Last updated:

Rescue bid for quality of care

Ward sign 16x9 

The BMA has today published a report on privatisation in the NHS. It calls for Government to implement eight recommendations in order to preserve the quality of services. Peter Blackburn reports

When commissioners put the contract for adult dermatology services in Nottingham out to tender in 2012, they had no idea that the deeply problematic consequences of that decision would still be felt nearly four years later.

Circle Partnership — which already ran a treatment centre on the Queen’s Medical Centre site — won the contract and expected 11 nationally recognised dermatology consultants to transfer via a TUPE agreement from Nottingham University Hospitals.

But only three accepted the move — with the others calling the decision ‘flawed’ and finding work elsewhere.

In the months following the catastrophic decision, services collapsed leaving patients travelling to other cities and a once world-class reputation, and training centre, in tatters.

One of the consultants involved told the BMA the collapse was a ‘tragedy’.

Arun Tangri, a GP in Bulwell, Nottingham and member of the Nottinghamshire LMC (local medical committee), adds: ‘It’s a really big issue. It was a feather in the cap of the hospital.

'Only now people are starting to feel happier — it’s not 100 per cent good at all, but it’s getting better.

'It’s been a long time for patients — there’s no doubt about that at all.

'It’s hard to see things like that happen as a fellow professional.’


Vital consistency

Patient Anjna Rani, who has been under the adult service for nine years, says: ‘I was very concerned when the decision was first made.

'Consistency is extremely important and seeing somebody inexperienced and having to explain the same things over and over again is very frustrating.

‘I am generally seen on time if I have had a concern with my skin flaring up, but I cannot contemplate how it has been for new patients — the thought of having to travel to Derby or Leicester is awful.

'It is exactly this sort of costly and embarrassing breakdown that a BMA report, published today, could help to avoid in the future — protecting the NHS from crippling fragmentation. If the Government listens.

The association supports a publicly funded and publicly provided NHS — but where private providers, defined here as those in the commercial and private sector, independent sector treatment centres and social enterprises — have to be involved, they must be subject to the same rigorous controls as NHS providers, the report asserts.

According to the recommendations outlined, this should include having to report patient safety and complaints details, being subject to Freedom of Information requests and being covered by the parliamentary and health service ombudsman.

More generally, the report asks whether a culture of handing contracts to private providers without due care and consideration can continue if the NHS is to overcome its current workforce, resource and demand challenges.


Waking Government

As BMA chair Mark Porter says in his column on the topic today: ‘Our new report attempts to wake the Government and some commissioners from their selective slumber, and to prompt the questions they should always have been asking on behalf of those who are cared for and who pay for the service — does the private sector provide value for money, and comparable quality and safety to patients, and how does it impact on other services?’

The BMA is also asking for Government to consider that an increased reliance on the independent sector by the NHS could have serious workforce implications – with staff unlikely to receive the breath or intensity of training that they would normally do.

As workforce and recruitment troubles spiral, such short-term problems will quickly become long-term crises.

This report is not ideology out of the blue. Members are particularly concerned about problems occurring as a result of privatisation in their local areas – in fact, a BMA survey revealed that more than two-thirds said they were uncomfortable with the independent sector being involved in NHS work.

Just ask Sussex GP Brian Goss, who has seen the potential destabilisation of services that can result from contracts being put out to tender.

Dr Goss watched as an ineffective musculoskeletal triage system was put in place in the county in 2013, delaying the point at which the clock started ticking for patients to have to see a physiotherapist.

The service was soon handed to BUPA in a £235m deal.

But an analysis of the decision — undertaken after it had already been rubber-stamped — soon revealed that to go ahead would plunge the local hospital trust into deficit.


Local outcry

Dr Goss says: ‘The way it impacted on most of the system was not favourable.

'It would have put the local hospital out of business and would have put other similar services at risk. There was something of an outcry locally.

This is an example of what a market approach can do in the NHS.

It’s about resourcing, but it’s also about fragmentation. Here we are trying to integrate our health service and it is difficult to do that if the providers are changing and new relationships have to be formed.’

Dr Porter says: ‘Allowing the private sector to cherry-pick profitable, high-volume work will inevitably have a destabilising effect on the wider NHS.

'In some cases, it may be enough to push trusts already facing record deficits to the point of collapse.

'This betrays a complete lack of strategic sense as to how an integrated and effective health service should be run.’

These stories of costly failures are mounting and there are few positive stories to act as a counterbalance.


Unequalled failure

In 2012, the story of perhaps the greatest failure in the area began when the management of Hinchingbrooke Health Care NHS Trust was handed to independent sector provider Circle — in a 10-year deal.

Just three years later, the hospital was back with the NHS after being plunged into special measures and with worrying financial pressures.

Concerns that the deal hadn’t properly been assessed were raised and Circle was only liable to pay for £7m deficit, despite this being only a percentage of the total and the NHS was left to turn the situation around.

With a system-wide budget deficit of at least £22bn, such costly mistakes are simply unaffordable — and these recommendations must be implemented.

Dr Porter says: ‘This needs to be monitored carefully and not something that’s brushed under the carpet and forgotten about.

‘One of the things we’ve learnt is the private sector may be able to provide short-term local solutions but couldn’t provide services of the seriousness and complexity that the NHS does. The NHS has a power and reach private organisations can’t match.

‘We are encouraged to look at switching energy providers, but there are major obvious differences [between that and the NHS]. The product that comes out of the plug is the same, but that’s not the case when we talk about complex clinical services.’

While concerns among doctors are clear, privatisation hasn’t accelerated at the anticipated rate in recent years.

In 2014/15, £6.9bn was spent on procuring services from the independent sector — a 5.4 per cent increase on the previous year.

In context, the total NHS budget is currently around £116bn.


Major concern

Dr Porter says: ‘Privatisation remains a major concern for our members because it has seemed to be a thread through the previous three Governments.

'But one of the key things we’ve discovered is while members are very concerned about it and it’s penetrated some areas, there’s not the wholesale privatisation of the NHS today that we might have expected.’

The consequences of privatisation can run deep, however, as recent history has shown. And for Dr Porter the message is simple — the BMA is keeping a ‘watching brief’ and will campaign for the changes in process and policy that are needed to protect the NHS, such as the ones set out in this report.

He says: ‘The NHS exists to provide the highest-quality care for its patients. Anyone who doesn’t accept that, or gets in the way of achieving it, should not be allowed near it.

'That’s true for anyone who works in the health service, and it’s also true for any individual or company providing services within it.

‘It’s not our job to support their shareholders. It’s their job to support our shareholders – every man, woman and child in the UK who uses the NHS.’


Case study: dermatology and devastation

Consultant dermatologist Stuart Cohen felt he had been left with little choice when he was told to decide between transferring to a private provider or leaving his patients behind and starting a new job more than 100 miles away.

Mr Cohen had been part of a service recognised as world class at Nottingham University Hospitals NHS Trust when commissioners handed local contracts for adult dermatology to private firm Circle Healthcare — but had no desire to leave the NHS.

Dr Cohen, who now works in Liverpool, says: ‘It was devastating for the team.

‘We had what was widely regarded as one of the best dermatology departments in the country.

'We had a number of national big hitters and we actually got on very well.

'We had national leaders in many areas. We had a great team and that was just exploded.’

He adds: ‘Doubtless patients have been caught up in the mess.

'I expect Circle would say they have continued the care, and to an extent that would be the case, but I am aware of individual patients who have ended up seeing several different locums in succession rather than having the continuity of care.

'For some patients, particularly those with complex disease, it can be very dispiriting to see somebody new each time.

‘The current big issue, as I understand it, is with acute dermatology, so the really severe end of skin disease because the hospital trust has so few dermatologists – only the paediatric ones are left.

'We ended up sending seriously ill patients to Leicester — which is ridiculous.’

And the process has been disruptive for staff, as well as patients.

Dr Cohen says: ‘I have changed job, moved family, bought a house, sold a house, paid a lot of tax and it’s been very disruptive.

‘My wife had to find a new job and it’s very difficult. It’s exceptionally undesirable.’

Amanda Roberts runs a support group for people with skin conditions in Nottingham and has used the local services in the past.

She says: ‘It’s still deeply concerning — it’s just incredibly poor.

If you’ve got a long-term condition, you are never going to build up confidence or a relationship.

'That worries me. Without the adult dermatology service, the worry is the children’s service will collapse. It will just be frittered away.

'It will take a long time to rebuild and these are some of the problems of privatisation. These can be the things that people don’t appreciate.’

Read more about the BMA report on privatisation; see the numbers and see our eight recommendations



The story so far

Read more from Peter Blackburn and follow on Twitter.