Delivery Plan turns NHS into a cash cow

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While NHS resources are facing a renewed and tightening financial squeeze in Rishi Sunak’s newly-imposed austerity, the limited funds available are more likely than ever to be diverted to paying for services in private hospitals and clinics, while NHS beds and resources remain closed or under-used.

This article is adapted from The Lowdown (the free to access online news and analysis on the NHS) and appeared in Roy Lilley’s eLetter on 4 April. John Lister is editor of Health Campaigns Together and founder member of KONP

We know this from NHS England’s ‘Delivery Plan,’ published in February. It is supposed to enable the recovery of acute services from the after-effects of the pandemic, but in fact it accepts that waiting lists could rise to 14 million before they fall, and that waits of over a year won’t be eradicated until 2025.

The Plan is heavily – one might almost say obsessively – focused on the need for long-term reliance on the “capacity” of the private sector.

It’s far and away the most consistent theme running through the 50-page document. Here are the key passages:

“The physical separation of elective from urgent and emergency services … will include a strengthened relationship with independent sector providers to accelerate recovery.”

“More people offered the option of treatment by high quality independent sector providers, free at the point of care.” “As we tackle the elective backlog, a long-term partnership with our independent sector partners, including charities, will be crucial in providing the capacity we require to deliver timely and high quality care for patients.”

Independent sector providers have a significant role to play in supporting the NHS as trusted partners to recover elective services, including cancer, as they have throughout the pandemic.

Systems will include local independent sector capacity as part of elective recovery plans and will work in partnership with independent sector partners to maximise activity to reduce waiting times sustainably.”

…even if EVERY available private bed was block booked, it could only compensate for less than a third of the capacity that has been lost to the NHS.

“Elective care boards within each integrated care system (ICS) have been established to bring together local providers, including the independent sector, to agree priorities and solve operational challenges.

Systems will work with the independent sector within the context of their broader recovery strategy, population and local plans.”

“The development of successful local partnerships between providers and the independent sector will be built on nationally agreed principles ensuring that local areas:

  • Clearly articulate how patients can choose their place of treatment at all stages. This will be supported by clear and consistent communication with patients that explains the role of and options for using the independent sector. […]
  • Clearly demonstrate how independent sector providers are contributing to overall elective recovery, including for cancer diagnosis and treatment.”

“Local areas will be encouraged to develop partnerships with the independent sector that support long-term contracting with sector providers, act at system level to respond to local challenges and allow partners to plan ahead. In addition, joint regular reviews of demand for services and available capacity will support the clinically appropriate transfer of high volume and low complexity conditions, as well as some cancer pathways and diagnostics, to the independent sector. …. More complex cases can also be treated in independent sector sites that can deliver this level of treatment.”

To further guarantee the effectiveness of partnership working, systems will have the opportunity to design a joint approach with the independent sector on workforce.”

… any lingering hopes there might be any ‘levelling up’ of access to health care, or any medium or long term plan to bring down the waiting list should now be discarded.

Why private providers can’t be the answer
Quite apart from any ideological objections that might be raised to funnelling public money to profitseeking private providers, there are practical problems with this scenario for the NHS.

Firstly, the private sector cannot bridge the gaps in capacity that have been opened up in the NHS by the decade of austerity and bed cuts and the impact of Covid.

The most recent official statistics on bed numbers, to the end of last year, show 11,400 of the 100,000 general and acute beds that were technically “available” were not being used. There is no capital to enable trusts to reopen beds that have remained empty since the Covid pandemic first struck.

The combination of beds still unused, and beds filled with Covid patients is currently over 25,000 NHS front-line beds (one in four) currently out of action for either emergency or waiting list patients.

But the whole of the private acute hospital sector according to Laing Buisson comprises just 8,000 beds, and many of these are not affordable, not available or not suitable for high volumes of NHS elective care. The average private hospital has just 40 beds.

But even if EVERY available private bed was block-booked, it could only compensate for less than a third of the capacity that has been lost to the NHS.

The cost would also be prohibitive, since the NHS would have to pay well above NHS tariff prices to make it profitable for private hospitals to treat NHS patients rather than a growing number of ‘self-pay’ private patients. And there is an organisational impact.

Diverting large numbers of NHS patients from NHS hospitals to private hospitals often several miles away will in many cases mean also dispatching NHS staff to deliver the operations, since the private sector is not staffed up to work in such intensive fashion.

This means taking staff out of multidisciplinary teams in NHS hospitals, where they could otherwise be on call to cover emergencies. It will inevitably make trusts much less efficient.

Any further expansion of the private sector would also mean they would be seeking to recruit more staff from the same limited pool of professional staff, all of whom are trained by the NHS – effectively robbing one sector to staff another.

Spending extra money to deliver the least complex operations in private hospitals, which generally lack ICU facilities and are geared only to the simplest of surgery (and patients with few if any complications) also means that the NHS will get fewer operations for the same money.

There will be less funding and fewer staff available for the NHS to treat older and more seriously ill patients. Waiting times for more complex conditions are likely to go up, even as treatment for more straightforward cases is speeded up. This is a new “inverse care law,” prioritising the cases that have least serious needs.

It’s also only NHS hospitals that will face the logjam of delayed discharge of patients after longer stays in hospital, as the lack of social care and community health care limit their efficiency. NHS England has tried to bully this problem away, sending out an edict on December 12 last year telling trusts to cut by half the number of patients with “no reason to reside” who were still in hospital.

But without any alternative support available for discharged patients, the actual numbers of long stay patients grew by almost 10% in the first month, and has remained consistently higher than it was when the order was sent out – with the latest sitrep figures showing numbers of patients in hospital for more than 3 weeks has increased by 14% since December 12.

The outlook is gloomy, too for improvements in emergency services and for mental health, neither of which are included in the Delivery Plan.

With an increasing flow of investment towards private providers, who have always studiously avoided offering emergency services, it seems certain the deadly combination of staff shortages and lack of front-line beds will continue to delay patients’ process through A&E.

NHS England admits that upwards of 1.4 million people need mental health treatment but are not able to access it: the more resources are squandered on private provision of acute care, the less chance that any new investment will flow to mental health.

The new inequalities

The other problem which the NHS England guidance does not address is that the private hospitals are not equally distributed across the country, but focused on prosperous populations and areas, with 60% located in London, and more in the south east of England. Any recovery strategy dependent upon private rather than NHS capacity will therefore inevitably offer a raw deal to other parts of England, notably the more deprived areas of the midlands and the former “red wall” northern areas that swung on the Brexit issue to give Boris Johnson his large Commons majority in 2019. These areas have consistently lost out over the past decade, as austerity has widened social inequalities and stalled and even reversed the historic trend towards increased life expectancy.

The Telegraph quotes cancer doctors stating the advice was “morally outrageous,”

Once the NHS has become institutionally dependent upon the private sector, it will take even bigger investment to break from it. So any lingering hopes there might be any ‘levelling up’ of access to health care, or any medium or long term plan to bring down the waiting list should now be discarded. The new inequality is taking shape alongside Rishi Sunak’s new austerity.

Transforming the NHS into a cash cow for the private sector has never been dependent upon legislation, but has always been linked to the austerity squeeze on NHS funding and capacity, and accelerated by the Covid pandemic.

Under the Delivery Plan the private sector will not need to tender or compete for contracts – they will be firmly entrenched in long term, one-sided local “partnerships,” in which they take the profits … and the NHS shoulders the burden.

NHS England plans – for private patients

However NHS England’s thinking now seems to revolve around the existing private sector – and urging trusts and foundation trusts not to focus on reducing waiting lists and treating NHS patients, but instead to “explore and develop opportunities to grow their external (non-NHS) income.”

The document commits NHS England to work with trusts to “identify and scale-up NHS export opportunities and support development of private patient opportunities to generate revenue and provide benefits for NHS staff and local patients and services.”

However, there is precious little, if any, evidence to show that most of the private patient activity conducted by the NHS generates any significant revenue – and even less that this is more beneficial to NHS patients than using NHS facilities and staff to offer them more speedy treatment.

In 2018 a UNISON survey of hospital private patient units in the East of England found that they were under-used, and either costing the NHS money – or trusts simply refused to divulge the figures.

Even the Daily Telegraph has spotted how unpopular this NHS England policy will be with millions of NHS patients. Its headline was : “Outrage as NHS hospitals told to target more private patients, despite record waiting list.”

The Telegraph quotes cancer doctors stating the advice was “morally outrageous,” and highlights new figures from the Private Healthcare Information Network showing “a near-tripling in the number of self-funded hip operations since the pandemic.”

Of course large queues and long delays will drive more desperate patients to seek private treatment … and drum up customers for new NHS private wings. The conflict of interest exposed by this document means that the NHS England staff who drew up the leaked document should resign or be sacked.

The very least NHS patients need and deserve is an NHS led by people committed to its values and its future as a public service, not looking for ways to undermine it and create a two-tier system. If the [NHS England] Board cannot show themselves capable of any positive action to address the growing crisis of the NHS, they should also be replaced.

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