Intended for healthcare professionals


Monitor failed to interview a single GP over accusation that GPs weren’t promoting choice, CCG chief says

BMJ 2014; 349 doi: (Published 29 September 2014) Cite this as: BMJ 2014;349:g5916
  1. Matthew Limb
  1. 1London

England’s health sector regulator Monitor has dealt a blow to the Spire private health group by ruling against its complaint that anticompetitive practice by the NHS made it lose patients.

However, in a judgment that has drawn criticism from antiprivatisation campaigners, Monitor found that two NHS clinical commissioning groups did not do enough to ensure that patients were offered a choice of hospitals for routine surgery.

Clive Peedell, of the National Health Action Party, which campaigns against NHS privatisation, said that the “double edged” verdict showed that government legislation on competition was in a “complete mess.”

Amanda Doyle, chief clinical officer of NHS Blackpool CCG, one of the pair told by Monitor to be more “proactive” on patient choice, was scathing about the judgment. Doyle said, “It is somewhat concerning that in their [Monitor’s] search for evidence to demonstrate whether choice was promoted and offered in GP surgeries, not a single GP, practice manager, or patient was spoken to by the investigating team, nor was a single practice visited.

“Placing the burden of proof on CCGs in this way causes unacceptable pressures in terms of both cost and administrative capacity.”

Spire Healthcare had alleged that its Fylde Coast hospital in Lancashire lost referrals because Blackpool CCG and Fylde and Wyre Coast CCG directed patients to nearby Blackpool Teaching Hospitals NHS Foundation Trust, which came under a block contract. Spire claimed that the decline in patient referrals was both significant and sustained as a result of actions by the CCGs that broke the rules governing the conduct of commissioners.

But Monitor, in a report published on 25 September, said that analysis of patient referral data for the relevant period did not support the claim.1 It also said, however, that commissioners were required to take “proactive” steps to ensure that GPs and other referrers offered patients a choice and promoted options. Neither of the two CCGs had ensured that patients were offered a choice of provider when referred for their first outpatient appointment with a consultant, it said, nor had they publicised or promoted availability of choice in accordance with regulations.

Monitor said that since the investigation started Fylde and Wyre CCG had become more “proactive” but that Blackpool CCG’s plans did not go far enough and that it would consult on steps needed to fix this.

Catherine Davies, Monitor’s executive director of cooperation and competition, said, “Patients have legal rights to make choices about aspects of their NHS care, and commissioners have an important job to do making sure that patients are offered a choice by their GPs.”

She said that commissioners in other parts of the country might learn from the case.

Doyle said, “We recognise that Monitor did not find enough evidence that we promoted choice in GP surgeries or on the home page of our website. We will be looking to implement their recommendations in this regard.

“We will now make every attempt to help repair the relationship between this provider and the local GPs whom they have wrongly accused of acting against the best interests of patients.”

Doyle said that the process raised questions about the “discrepancy” between Monitor’s finding and the outcome of NHS England’s authorisation process, which had earlier found that the CCG was “fully compliant with its duties around promoting choice.”

Charles Alessi, a supporter of government health policy, who is senior adviser to the representative group NHS Clinical Commissioners, welcomed Monitor’s ruling. He told The BMJ, “As an individual within the population served by that CCG your aspiration is to have as much choice as possible and as much diversity in terms of delivery as possible within the resources that are available. Monitor has delivered what it was designed to deliver.”

But Peedell, who is a clinical oncologist, said, “On the one hand it’s saying there’s nothing to answer for—that the CCGs didn’t do anything wrong—but on the other hand they’re saying, ‘No, you should be opening up to more competition.’ It’s a nonsense really. It’s opening up a can of worms, and I think we’ll see more and more of this over time.”

In a statement Spire Healthcare said it was pleased that Monitor had “agreed that the CCGs were not providing sufficient objective information to support patients and their GPs in choosing a hospital for routine elective care.”

Liz Cousins, hospital director at Spire Fylde Coast Hospital, said it had brought the complaint “reluctantly.” She said, “We felt strongly that the rights of patients to choose to be treated at their preferred hospital, which is guaranteed by the NHS Constitution, should be defended.”

Meanwhile, Monitor has approved the first acquisition of one NHS foundation trust by another. Frimley Park Hospital NHS Foundation Trust is to acquire troubled neighbouring Heatherwood and Wexham Park Hospitals NHS Foundation Trust. Wexham Park was placed in special measures by Monitor in May 2014.2 Monitor said that it had conducted a detailed review of the acquisition proposals to ensure that any risks concerning the sustainability of the enlarged organisation “have been identified and will be appropriately managed.”


Cite this as: BMJ 2014;349:g5916


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