As the NHS is opened up to a tsunami of privatisation, the first alarming revelations about the potential disaster it will cause have already been revealed, in a number of articles in the Guardian over the last week — one dealing with “an assessment by the Faculty of Public Health (FPH) of the risks involved in the forthcoming overhaul of the NHS in England,” and the other dealing with reports that children’s services in Devon are likely to be privatised. Please note that Serco and Virgin Care, who are competing in Devon to run children’s services (despite having no experience), where insiders have explained that one or other company is likely to end up winning out over the NHS bid, were also targeted for direct action by the “Block the BIll” activists (as I explained here).
A risk assessment by the Faculty of Public Health
The first Guardian article provided an overview of a risk assessment by the FPH, which represents 3,300 public health specialists in the NHS, local councils and academia. The authors state, unequivocally, that the bill poses “significant risks … to patients and the general public” and could well damage “people’s health and patients’ experience of care.” They add, “It is likely that the most vulnerable who already suffer the worst health outcomes will be disadvantaged as a result of the enactment of the bill,” noting also that, as the Guardian put it,. “[p]oorer people are unlikely to be able to use the greater patient choice that the bill entails,” or, as the authors describe it, “Operation of choice in an environment of multiple providers will disadvantage those who are less educated, have reduced access to resources such as the internet, or for other reasons are less able to navigate the healthcare market.”
As the Guardian also explained, “Whole areas of healthcare provision may disappear and patients could be forced to go private because clinical commissioning groups (CCGs) — the new groups of local GPs who will become responsible for agreeing and paying for patients’ treatment from April 2013 — are only tasked with deciding what services are needed in order to ‘meet all necessary requirements’ of the populations for whom they are responsible.”
“As such,” the authors stated, “it is possible for CCGs to cease to commission services which are currently available through the NHS if they do not consider them to meet a reasonable requirement. Access to such services in the future might be available only through private healthcare.”
The Guardian also noted, “Handing GPs the right to decide what care is and is not provided “will also lead to an increase in geographical variation in service provision – the postcode lottery,” and such variation may become ‘more overt’ owing to doctors or patients lobbying CCGs.” It was also noted that “[i]mposing ‘a competitive market’ on the NHS will make it difficult to provide joined-up care for the rising number of patients with long-term conditions, as separate organisations collaborating to provide care ‘may be seen as anti-competitive and incur substantial financial penalties.’”
Dr. John Middleton, the vice-president of the FPH, said: “Patients with long-term conditions such as diabetes need co-ordinated care between GP, community and hospital. Under the current system they go to the primary care trust if any aspect of their care is at fault. Under the new system they may need to go to the NHS commissioning board for GP or optometrist care, the CCG if their hospital service or chiropody causes them a problem, Public Health England for their eye screening and the local authority public health service for their weight management and lifestyle services — it’s a recipe for uncoordinated care and everyone passing the buck. The current reorganisation is a recipe for things getting worse, not better.”
The document also, as the Guardian put it, “echoes warnings about the perils of the overhaul of child health already made in some primary care trust risk registers,” which are discussed in further detail below. The authors note, “Of particular concern are the risks identified around safeguarding children from abuse and neglect. The loss of designated professionals and weaknesses in information sharing between organisations poses an increased risk to the safety of children.”
Dr. Middleton also told the Guardian, “After several years of relative stability, this unwelcome and unnecessary reorganisation is disrupting services and splitting apart professional relationships which are needed to protect patients and the public.” He added, as the Guardian described it, that “NHS arrangements for emergency planning, screening and immunisation programmes are also ‘unsafe’ because of flaws in the bill.”
In conclusion, Dr. Middleton said, “The FPH remains concerned at the risks to public protection in emergency planning. NHS commissioning board directors of emergency planning cover huge geographical areas: from Land’s End to Dover, from Yarmouth to the Welsh border, and from Cheshire to Northumberland, and London. Each of these areas is huge and covers multiple Local Resilience Forums around which blue light services are organised, so NHS directors of emergency planning face extraordinary difficulties covering their sectors. Directors of public health at local authority level will ‘assure’ the system, but will have no powers or resources to enforce what needs to be done to make the systems safe.”
The Guardian added that the FPH also warned that “allowing private operators to provide more state-funded health services, together with the increased competition between NHS organisations, will increase the amount of money spent on administering the system and incentivise hospitals to treat patients needlessly” –huge examples of waste and fraud that are familiar from the US system.
The authors also stated, “The market environment will increase transaction costs and lead to the loss of economies of scale as large providers could be broken up. Market incentives will lead to supplier-induced demand where hospitals perform unnecessary and potentially harmful treatments to generate income. Management costs will also increase as the new GGCs will need to buy in legal and procurement expertise to support them in fulfilling their new commissioning responsibilities.”
Privatising the care of children
The second Guardian article explained how NHS Devon and Devon County Council had “shortlisted bids led by two private, profit-making companies — Serco and Virgin Care — to provide frontline services for children across the county, including some of the most sensitive care for highly vulnerable children and families, such as some child protection services, treatment for mentally ill children and adolescents, therapy and respite care for those with disabilities, health visiting, and palliative nursing for dying children.”
Although the shortlist for the £130m, three-year contract also includes bids by Devon Partnership NHS Trust, Barnardo’s and other charities, “a source close to the process” told the Guardian that “one of the two commercial companies’ bids look[ed[ likely to win the tender.” The final decision will be made in May, but the contract will be awarded to “the most economically advantageous” bid, according to criteria listed on the European Commission website, which is obviously a sign of what to expect in the future across the NHS as a whole.
The fact that this invokes the care of the most vulnerable children makes it particularly alarming, as the Guardian also noted, explaining, “The deal is believed to be the first of its kind involving children’s services on such a scale, although a small number of more limited contracts have also been awarded under reforms originally introduced by the Labour government,” and adding that critics “fear that the pro-competition measures in the new NHS bill will lead to a big increase in such deals.”
Voicing her criticism, Dr. Clare Gerada, the president of the Royal College of GPs, warned, “This is exactly what the bill is about. Devon is just one example. Once the bill goes through it will solidify what is already going on now. Contracts will be commercial in confidence, GPs will end up rubber-stamping them and any company for profit will put shareholders before patients. We will find the NHS as we know it fragmented.”
As the Guardian also explained:
Neither private company in the Devon bids has experience of running specialist children’s health services for the NHS. Serco, a London-listed company that made nearly £300m profit last year, plans to run the services in partnership with Cornwall Partnership NHS trust, which provides mental health and disability services to adults and community health services to children in the neighbouring county. But the extent of the NHS trust’s role is not clear and the PCT said it was commercially confidential.
Several public health experts critical of the bill expressed dismay and disbelief that high-risk children’s services were being contracted out. They questioned whether they could be safely run for profit.
John Ashton, director of public health for Cumbria, said: “What on earth are they doing taking risks with our children like this? Children’s services such as these are very complex and involve working with lots of agencies, from local authorities to police and schools, over long periods. How on earth a private company can function in that area when it needs to identify ways of making money is really hard to see.”
Professor Terence Stephenson, the President of the Royal College of Paediatrics and Child Health, which also opposed the bill, also questioned “whether private companies could run such important public services,” as the Guardian described it. He said, “It is hard to understand why a tender for something as important and complex as children’s services has not been put into the public domain for scrutiny by professionals. Children’s services are complex, as some tragic high -profile incidents have shown. It is essential that any provider has proven expertise in managing not only clinical services but also key areas such as safeguarding and, on the face of it, it does not appear that all of the shortlisted bidders have experience in managing such services.”
The Guardian also noted that Serco “has many contracts to provide management services to the government and local authorities, including running prisons,” and in 2006 was “contracted to provide the out-of-hours GP service” in Cprnwall. However, it “has drawn sharp criticism from health staff and the Liberal Democrat MP Andrew George, accused of compromising safety with cuts.”
Serco “was given an improvement notice by the NHS primary care trust that had commissioned it in 2007 following a number of incidents,” and in 2010 was implicated when a six-year old boy, Ethan Kerrigan, “died as a result of a burst appendix when the Serco out-of-hours service advised putting him to bed rather than sending a GP to examine him.” Local GPS have accused Serco of cost-cutting that has “left the service with insufficient transport and staff to meet needs,,” and explained that, one Christmas, “nearly one-fifth of calls to the service went unanswered because of lack of capacity.” The Royal College of Nursing has also criticised Serco, complaining that “proposed cuts to nursing staff working for the Serco out-of-hours service in Cornwall would compromise safety.”
Virgin Care, as the Guardian noted, “came into being at the beginning of this month, following a £4m investment by Sir Richard Branson for a 75% stake in Assura Medical, the loss-making medical services part of the Assura Group, a company listed on the London stock exchange, which acts as commercial partner in property and pharmacy services to GP consortiums.” Although it has no track record yet, it is already involved in “a major dispute with the NHS in Yorkshire, where it has reported the NHS primary care trust to the new adjudicator of contracts, the co-operation and competition panel for NHS services, for awarding a contract to the local NHS York Hospitals instead of to Assura/Virgin.” The Guardian noted that critics fear that “the increasing involvement of the private sector will divert NHS resources to legal fees and contractual disputes such as these with commercial bidders,” and I’m sure they’re right.
Professor Allyson Pollock, a leading critic of the NHS reforms, called the Devon tender “a clear privatising of the service for the most vulnerable,” and added, “It has huge implications elsewhere and serious questions have to be asked about why they are doing this when the bill is not yet law and it is not even clear what the statutory requirements will be for children’s services.”
In response to the news about Devon, John Ashton, the director of public health for Cumbria, and Maggi Morris, director of public health for Central Lancashire, were severely critical of the developments, and wrote the following article for the Guardian, which, for now, will stand as my final word on the Tory-led destruction of the NHS, and why it is such terrible news, and my introduction to the ongoing battle to mitigate the worst effects of Lansley’s reforms, and to campaign for the reforms to be scrapped:
Privatising NHS children’s services is a recipe for disaster
By John Ashton and Maggi Morris, The Guardian, March 16, 2012
Services for women and children’s health are a foundation stone of modern societies around the world. Public health services just about anywhere start by addressing the things that most affect the health of their children, from maternity care, to obstetrics, immunisation of babies and provision for healthy children. It is accepted and understood that these are too important to be left to individual attention and that the state assumes a responsibility for making them available.
That’s why the idea of privatising services affecting children is such anathema. The news that Devon is considering privatising a comprehensive range of its children’s services is alarming.
It’s true there are certain parts of maternal and child health that can be attractive to the private sector, and where they are predictable in terms of costs you can find very good examples of social enterprise running them effectively, for example in family planning. But when you move into the world of neonatal and obstetric care or complex childcare cases involving special needs, the private sector is very wary, precisely because when things go wrong the bills can be enormous.
When you move into the messy realities of children with multiple disabilities or multiple problems, involving lots of expenditure, how can you write legal contracts that are robust enough to cover every eventuality?
In public services, sadly we have to deal with cases of children who may need the involvement of many different agencies, from mental health services, to school, social workers, probation officers, the police, and drug services all working together. Who is going to write a contract that is legally binding for safeguarding children in such cases, and make sure there are not exclusion clauses that allow the provider off the hook?
In such cases, people have to work in partnership on the basis of trust, where a no-blame culture is developed that allows engagement with parents to do the right thing. This is the really important but undefinable work that is highly complex but generous enough to think of families in the round. It requires agencies to work as an interdependent team that puts the child at the centre. To mix profit into this equation is potentially disastrous. The only people who should profit from children’s services are the children and their families.
The private sector makes its money by making sure every burger is brought to exactly the right temperature in the same way. In health, that conveyor-belt system is a recipe for poor service. How many units of care will be in the contract for the child who has specialist needs because they were born with a heart problem or spina bifida? When a vulnerable child is at risk of abuse, you cannot refer to a contracted number of units of care or predict and put a limit on the cost.
The private sector segments risk and only picks up that which it can make a margin on. Based on a consumerist model of services, it will keep people in need and buying its services rather than doing what the public sector aims for, which is not just to treat sickness but to build resilience in children and adolescents so that in the future, when they become parents, their families will not fall into the same cycle of need.
The whole principle of the NHS, and one of its greatest achievements, is that it has been a social contract to pool risk. It is tragic that we are now about to throw that away.