A third of NHS contracts awarded since health act have gone to private sector, BMJ investigation shows
BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g7606 (Published 10 December 2014) Cite this as: BMJ 2014;349:g7606
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Sir,
This study shows a lower percentage and value of contracts being awarded to non-NHS sources than the study by the NHS Support Federation, "NHS for Sale?", which reported that 67% of the awards from the eighteen months from April 2013 have been clinical awards won by Non-NHS providers – totalling £2.4bn in value. A further £760m was shared in 10 joint contracts.
They also reported that £13bn remain in the pipeline. This is very likely an underestimate as around a third of tender adverts do not publicly reveal their contract value. However they estimated that non-NHS bodies stand to gain £6.6bn from the contracts still in the pipeline, if they continue to win contracts at the current rate (50% of the total value tendered)
The full report is available at http://www.nhsforsale.info/privatisation-list/contract-alert/contract-re...
Competing interests: No competing interests
The analysis of NHS contracts awarded since April 2013 raises two questions. First, how can the NHS succeed in commercial tenders? It is in this domain that it really loses out to the private sector. Second, how useful, in terms of the overall health economy, is commercial tendering?
My personal involvement has been with commercial tenders within the limited field of offender care. This has involved a NHS FT competing with other NHS providers, large private sector companies and the Third sector. Service stagnation and probably extinction would have resulted if the service line had not won multiple tenders.
Learning, quickly, how to compete, was essential. Anecdotally, success requires all of the following: an enterprise culture within the NHS organisation, designated bid teams, rapid financial modelling to underpin clinically desirable and defensible services, clarity of time-frames and responsibility for bid sign off as well as clinician availability and engagement with a process that may be both alien and personally distasteful. Tolerance for stress and a willingness to go the extra mile for one’s vision of health care is also very useful. The NHS, as a whole, may need help to gear itself up to this. Equally, withdrawing from competitive tenders that do not provide enough money to run decent services is vital. Winning an unaffordable service is a disaster for patients and services.
The jury is out as to whether running tenders and managing new contracts is better value for NHS money than improving the performance of existing providers with available “sticks and carrots”. Bidding success is gratifying to the winner but expensive to the losers, whoever they are. But competitive tendering does provide an opportunity to improve inefficient, outdated services; detailed new service specifications allow best practice to be embedded authoritatively in new contracts. These can make care costs transparent, in contrast to the vagueness characteristic of old style, block contracts. It may be an unpleasant reality that the nature of the organisation providing care, be it the NHS, the private sector or the Third sector (or some combination of all three) may not matter too much to the patient, if care is better. It matters philosophically as the Bevanite vision of the welfare state fades.
The NHS may no longer be the only, truly legitimate, health care provider but, from our experience, it can, at times, perform strongly against the private sector and others, without compromising its core values.
Annie Bartlett
Clinical Director (Jt) Offender Care, CNWL FT
Reader and Honorary Consultant in Forensic Psychiatry, SGUL and CNWL FT
abartlet@sgul.ac.uk
Competing interests: I am Clinical Director (Jt) of CNWL Offender Care and have responsibility for a range of offender health care services, including several specified in contracts awarded after competitive tenders by specialist commissioners, in London and the South East. I am Chair of the Health in Justice (NHSE London) Strategic Clinical Network which advices specialist commissioners in this field.
We were very concerned to read the BMJ investigation on NHS contracting, which reported that one third of NHS contracts were awarded to private providers and described ‘cherry-picking’ of simple procedures.1 Both the Royal College of Ophthalmologists1 and the British Association of Dermatologists2 have expressed serious concerns about threats to complex service provision, fragmentation of services and training.
Many of these concerns are also emerging in the sexual health and HIV service provision across England. These were not covered by this investigation as they are predominantly commissioned outside the NHS. We believe the quality, safety and future of these key clinical services are under threat, as a result of dysfunctional commissioning practices.
In April 2013, for the first time local authorities became responsible for commissioning services for sexual health, HIV prevention and testing. Treatment and care for HIV remained as a specialist service commissioned by the NHS and abortion services, after a brief period of commissioning by local authorities, became commissioned by clinical commissioning groups.
After a short moratorium local authorities in some areas started to procure sexual health services using tender processes. Since then our Association has received reports from its members across England about issues with commissioning, compromised patient pathways and fragmentation of sexual health services.
We are aware of models of contracting where the focus on cost efficiency appeared to override that of quality; where patient pathways, including those for complex sexual infections and specific groups, such as men who have sex with men (MSM), have been put at risk; and where postgraduate training has been seriously compromised because the service specifications have failed to take these requirements into account.
Some local HIV services have been de-stabilised and access to testing and treatment for sexually transmitted infections (STIs) for people living with HIV has been reduced.
Sexual health is a key clinical component of public health. A much higher proportion of adults in a local community are sexually active compared with those who smoke, are obese or have drug and alcohol problems. Overall, 1 in 5 adults will visit a sexual health clinic at least once in five years.3 Over 1 million HIV tests were performed in STI services last year, with a total of almost 450,000 new STI diagnoses recorded.4 Most STI services also offer HIV outpatient treatment, giving the UK one of the best performances in the world for retention of those diagnosed HIV positive into care, into treatment and to successful suppression of viral replication, thereby reducing transmission risk.5
We call for a strong national steer for co-commissioning of HIV, sexual health and reproductive health services.
Robust model contracting templates need to be used that recognise the requirement to deliver both basic and complex sexual health care, encompass specific groups, and retain seamless care from HIV testing into ongoing outpatient HIV care. Workforce development and specialist services of local relevance need to be contracted for alongside routine clinical care.
The clinical nature of the local authority contracts for sexual health needs to be recognised by sustained ring-fencing of resources. Sexual health does not feature in the NHS plan for sustained and protected funding. In fact, ring fencing of the public health budget will disappear in 2016/17 leaving services highly vulnerable.
We believe an investigation of the processes in local authority procurement exercises should be undertaken to reveal the extent of fragmentation of, and risk of damage to, one of the most important public health interventions we provide - clinical services to detect, treat and prevent HIV and other sexually transmitted infections.
We fear that a serious risk to public health is developing and urgent revision to the procurement process for sexual health is required to address these crucial issues.
1. A third of NHS contracts awarded since health act have gone to private sector, BMJ investigation shows. BMJ 2014;349:g7606.
2. Eedy DJ, Levell N. Dermatology decimated. http://www.bmj.com/content/349/bmj.g7606/rr/826246 (Accessed 20 December 2014)
3. Sonnenberg P, Clifton S, Beddows S et al. Prevalence, risk factors and uptake of interventions for sexually transmitted infections in Britain: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal3). The Lancet 2013;382:1795-1806.
4. Public Health England (PHE). Sexually transmitted infections: annual data tables. London. https://www.gov.uk/government/statistics/sexually-transmitted-infections... (Accessed 20 December 2014)
5. Public Health England (PHE). HIV in the United Kingdom: 2014 report. London. https://www.gov.uk/government/uploads/system/uploads/attachment_data/fil... (accessed 20 December 2014)
Competing interests: No competing interests
We read with interest and concern your investigation into awarding of contracts by CCGs, revealing that only 55% go to the NHS.
The news today that Nottingham University Hospitals Trust - once one of the biggest teaching trusts in England - has been forced to axe its once renowned acute dermatology service due to an exodus of staff following the transfer of their contract to a private provider, is just one example of the impact of poor commissioning decisions.
Dermatology is a prime example of how political meddling is decimating the NHS, despite 54% of the population each year suffering from skin diseases. This specialty has suffered disproportionately, because it has been perceived as being easy to shift ‘into the community’ using private providers, due to the mistaken view that skin diseases are easy to diagnose and treat locally. However, the shift to the community has led to decommissioning of dermatology hospital services, and has not achieved its intended aim of improving patient care. Where implemented, NHS community services were associated with a 67% increase in referrals to local secondary care and private community services use similar care models. The cost usually remains the same per head of patients as in the acute hospital service so the net effect of the increased referrals is greater expense for the local health economy. Plurality of services under Any Qualified Provider has not provided integrated care despite being a requirement of the Service Specification and contract. Instead, there are increased referrals to both community and hospital services with increasing waiting times to see dermatologists.
‘Cherry-picking’ by private healthcare providers, who take on profitable high volume, routine dermatology surgery work, leaves local NHS hospitals with more difficult and expensive cases, aggravating hospital financial pressures and destabilising secondary care services.
Loss of staff threatens provision of specialised services. Loss of high quality hospital training programmes will reduce the sustainability of health care in the UK. Closure of high quality research will stifle innovation. What is happening in dermatology today will affect other specialties now and in the future.
Our secondary and tertiary services in every specialty have been built up over many years to provide sustainable care, training and research for serious diseases. Change is essential to maintain the affordability of health care in the UK. However political healthcare experiments should be piloted in localised areas and evaluated to determine efficiency in an objective way.
Competing interests: No competing interests
"It's about working together"- the final sentence in your article regarding NHS contracts going to private providers.
I have experience working in the NHS as both a GP and a GP endoscopist. Latterly I work in the private sector delivering endoscopy services to NHS patients..
In 2010 my colleagues and I were awarded an AQP contract to deliver a Community Gastroenterology service to patients in Bristol. Prime Endoscopy Bristol is joint venture between three GP'swSI and a private provider of diagnostic services.
Historically in Bristol, like many other parts of the country, there have been long waits for diagnostic endoscopy and gastroenterology out patient appointments. GP's wanted us to improve this situation and in 2009 we audited gastroenterology referrals to secondary care. We calculated that we could ,with our expertise, deal with 50-60% of these referrals quite safely. We are not cherry picking but playing to our strengths. We have had excellent support from our colleagues in the University Hospital of Bristol and consequently this year have started Bowel Scope Screening.
There have been joint educational meetings and regular dialogue.
We offer both diagnostic and therapeutic endoscopy as well as community clinics. We perform transnasal gastroscopy which is better tolerated than the traditional oral route and often requires no sedation. The unit is housed in a modern GP practice where I used to work as a GP partner..
Services are costed below the national tariff.
Both patients and GP's have indicated high levels of satisfaction with the service they are getting. Patients are seen within six weeks of being referred. We have robust links with the hospital cancer MDT's and have detected several cancers- we are however not presently contracted to see two week wait cancer referrals.
Initially in our first year we made a financial loss but in the subsequent year we made a small profit and last year a modest profit. Our endoscopes need upgrading in 2015 and we also require more decontamination equipment. The profit we make will pay for this.
There is much controversy regarding private providers working in the NHS. Currently in endoscopy there is a capacity crisis. More bowel cancer screening has lead to a shortage of endoscopists.
Our model demonstrates that a symbiotic relationship can exist between private providers and the NHS. This is of considerable benefit to patients and GP's alike potentially freeing up hospital services for more complex cases..
Dr Mike Cohen BSc. FRCP.FRCGP
GPwSI Gastroenterology
Competing interests: No competing interests
Hi. I am a few months shy of working in the NHS and am trying to grasp the concept of the changes being made in the NHS which will ultimately affect my career choice. I have a few questions that may seem rather absurd but I would be most grateful if they're explained to me:
1 An example was given where a private firm selected as any qualified provider to perform opthalmology decides to leave complex cases behind for the NHS to deal with. I am a bit preplexed by this because
if non-NHS providers are awarded 69% of the contracts and the NHS only 30ish%, then where is the regulation that ensures that a complex workload is not dumped on the NHS, which has a limited budget?
2 Also how do contracts offered to compatitive tender differ from "any qualified provider"? ie in both cases is it permissible for the non-NHS provider to fall back on an NHS provider even though a proportion of the funding for that service has gone out of the NHS pocket towards the non-NHS?
Competing interests: No competing interests
A Pandora's Box
This article warns fearfully about 'cherry-picking' and diminishing transparency.
One might note that, in the old state- funded NHS, the canker of conflict of interest seemed, by definition, less possible.
Privatization, which is now inevitable, will unleash the nasty contents of the Pandora's Box that is conflict of interest.
Creeping privatization always becomes wholesale privatization in the end.
Competing interests: No competing interests