Feature

Now inject some accountability

In October ministers signed a ‘concordat’ between the NHS and the private sector. But if this marriage is to last there are some relationship issues to resolve first, warns Martin Rathfelder

The Independent Healthcare Association estimates that the private sector can deliver 150,000 operations a year in its 211 hospitals. This is small beer compared with the 6,500,000 NHS operations annually.

But the private sector already delivers 20 per cent of all acute mental health provision, 80 per cent of brain injury services and 55 per cent of all medium-secure care. There are 450,000 beds in private residential care, more than the NHS and local authorities combined, and there is capacity to provide 40,000 more.

Alan Milburn says it is ‘the right thing to do for patients’ to make more use of private facilities. If the NHS has no facilities for patients when they need them it will not disadvantage them individually to go to the BUPA hospital for nothing and enjoy the benefit of a private room with shower and decent food.

We already have a mixed economy of private and public provision in many sectors and, since the collapse of the Berlin Wall, there are few people advocating that the whole economy should be nationalised. The Labour Party has adjusted its definition of socialism accordingly. We now fight for ‘a dynamic economy, serving the public interest in which the enterprise of the market and the rigour of competition are joined with the forces of partnership and co-operation to produce the wealth the nation needs – and high quality public services where those undertakings essential to the common good are either owned by the public or accountable to them’. It is not quite as inspiring as it was before, but perhaps it is more useful as a guide to policy.

But what effects might the new public-private health ‘concordat’ have on the NHS in the longer term? If a mixed economy is a good thing – and this is a fundamental assumption not accepted by everyone – then the balance between services provided by the public sector and by the private sector is about quality and cost.

The fundamental principle of the NHS is that care should be provided when it is needed without charge to the patient, not that it should be provided by the public sector. If we could get more health gain for less cost by contracting all NHS services to the private sector then we should do it. All that the concordat proposes is a bit of readjustment of the balance, and more planning of how this balance is to be managed.

But will this arrangement lead to an improvement in the services provided to patients? And will these private health undertakings, which are clearly already essential for the common good, be accountable to the public?

Staffing

Many private hospitals are operated by NHS staff moonlighting, as are many NHS hospitals. Conditions in the NHS must be attractive enough to keep trained staff doing their proper jobs – not going back to their own wards as an agency nurses for more money.

If we are going to lay down stricter conditions on how and when doctors work privately we might need to do the same for other staff. The costs of training are entirely met by the NHS for most staff and it is not unreasonable for the NHS to have first call on those staff for whose training it has paid.

Costs

The national plan proposes protocols for transfers between the two sectors. Perhaps private hospitals should have to pay a transfer fee if they recruit an expensively trained NHS doctor. Many private hospitals rely on the NHS for back-up if something goes wrong, and it is obviously cheaper to do routine surgery if someone else meets the cost of the intensive care bed which is needed from time to time. It would hardly be ethical to turn patients away because they had been in a private hospital, but perhaps the cost of this back-up service could form part of the agreement.

Private hospitals concentrate on cold surgery and they might, if permitted, corner the market in particular conditions such as hip replacements, cataracts or bypass grafts and then drive up prices as seems to have happened with sex-change operations, which are almost all done privately.

Health secretary Alan Milburn has suggested that we might have dedicated surgical centres. They could be more efficient, although their efficiency might be gained at the expense of a loss of flexibility elsewhere in the system: it might not be desirable to have medical patients in surgical beds but when there is an epidemic it is very useful to have them.

We need to ensure that the costs of private surgery are not higher than costs inside the NHS, which will entail some difficult negotiation about the marginal costs of extra work. If we are to show greater health gain from using the private sector then we must make sure that all the costs to the NHS are counted in. Private operators are far more experienced at laying off costs onto the NHS than its managers are at spotting them.

Waiting lists are the main driver for private acute work. We have to end the practice whereby a consultant can say to a patient: ‘You will have to wait 42 weeks for this procedure on the NHS but at my private rooms I can see you next week.’ Consultants may do this from the best of motives. They would like to do more NHS work but they cannot get the theatre time or beds to do it in.

The NHS Plan must reduce the incentive for patients to go privately, and we need to make it clear to consultants that diverting business from their employer to the competition is unethical. It gives patients the impression that the NHS is a second-class service. Most people know this is untrue, but it is easy to see how, given the poor state of things like furniture, decoration and food, they could reach that conclusion.

Facilities

We need to improve facilities in NHS hospitals and perhaps consider whether patients should be permitted to pay for more extras: paying for TVs and telephones seems to be acceptable.

In our local psychiatric unit patients send out for a curry if they don’t fancy the hospital food. Perhaps patients could also be permitted access to the hospital wine cellar if they were prepared to pay for it. In our increasingly diverse society, the institutionalised uniformity of the NHS hospital environment is one of its least inviting aspects.

But allowing people to pay for extras must be managed sensitively, without allowing the basic provision to degenerate.

Accountability

How are we to make this private care accountable to the public? The track record on quality monitoring has been mixed up until now: private hospitals have not been subject to inspection by community health councils or subject to any complaints procedure, and have relied on local NHS provision, especially of intensive care beds, to bail them out – at considerable cost – if something goes wrong.

The Care Standards Bill will ensure some improvements to this situation, but there seems no good reason for not extending the work of the Commission for Health Improvement into the private sector.

Residential care has been subject to increasingly rigorous inspection in recent years and there are encouraging signs that standards have risen and some of the worst homes have gone out of business. But in many of the areas in which the NHS has used private provision the most, such as medium-secure accommodation and eating disorders, there seems to be little expertise or interest inside the NHS, and certainly not much in the way of planning.

If we are going to use the private sector more constructively, then planning and commissioning services will have to include its facilities in a more strategic way. It cannot be left to provider trusts merely to contract out business opportunistically.

Accountability is not just about monitoring quality, it has to extend into the planning processes which will be a challenge to the private sector. But part of the price it will have to pay for a more stable relationship with the NHS must be an agreement that it will not undermine local NHS provision.

Competition will have to be constrained, especially if local councils are to be convinced that what the concordat proposes is acceptable. And we need to see transparent complaints processes and user involvement in managing services.

Whatever mechanisms replace CHCs must extend into the private sector. If there is to be a patients’ forum, an advocacy service or scrutiny by the local council, then private facilities will have to be included in that scrutiny if they form part of local NHS provision.

Accountability implies an openness which the private sector may find challenging – as indeed do some in the public sector.