthcare Organisations (AIHO).

Rogers’ attack begins with the story of a man (a Director of a high-end car company) who underwent surgical removal of the prostate (no small procedure) in a private hospital, only to be told years later that the surgery had not been necessary. According to the Mail’s journalist he is just one of at least 66 people, who believe they were misdiagnosed or underwent unnecessary surgery at the hands of a particular surgeon. For the full story go to http://www.healthmatters.org.uk/blog/nhs/daily-mail-attacks-private-medicine/ .

Daily Mail

EXPOSED: How the NHS is paying millions to private surgeons for operations that we may not need – and could even HARM us

  • The quality of care received by NHS patients in private hospitals is under review 
  • Insiders fear countless people are paying for needless, expensive operations   
  • There’s also been a sharp rise in complaints from unhappy or worried patients
  • Those treated in private hospitals are often not compensated  if things go wrong

By Lois Rogers for The Daily Mail Published: 22:06, 12 June 2017 | Updated: 13:57, 14 June 2017

 This story is the tip of a much bigger iceberg in private hospital care, Rogers asserts, because the private sector has particular problems with lack of scrutiny of what surgeons are doing. Doctors working in private hospitals have a financial incentive to be interventionist about operations. They are not subject to the same monitoring and scrutiny as in the NHS, and private hospitals don’t have to monitor outcome trends to detect substandard surgeons either. Medical insurance cover is also a problem. Rogers believes that many private patients who have undergone unnecessary surgery may never be compensated.

The Mail article argued that NHS patients should be made aware of these risks before being treated in private hospitals. The article then goes on to mention by name NHS consultants who have been accused of over-treating patients in the private sector.  Unsurprisingly the AIHO was not pleased by these claims and responded sharply, pointing out that surgeons in the private sector are all responsible to the General Medical Council, mostly work for the NHS (where they are scrutinised), and work privately in hospitals that are inspected by the Care Quality Commission. The AIHO says “failings of a handful of rogue surgeons does not represent the high quality and compassionate care delivered day in and day out by the independent sector as a whole”.

The AIHO insists that the ‘independent’ (private) sector is actively working with NHS England to bring the level of reporting of surgery in line with the NHS’s own. Independent hospitals are already required to provide detailed data on every private episode of care, and they are beginning to publish performance measures for 149 common procedures at over 250 hospitals. More will soon follow, according to the AIHO, including measures of consultant performance in 2018.

This spat matters. Treating NHS patients is big business for private hospitals. 530,000 surgical procedures were carried out on NHS patients in the private sector in 2016. A third of all NHS-funded hip and knee replacements are now being carried out in private hospitals. The NHS paid the private sector £8.7 billion for services last year, amounting to 28 per cent of private hospitals’ income. The private hospital sector constitutes a source of spare surgical capacity for the NHS, and are in effect in the NHS’s public domain (as distinct from the state-run public sector) when they do NHS work. They are, then, like GPs, dentists, pharmacists and other contractees to the NHS, and they have to perform according to NHS rules. That is why the Mail – always ready to occupy the moral high ground – sees them as fair game for the critical journalist.

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If something can’t go on for ever then eventually it will stop – so says Stein’s Law – attributed to the eponymous American economist.

Senior Health service managers are now openly admitting that the NHS cannot continue in its current state. Writing in the Observer recently, Chris Hopson, Chief Executive of NHS Providers commented: ‘It is surely now time for our national health and political leaders to publicly acknowledge that the NHS can no longer deliver what is being asked of it for the funding available. The evidence that there is now an unbridgeable gap between what the NHS is required to deliver and the money to pay for it is both widespread and compelling.’

The much vaunted plan to save £22 billion through ‘efficiency savings’ has been described as ‘virtually impossible’ by former Health Minister Norman Lamb and as being ‘substantially off target’ by the Health Foundation.

Despite the sombre inevitability of Stein’s Law, the NHS shows no sign of going down quietly. As former chancellor Nigel Lawson observed, the NHS is the closest thing the UK has to a national religion. Any politician brave or foolish enough even to suggest that the funding model for the NHS requires amendment or adjustment is instantly attacked by a variety of NHS zealots in a manner verging on the hysterical. Taking on the National idol is a recipe for political suicide, so Mr Hopson’s call for an ‘open, honest, realistic, national debate’ about the future shape of NHS services seems unlikely to be realised.
After 30 years working at the coal face in the NHS I have come to ignore what politicians and managers say and instead watch what they do. Few informed people dispute that the way the NHS does business needs to fundamentally change – the tricky part relates to who can make that case to the public and, more importantly, who is going to be responsible for forcing the change through in the face of personal and political abuse verging on the criminal – just take a look at the behaviour of junior doctors towards the current Health secretary for an example.

Redrawing the boundaries of what the NHS provides is one way by which the NHS reduces the volume of work it has to do. In my own specialty, the boundaries for varicose vein surgery have been changed substantially – it is no longer sufficient for patients to have aching and discomfort from varicose veins to get effective treatment. Instead the definitions have been changed, so that only the most severe cases with established skin damage leading to an ulcer can be put on the operating list. Elective surgery like varicose veins is an easy target for this type of manipulation – by redrawing the boundaries, health service managers simultaneously reduce the number of patients on waiting lists (thereby facilitating attainment of targets) and reduce the number of procedures carried out – thereby reducing cost to the commissioning groups. Similar schemes are in place across most of the country for a variety of other complaints such as hernias, cataract surgery and joint replacements. Initiatives to deny treatment to patients on the grounds of smoking habits or obesity have recently been reported.

Restriction of access to treatment on grounds of ‘insufficient severity’ preserves the ideological purity of the NHS ‘free at the point of use’ by sweeping the problem under the carpet. Unfortunately, pretending that the need has disappeared by a semantic redefinition does not make the problem disappear for the patient who cannot afford to pay for private treatment. This is not an open and honest way of dealing with real world clinical problems.

A serious examination of low cost social insurance systems or co-payment plans similar to those that exist in most developed Western economies is long overdue. Dogmatic adherence to a monopolistic model of centrally funded universal healthcare paid for exclusively via general taxation will not meet the health requirements of our population in the coming years and redefining the definition of severity of varicose veins isn’t going to solve the problem either.

Eddie Chaloner is a consultant vascular surgeon who operates at Lewisham and Greenwich NHS Trust and through his private practice Radiance Vein Clinic. Chaloner pioneered endovenous laser surgery treatment for varicose veins in the UK, which has revolutionised the treatment of this common condition worldwide.

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In the last two decades, many different types of cosmetic surgery have become quite popular among different categories of people. Even though there is nothing wrong with accepting your natural look, it is not a bad idea to invest in cosmetic surgery and improve your appearance. Thanks to modern medicine, people can alter almost every feature of their face and body and look much more attractive. It doesn’t really matter whether we are talking about the elimination of birth defects or simple beautification, any individual can alter the appearance of their chin and other body parts. According to official statistics, the number of people who decide to use chin augmentation is growing every year. This is especially true for cities with a high number of qualified and experienced surgeons like Toronto for example. Chin augmentation Toronto is one of the most searched terms when it comes to cosmetic surgery in North America.

There are a huge number of people who believe that good looking chin and jaw line make men more masculine. As we all know, not all men have jawlines and chins like this, but the good news is that a good cosmetic surgeon can solve this issue. So, with a simple surgical procedure, any individual can get an attractive chin and face. Let’s be clear, a well-defined chin will beautify women too. Men usually avoid women who have large chins or chins with certain bone defects in this area. After a consultation with a cosmetic surgeon, they can get the right treatment to resolve this problem.

There are hundreds of surgeons around the globe offering chin augmentation. The fact is that not every surgical procedure like this is the same and there are situations where this procedure is very simple and there are cases when it’s a little bit complicated. However, an experienced surgeon won’t have a problem in any case.

Regardless of the intensity of this procedure, surgeons use anesthesia before the procedure begins. Typically, they use grinding of the bone in this area so they can eliminate the defects and get rid of growths and other structures that don’t belong there.

Generally speaking, the recovery time is not long, but it depends on the level of work. In many cases, patients are fully recovered after six weeks. During the recovery period, patients might experience swelling, redness, inflammation and few other side effects that can be treated easily. Patients get detailed instructions about the things they should do in order to speed up the process and avoid problematic situations.

Even though there are some problems and issues associated with chin augmentation, many people are not discouraged because they know that the final results are worth it. This is the reason why the number of these procedures is growing every year and according to many experts, this trend won’t stop in the near future.

There is no doubt that chin augmentation should be taken into consideration by any individual who is dissatisfied with the look of their chin. It is good to know that people can have this procedure independently or together with few other plastic surgeries. Those wondering whether they are the right candidates for chin augmentation should schedule a meeting with a qualified and experienced cosmetic surgeon. They will evaluate their chin and provide additional information about the procedure.

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With the national health services rolls expanding, patients all across the UK are experiencing longer than anticipated wait times for visits with their general practitioners (GPs).  Patients are also being cautioned to expect fewer necessary services being offered as more and more GPs reduce their offerings due to the necessary reduction of time spent per patient.  Industry experts are also anticipating a loss of quality in routine treatments as resources are maxed out in an effort to serve more patients with the same or fewer resources in staff and equipment on hand. With this news, the proactive purchase of private medical insurance has become a health wise decision, one that provides a sense of financial well being.

One clear difference between private medical insurance experience and the offerings of the public health services is a matter of choice.  The required referral of a GP who has control over whether or not you will be referred to a specialist as well as the location and facility where the treatment will be carried out.  If the idea of making the best decision for you and your health appeals, then consideration of the pros and cons of private or public healthcare should be of keen interest.

Besides choice, the matter of quality has become another significant talking point of the medical industry across the UK.  Accessibility to doctors who are well trained and at the cutting edge of their specialty in the use of the most up to date medical equipment and breakthrough treatments can significantly reduce a patient’s treatment and recovery times; meaning the loss of income due to work stoppage is reduced and the patient’s quality of life is more quickly set to rights.  Patients with private medical coverage are also less likely to be held at the mercy of the cumbersome approval process as governed by the NHS, and are more apt to be involved with decision making process regarding his or her treatment and the services deemed necessary by the doctor.  Decisions for treatment and access are granted in a matter of days, and based on the specific needs of the individual as opposed to the public health guidelines, which takes a more one-size-fits-all approach to healthcare.

In the Greater London Area, a GP referral for a heart valve operation can take anywhere from 4 to 19 weeks before fulfillment at an NHS governed facility;  this time span is in line with the 18 weeks of wait time between referral and an appointment in accordance with the public health guidelines.  With private insurance coverage, one could consider Spire Healthcare- where one can book a diagnostic appointment with a specialist for as few as 24 hours from the time of the initial inquiry.  Clearly the patient with private medical insurance coverage is able to act to his or her own advantage regarding choice of specialist, the timing of medically necessary procedures and they enjoy having a greater say in their own treatment timeline.

The Insurance Service was established with the goal of meeting the needs of clients with an interest in preserving his or her quality of life in the event of a major illness or accident and, even death.  When considering the future, protecting your family and assets against the unforeseeable is an important aspect of long-term financial health.  Don’t leave to chance the access to choices, a higher quality of care and efficiency of service when all of these things can be so easily attained.

 

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The introduction of a controversial healthcare act in England is encouraging hospitals to treat more private patients to raise funds – allegedly increasing waiting times for those being seen on the NHS.

NHS for sale

The Health and Social Care Act 2012 opened up the possibility for hospitals to raise up to 49 per cent of their income from treating private patients. Previously they were only allowed to raise about 2 per cent from private sources.

Critics at the time voiced concerns that those who could afford to pay for their own treatment would be prioritised over those who depend on the national healthcare system. It was felt waiting times would increase and the lives of the most vulnerable – those who cannot afford to pay for treatment – would be put at risk.

Certainly it seems that hospitals are making use of this potential new cash stream. In November The Guardian reported that some hospitals in England had increased their private income by an average of 10 per cent since 2010. More ambitious figures were revealed for the more industrious and enterprising NHS trusts.

Moorfields Eye Hospital NHS Foundation Trust increased its private income by 60 per cent, bringing in £8 million in the space of just five financial years thanks to the act. Poole Hospital NHS Foundation Trust saw its private patient income leap by 123 per cent from £613,000 in 2009/10 to £1.5 million in 2014.

And with many hospitals opting to take on more private patients it seems that NHS waiting times have increased, which has led to a ‘crisis of confidence’ for NHS customers – also discussed in the same Guardian article.

It seems the 2012 act is only adding to the concerns of patients who cannot afford private healthcare.

A survey from Saga Health Insurance in March last year found that 42 per cent of over-50s felt the quality of care provided by the NHS was poorer – a significant increase from a similar survey conducted in 2009, which showed only 17 per cent shared these sentiments.

As customer satisfaction drops and waiting times grow, health insurance providers are finding new and inspiring incentives in a bid to encourage patients to take out a healthcare policy.

Saga is one such operator that not only pledges to offer affordable protection, but a unique four week wait option that guarantees patients on the plan will be seen immediately by a private hospital where the NHS waiting time for a procedure is longer than four weeks.

Furthermore those experiencing one of nine common conditions such as varicose veins or cataracts will receive immediate treatment even if they have taken out the four week wait option.

It’s an assurance that some hospital departments are struggling to give.

Some fear private patients are ‘jumping the queue’ and yet more and more people are dissatisfied with the NHS, meaning the allure of affordable alternatives for those who want – or need – to be seen sooner are becoming feasible alternatives.

Perhaps the future of healthcare is a public-private blend, one that provides a level of assurance to vulnerable patients and removes the concerns over NHS care.

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So much has been written and broadcast about terrible standards of care in some NHS hospitals in recent years, most notably but by no means only at Mid Staffordshire, that it would be easy to gain the impression that it might be safer to be treated in a private hospital. The profit-making concerns who run private healthcare have probably benefitted significantly from recent NHS scandals.

However, as our experience at Action against Medical Accidents (AvMA) and the report from the Centre for Health and the Public Interest (CHPI) points out, whilst there is no denying the urgent need for improvements to the promotion and regulation of patient safety in the NHS, there is little or no compelling evidence that the private sector is any better.

In fact I would argue that a combination of a false sense of security based on the assumption that if it is private and paid for it must be better, together with the gaps in the regulatory system and patients’ rights in the private sector, create an unnecessarily risky environment. It is also a credible argument to say that where there have been the worst problems with safety in the NHS some have at least in part been a consequence of imposed competition and fragmentation through part privatisation. Take the problems with GP out-of-hours services for example.

There has at least been progress with the regulation of private healthcare in England now coming under the same regulator as for the NHS – the Care Quality Commission (CQC). In theory, a private hospital has to demonstrate that it meets the fundamental standards required by the CQC just as much as the NHS. However, a deeper look at the system reveals an uneven playing field.

As the CHPI report points out, the same requirements to report incidents do not apply to private providers as they do to the NHS, which in itself makes it hard to monitor how safe or otherwise private services are. Information about clinical negligence claims against private providers are not publicly available, as they are in the NHS. The CQC has, to meet ministerial and public expectations, prioritised inspecting and monitoring the NHS. Bizarrely, as recently as this year the Government passed the Care Act, which exempted providers of privately funded care from the new criminal offence for providing false or misleading information to the regulators. As if this could only happen in a publicly run service.

Patients themselves have fewer rights in the private sector. Whilst there is a general requirement to operate a complaints procedure, unlike the NHS complaints procedure, those used by private providers afford no statutory rights to the complainant and there is no recourse to the Health Service Ombudsman in the case of private care. There is no statutory requirement to provide for independent advice and support with complaints which is the case with the NHS. Consequently it is much harder to hold a private provider to account. Even taking legal action for clinical negligence against a private provider is more problematic than with the NHS, where everything is overseen by the NHS Litigation Authority. A claimant against a private provider can be faced with complications over whether it is the hospital or the individual surgeon or sub-contractor who is liable.

AvMA’s experience confirms many of the CHPI report’s conclusions. In our experience the chief risks in the private sector have been where there are insufficient facilities and consultant cover to cope with emergencies; insufficient continuity of care or after care; and the lack of a critical mass of experienced doctors in situ as well as the aforementioned gaps in regulation.

All too often, in addition to the patient who is harmed through no fault of their own, it is the NHS which ends up picking up the pieces (and the tab) when things go wrong in private healthcare. It is time to shine just as bright a light of scrutiny and regulation in the private sector as we have begun to in the NHS.

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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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Care UK sees an opportunity to make money out of NHS rationing decisions

Care UK GP Newsletter

Care UK GP Newsletter

Charges advertised to doctors for people not eligible for NHS treatment:

Care UK Tariff

Richard Blogger’s articles about NHS hospitals doing private work

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Almost one in five NHS patients seen in secondary care now treated by private firms, after Labour’s ‘patient choice’ reforms led to an expansion in the independent healthcare market, a report by the Nuffield Trust and the Institute of Fiscal Studies concludes.  But as John Lister writes “These figures are evidence of private sector expansion but need to be treated with caution: they only relate to elective treatment – and in fact the study only looks in detail at three elective treatments (hip replacement, gall bladder removal & hernia), with a grand total Independent Sector Treatment Centre provision of 24,000 episodes between them.

By contrast the NHS dealt with 9.8 million elective admissions and 5.2 million emergencies. ISTCs did 12,000 hip operations: the NHS handles 856,000 operations on “bones & joints” each year.

0% of emergencies are seen by the private sector, and on none of the categories of elective treatment analysed do the figures go above 17%: gall bladder ops are just 6%.

The percentage of outpatient activity in the private sector is even smaller: so to claim that 20% of NHS patients are “now treated by private firms” is just grossly inaccurate and misleading.

All this use of private providers is expensive, wasteful and undermines the proper provision of a comprehensive health service. It is a terrible legacy from a Labour government that could have spent the money and the time to strengthen public sector provision and protecting it against the ravages of the Tories and their LibDem sidekicks.

But let’s not allow the false, defeatist picture to be generated that suggests the NHS is already largely privatised. This does not help us defend what are still vital public services, few of which would be offered by private providers unless they could screw additional funding from government over and above the NHS tariff.

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Bernie Creaven, executive director of  BMI Meriden Hospital, Coventry  ordered an immediate four-week postponement of operations on NHS patients referred to the hospital, which will be extended to a minimum of eight weeks by September.

In a letter to the hospital’s consultants dated 13 July, seen by The Independent, Ms Creaven said the imposed delays were to discourage patients thinking of going private from opting for treatment on the NHS.

Private hospitals receive taxpayer money for treating NHS cases, but can make larger fees if the patients go directly to them for treatment.

“I believe time to access the system is the most critical factor for private patients converting to NHS patients,” she wrote. She added that “other aspects of differentiation” would be introduced over the next few weeks to make NHS treatment at the hospital relatively less attractive”.

The 52-bed BMI Meriden Hospital in Coventry charges self-pay private patients from £8,500 for a hip replacement. The NHS cost is from £5,485.

In her letter to consultants, Ms Creaven says: “Over the past few months I have had numerous discussions with consultants regarding the lack of differentiation between NHS and private patients and there is significant anecdotal evidence to suggest that the lack of differentiation has had a negative effect on our private patient referrals.

“I now wish to implement with immediate effect a new rule which will mean that operations on NHS Choose and Book patients will not be able to take place until at least four weeks following their outpatient consultation. Also, in each subsequent month, I will extend this by another week until September and the time will be eight weeks from initial consultation. I believe that this time to access the system is probably the most critical factor for some private patients converting to NHS patients.”

A spokesperson for BMI Healthcare said: “We treat both NHS and private patients to the same high standards of clinical quality.”

I suppose this is what they call a free market in healthcare?  The patients are not the consumers.  They are the commodity from which profits are made.

 

 

 

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