Still not for sale?
The debate over whether the NHS is being sold off, privatised or improved by putting services out to competitive tender even reached the BBC last week, thanks to evidence collected by the NHS Support Federation. Their research found over £5 billion worth of contracts to run or manage ‘clinically related NHS services’ have been advertised in the first 9 months since the competition regulations (section 75) were passed by Parliament in April 2013. 70% of the contracts have gone to commercial companies (38 to the private sector, 15 to the NHS and two to charities and one shared between the public and private sectors). The contracts cover over 70 different services across the NHS.
Supporters of the Health Act argue that the NHS will raise its game from this ‘constructive discomfort’ of private competition. The phrase was coined by Simon Stevens, Blair’s (and Dobson’s and Milburn’s) former health adviser who is returning as CEO/Messiah of NHS England in April, having cut his teeth with American health giant UnitedHealth. UnitedHealth’s incursions into the NHS market, particularly in GP services, and subsequent withdrawals having failed to make a profit (and posted substantial losses), highlight the danger of this approach. Large private companies have the up-front muscle to win NHS contracts but pull their services if there is no profit to be made, leaving holes for the NHS to fill.
If the trend of private companies winning NHS tenders continues, NHS trusts will lose business and face an even bigger challenge balancing the books. Although Foundation Trusts do not pay money to shareholders, they – and hospitals that aspire to become FTs – are now very ‘profit focused’, prioritising treatments that make the most money. Treatment becomes less about satisfying the needs of patients and more about satisfying the needs of Monitor, the economic regulator of the NHS. Last September, Peter Gladwell, a Clinical Specialist Physiotherapist at Frenchay Hospital in Bristol, wrote to Monitor asking it to explain whether handing over taxpayers’ money to shareholders’ of private NHS providers satisfied the promise in the NHS Constitution that all NHS spending must be ‘for the benefit of patients.’
The answer, from Claire Upton (Enquiries and Complaints Officer) was both unhelpful and very illuminating: ‘I am afraid I cannot confirm whether your interpretation of item 6 of the NHS constitution is correct. I understand the NHS Constitution was produced by the Department of Health (DH), who may be able to assist you further. However, we know the NHS needs to change to meet the challenges of the future and that, as the sector regulator, Monitor must facilitate that change. This means we will encourage new ways of delivering care and will use the tools we have, such as pricing incentives, to encourage innovation. We will also be pragmatic and flexible in applying rules. We are not pre-disposed to any particular solution to the challenges facing the NHS; instead our decisions and actions will be based on the available evidence. Where relevant evidence is scarce, we will commission research to establish the facts. What matters to us is that all our work helps to improve the quality of services so they are clinically effective, safe and provide a positive experience for everyone who uses them. Where we have complex decisions or trade-offs to make we will be guided by one simple principle: we will do whatever is ultimately in the best interests of patients.’
The trouble for Monitor is that many NHS staff and patients doubt it has the ability and wisdom to act in the best interests of patients, rather than the market, and they don’t trust it either. To simply pass the buck for such an insightful question back to the DH, when the whole of the NHS is supposed to be beholden to the Constitution, is pitiful. GPs are also private providers of NHS care, but they treat patients and are mostly of benefit to them. Shareholders clearly are not.
Tim Kelsey, NHS England’s National Director for Patients and Information recently dismissed the idea that the English NHS could ever be privatized as ‘bollocks’, presumably meaning that it will always be tax-payer funded. But where public money ends up matters. Kelsey is responsible for publishing outcomes in the NHS, which should eventually show if private providers improve NHS care or not. In the 2 years to March 2012, a year before the competition regulations were passed, NHS productivity and quality of care both improved with very little private competition. There is no evidence it is needed.