August 12, 2011 : Co-operating and competing to privatise the NHS

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“NHS delays operations 'as it waits for patients to die or go private'” thundered the front page of the Daily Telegraph after the release of the Co-operation and Competition Panel (CCP)’s report on choice and competition in elective care late last month. Most of the major papers and news broadcasters jumped on board, the majority repeating that Primary Care Trusts (PCTs), in an attempt to cut costs, are setting minimum waiting times for patients, who then either “die or go private.” A Daily Mail leader declared: “it’s hard to conceive of a more barbaric tactic than making patients wait so long for surgery that they either go private or die.”

But reading the report, it turns out they were getting all worked up for nothing. For a start, the report is looking into elective care. Elective care includes things like hip replacements, knee replacements, foot surgery, tinnitus, varicose veins and so on: “pre-arranged, non-emergency care that includes scheduled operations,” in the words of the Department of Health. Serious, painful conditions of course, but not ones that will kill you if you have to wait a couple more weeks for an operation. As a weary David Stout, director of the Primary Care Trust Network, told the Today programme: “the suggestion people are dying waiting for routine elective care doesn't make sense.”

So what’s this “waiting for patient to die” claim? It comes from paragraph 131 of the report, in which the writers explain they were told: “increasing waiting times for patients did have the potential to save money overall” and then they quote someone who says: “Experience suggests that if patients wait longer then some will remove themselves from the list or will no longer require treatment when it is finally offered.”

This is footnoted, but not to explain who is being quoted. Instead, the note says:

“We understand that patients will 'remove themselves from the waiting list' either by dying or by paying for their own treatment at private sector providers.”

And that's what the fuss is about. One unsubstantiated footnote (if you trawl through the submissions you find the quote comes from PCT executive Charles Hollwey, writing in a personal capacity - he says nothing about patients dying). We asked the CCP if they had based this on any evidence but they didn’t reply.

So the Co-operation and Competition Panel – which, if the government's reforms go through, will become a decision-making body within the NHS - is saying that if someone's knee replacement is delayed by an extra two weeks they may choose to die rather than wait. As the Daily Mail put it: that is sickening.

We’ve been here before

Similar, albeit less extreme, stories were provoked by the release of the panel's interim report on the same subject in March. On closer inspection they also turned out to be over-cooked but the CCP, chaired by an ex-private healthcare executive who remains involved in healthcare investment and managed by a former management consultant, does not worry itself unduly with balanced analysis if there is a chance to manufacture negative publicity for public healthcare. As revealed by Spinwatch, the NHS Partners Network, which represents private healthcare companies, “lobbied and colluded” to get the Department of Health to commission the report in the first place, and the CCP was not going to let them down. The panel’s remit was to see how the “any willing provider” policy – essentially encouraging companies to come in wherever possible – was doing in elective care in England and to “identify any forms or patterns of behaviours that are inconsistent” with the Principles and Rules of Co-operation and Competition, the CCP's guiding document. It argues private companies should be allowed and encouraged to compete for business. When the CCP talks about what is best for the NHS therefore, it has a particular type of NHS in mind: one that funds as many companies within it as possible (its tag line is “For NHS Funded Services”).

Unsurprisingly then, the first two sections of the report are all about how great it will be when people stop complaining and accept that the more competition and “independent sector providers” (i.e. companies) there are, the better it will be for everybody. As Jo Maybin, a senior researcher in health policy at the King’s Fund said: “The not very deeply buried subtext here is: you are going to learn to like this.”

Who said what?

The rest of the report follows the same logic. We are told early on that it is based on “around 80 submissions from NHS providers, GPs, Primary Care Trusts, Strategic Health Authorities, independent and third sector providers, representative organisations and others,” but that those submissions made by the independent sector providers – i.e. private companies – will not be disclosed due to: “concerns that publication of these submissions would be likely to prejudice the commercial interests of the organisation which had made the submission.” This makes things difficult, because the report is based on the companies’ allegations that PCTs are unfairly denying them work by encouraging patients to use public healthcare providers. Quotes of no more than a couple of sentences are pulled out of the companies’ submissions, but we are never told which company made them or what context they were made in.

Reading through the submissions made by the PCTs which we are allowed to read, it seems they were kept in the dark too. Many seem confused because the CCP has told them they have been accused of something but they haven’t been told what. NHS Somerset, among others, says it is “difficult to comment directly on the points raised without sight of the specific allegations raised.” NHS North Yorkshire and York note: “without further detail or specific examples it is difficult to respond to this allegation.”

Recommendations for the whole NHS are conjured up from a combination of accusations from a few un-named companies, explanations from a few PCTs and the panel's “understanding” of the issue, which, as we have seen, isn't exactly foolproof. To show PCTs are encouraging GPs to restrict patients’ ability to choose which provider they go to for their treatment, for example, we are given two, single sentence quotes from un-named PCTs and three unsubstantiated allegations made by unnamed providers. There is no thorough analysis of all the evidence taken together and no suggestion of exactly how widespread this so-called anti-competitive behaviour is. Early on they say they saw “many” examples of PCTs “excessively constraining patients’ ability to choose” and then, later on: “a significant number of PCTs are restricting patient choice and competition in routine elective care,” but that's about it.

In fact, reading through the submissions made by PCTs suggests that, if anything, the majority of them are doing pretty much exactly what the CCP wants them to do. Of the 36 PCTs that made submissions, by far the majority say they are following the competition and choice guidelines or are in the process of extending them throughout their elective care services.

Those PCTs that do admit they are not following the CCP's rules to the letter argue that this is not because of any ideological intransigence but because of the precarious financial situation they find themselves in, with a government not willing to spend enough to meet increasing demand and insisting they make “efficiency savings” at every opportunity. As the CCP notes: “Submissions by PCTs and providers indicate that value for money concerns are the primary reason for PCTs using influence over GPs to restrict patient choice and channel patient flows to particular providers.” Indeed, it is only the PCTs in Central and Eastern Cheshire, Milton Keynes, North East Essex and Wiltshire that raise any significant criticisms of the theory underpinning the CCP's approach. But it's an impressive feat to blame increasing waiting lists, which all the affected PCTs say are because of the lack of money available to them, on the PCTs themselves rather than on the body which is cutting the money.

But seeing through the CCP’s misdirection reveals an uncomfortable reality for anyone sceptical of privatisation. If a clear majority of PCT managers who made submissions agree with the CCP that involving companies in the NHS wherever possible is a good thing, then the pro-market policies introduced by the previous government have permeated deep into the NHS even before the coalition’s Health and Social Care bill has been passed.

New tricks

The CCP is going to be producing more than slapdash research if the reforms go through. David Worksett, director of the NHS Partners Network that lobbied for the report, and no doubt satisfied that the seeds he planted had borne fruit, said his members will now be more willing to begin legal proceedings if commissioners were found to be in breach of the CCP's Principles and Rules, which the government plans to further strengthen by enshrining in law. Soon after the report was published the CCP ruled against NHS Wiltshire, after Circle Healthcare had complained they weren't getting a big enough slice of the pie. They will pass their recommendations for how to remedy this situation onto the Department of Health, Circle's demands will presumably be satisfied and another part of the NHS will be run, for profit, by a private company.

If the Health and Social Care bill goes through the CCP's remit will only widen. The Department of Health has already announced that the “any qualified provider” policy will be extended into community and mental health services and it will not stop there. David Cameron and his health secretary Andrew Lansley are always keen to say how their reforms will bring an end to the reign of pen-pushing bureaucrats in the NHS but they are quietly loading an unelected body run by bureaucrats with the power to censure and overrule any doctors, managers or staff that try to keep healthcare public.




A Corporate Watch article on the CCP’s previous, interim report can be found here.


See also:

Care UK and private equity: another Southern Cross?

December 22, 2011

Under the microscope: pathology gets the Serco treatment

November 9, 2011

The vultures circle: private equity and the NHS

May 10, 2011

Signs of things to come: The privatisation of the NHS

February 10, 2011