Fears that the concordat between the NHS and the private sector will lead to privatisation are unfounded. It’s more likely to be the nationalisation of private medicine, says Joan Higgins, professor of health policy and director of the Manchester Centre for Healthcare Management, Manchester University. Until recently she was the Chair of the North West Region of the NHS.
Published in HSJ January 2001
- The Commission for Health Improvement will have authority to monitor private hospitals treating NHS patients. The private sector will be subject to the NHS complaints procedure.
- The issue of medical staffing for private hospitals needs to be addressed.
- The uneven spread of private facilities across the country undermines the partnership.
- Arrangements to cut NHS waiting lists will reduce demand for private medical insurance.
When the government signed its concordat with the private sector last November, it was hailed by some as a ‘historic development’ and by others as ‘privatisation by the back door’ ‘ The Times said that it showed a ‘welcome lack of dogma, The Sun gave it ‘full marks’ and even The Guardian said that the deal ,made sense ‘but’ needed watching’. Health secretary Alan Milburn, announcing the concordat, said that it was wrong to leave private sector beds and operating theatres lying idle when neighbouring NHS hospitals had no capacity to treat patients. The concordat was clearly seen as a short-term tactic for addressing winter pressures, but it also included a commitment to a ‘more collaborative and proactive approach to long-term capacity planning’. The style of the present government has far more in common with the post-war pragmatism of the the health minister, Aneurin Bevan, than confrontational position of the 1970s Labour governments which, instead of squeezing out private sector, were at least partly responsible for its unprecedented growth.
The concordat is a slim volume that describes itself as an ‘enabling framework’ rather than a detailed blueprint for service delivery. It is based on the principle that treatment will be provided free at the point of use. The location of care maybe the NHS, private hospitals or the voluntary healthcare but the funding will come through contracts with healthcare commissioners in the normal way. There is an expectation that private providers will be embraced by health authorities in their development of health improvement programmes and seen as part of the total healthcare resource of an area, rather than an ‘add-on’
The concordat goes a long way towards addressing the anxieties that many critics had previously voiced about using the private sector for NHS patients. There are to be locally agreed protocols for the movement of patients across the public-private divide. These will include an agreement on the level of care to be provided in the two sectors, the circumstances in which patients will be transferred between hospitals and the standards of care to be maintained during the transfer. The existing practice is to move seriously ill patients from private hospitals to the NHS when facilities prove inadequate: this should no longer take place in an ad hoc way. The private sector will be expected to participate in care planning arrangements across the acute and long-stay sectors and work towards developing joint information systems for patient data.
The concordat is also explicit on other ‘quality’ issues. Whenever NHS patients are treated in private hospitals they will be subject to the same processes for ensuring good clinical standards as would prevail if they were in NHS care. National service frameworks will apply, as will National Institute for Clinical Excellence guidelines. Private hospitals will be required to report adverse clinical events in the same way as NHS hospitals are expected to, and services in private hospitals treating NHS patients will be monitored. NHS commissioners will be responsible for monitoring standards and private providers responsible for delivering them. The private sector will also be subject to the NHS complaints procedure: the Independent Healthcare Association has developed a code of practice and complaints system for private facilities. The National Care Standards Commission, which starts work in 2002, has a brief to maintain and enhance standards of care across the private sector, including domiciliary and social care services as well as residential and acute care. Every effort has been made, therefore, to ensure that the quality controls which have been introduced in the NHS in recent years will apply equally to the private sector.
The government has made no secret of the fact that its prime motivation, at present, is to address immediate winter pressures. It talks in the concordat about the private sector’s ability to provide ‘additional health and social care options during the winter’ However, it also commits itself to working with the IHA to ‘broaden the aims of the concordat’ and develop a long-term relationship between the NHS and the private sector.
Although the government has been criticised by its own backbenchers over the concordat, it has shown that it is quite closely in tune with public opinion in what it wants from a modern healthcare system. David Hinchliffe, the Labour chair of the Commons health select committee, has complained that it is wrong to ‘get into bed with’ the private sector and subsidise a struggling industry. Tony Benn MP argued that it was tantamount to the privatisation of the NHS. Both views seem exaggerated and out of line with the majority views of the public.
A MORI poll in August 1999, for example, showed that 75 per cent of those asked ‘strongly supported the view that the country’s healthcare needs would be better served if the NHS and the private sector worked hand in hand”. Furthermore, this support fell evenly across all three major political parties. The prime minister and health secretary will have known, when they spoke of the need to break down ideological barriers, that this would command widespread support. Conversely, an unwillingness to contemplate using empty beds and operating theatres in the private sector while the NHS struggled to cope would have attracted condemnation.
Although the concordat may seem radical to some, it is actually bringing the UK into line with models of public-private sector partnership which are common in the rest of Europe. Britain has been virtually unique in insisting that the founding principles of a socialist healthcare system can only be preserved if the care is both funded by and provided by the public sector.
Models for Partnerships
Various models for public-private partnership are envisaged. For elective care, the concordat suggests that primary care groups and primary care trusts could rent accommodation from the private sector but use NHS staff, on their normal contractual terms, to deliver the service. or a trust might ‘sub-contract’ the provision of a service to a private provider, who would be paid by an NHS purchaser via the trust. Third, a PCG, PCT or health authority might commission the privately provided service directly.
One of the areas of greatest potential for collaboration is intermediate care. The concordat stresses that “intermediate care is not long-term care’. The aim should be to promote independence through rehabilitation. Intermediate care is designed to prevent hospital admission as well as to facilitate rapid discharge, where appropriate. The concordat urges partnerships which are innovative and responsive to users needs.
Finally, the concordat envisages a collaborative approach to workshop planning in every locality. Private sector employers are to be invited to join the newly established workforce development confederations to facilitate the development of “overall workforce plans” in each area. The confederations will address both current and future staffing requirements and share information across the sectors to inform the planning of education and professional development
Other countries have seen hospitals as “workshops” in which health professions ply their trade, rather than system requirements which must be owned by the public sector. They have maintained that the really important qualities of an egalitarian healthcare system are that it is funded through progressive taxation or social insurance, that it is free at the point of need and that clinical standards are equally high regardless of the social status of the patient. If these fundamentals are preserved, the question of who owns and manages the buildings maybe of only secondary importance. Some more critical questions relate to what the concordat does not say. Two issues may undermine the plan’s smooth implementation, unless addressed constructively. First, the section on workforce issues does not mention that the private acute sector in the UK relies almost exclusively on NHS consultants for its medical staffing. The concordat will essentially displace elective work that would have taken place in the NHS if the beds and theatres had been available, but does not increase the number of doctors able and willing to do the work. Private hospitals have few junior doctors or resident doctors.
It will be essential to be precise about who will fund and provide private medical care and under what terms and conditions. The concordat refers exclusively to care commissioned by the NHS, but there maybe grey areas where NHS consultants in the private sector maybe unsure who is funding them to do what. More important, attention needs to be given to the perverse incentives that have existed for over 50 years for NHS consultants to allow their NHS waiting lists to grow to boost their private practice. Common waiting lists have never been fully introduced and maybe a weak mechanism for tackling the problem. Complex and highly delicate relationships are involved. They need gently teasing out so that NHS doctors are fairly treated, but NHS patients get the best possible care at the best possible price.
The second unspoken problem is that private sector facilities are unevenly spread across the country. Traditionally, acute services have been concentrated in London and the South East where private insurance coverage is most extensive and where a market for overseas patients is established. This means deprived areas of the North will experience a ‘triple whammy’. Levels of morbidity, mortality and health need are highest in the North. NHS acute facilities experience intense pressures there. However, comparatively few private sector facilities exist to relieve them.
There are no short-term solutions, unless patients are willing and able to travel outside their area for elective care. It complicates the notion that public-private collaboration, in terms of service delivery and workforce planning, can take place within the boundaries of a single HIMP or health economy. Some imaginative thinking around this issue needs to take place if existing inequalities in access to care are not to be exacerbated.
Finally, how will the new concordat affect the private and voluntary sectors? Are they laughing all the way to the bank -or worried that they have been compromised? Neither seems to be the case.
Leaders of the industry were concerned, before the concordat was published, that the NHS might simply want to use spare acute capacity at marginal cost over the winter months but have no commitment to a longer-term relationship. This fear appears to have been unfounded.
The private sector sees the greatest area of potential collaboration as being intermediate care. This is certainly one of the biggest gaps in public care and one where innovative joint-working could produce real benefits for patients. Paradoxically, however, the present gains for the private sector may lead to longer-term losses. If the British public sees the NHS tackling waiting times successfully (through the concordat and other measures), if appointment times become more convenient through booked admission systems, and if access to primary care and health information becomes quicker because of walk-in centres and the roll-out of NHS Direct, the incentive to take out private health insurance and ‘go private’ will be reduced.
The long-term trend, far from being privatisation of the NHS, may look more like the nationalisation of private medicine – not in the sense that the NHS would buy out private facilities, but in undermining the current demand for private medical care provided by NHS doctors and funded through private insurance. This scenario is a long way off, but is one possible outcome of the new concordat, which has opened up an array of possibilities in the delivery of health and social care in the UK.