Margaret McCartney: Do we want an NHS that depends on outsourcing?
BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k670 (Published 19 February 2018) Cite this as: BMJ 2018;360:k670
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The general limit of outsourcing doctrine is that NHS can not be considered as an independent factor from social, welfare or family budgets while health delivery is a part of national and personal budgets in a complex “communicating vessels system”.
As an example, mental health budget amounts to 3,5% of Italian NHS with the following distribution in 2015:
46,6% costs for outpatient care
12,4% costs for daily centers (not residential care)
41,0% costs for inpatient care (sheltered facilities)
That means 53,4% of costs are outsouced from the NHS budget. But, we should consider the personal (family or communal) quote for tuition as additional expenditure, and also what is lost for every admission in sheltered facilities: i.e. personal and social role of patients in working and family life. These are economical costs, which normally are not considered as part of the NHS budget, but as part of national and personal budgets in a complex “communicating vessels system”. The national health ministery considers personal and family costs as a part of outcome indicators, together with clinical and welfare costs. So we should begin to have an integrated management of the NHS, welfare and personal/family budgets, in front of mental health, especially in front of psychosis. The integrated work to limit the chronic involution of psychosis, and the growing need for sheltered facilities, is an essential key for a balanced budget, especially if we consider the following numbers:
Patients in Italian psychiatric hospitals:
12.913 in year 1875
36.845 in 1902
39.500 in 1905
54.311 in 1914
78.538 in 1978 (NHS institution and psychiatric reform)
15.943 patients in sheltered facilities in 2000
29.733 in 2015 (besides 28.809 in daily care facilities)
The mean duration of residential treatment is 756,4 days
Competing interests: No competing interests
Response:
The thema of outsourcing in NHS management needs some distinctions in order to have greater clarity. First point is about work places and workers qualifications, if they have been saved and ensured with the progressive outsourcing of functions; it could be not of strict relevance in management, but in a general view of society. The second is the attempt to have in NHS only closely health related professional, while all not health related can progressive be outsourced. Does it help to have more budget purely for health? We should look at this details in a long term retrospective to have a perspective expenditure forecast. The third point is the different national health politic, which gives relevance to outsourcing in several particular ways. From general to particular and from health system to mental health management, the field where I’m working, outsourcing is a big matter of discussion. Mental health departments (MHD), basing on italian health system, have acute and chronic care, preventive and therapeutical mandate. The task of MHD is working in network system with patients’ several stakeholders, in acute and long term phases. The long term care, facing psychoses, can need the access to sheltered facilities, which are frequently, if not always in the italian experience, a private domain. So MHD need rising founds to pay sheltered facilities and to perform the institutional mandate. These are two different ways to manage mental health diseases, without competition, the outsourced and the institutional, when they can work toghether patients can improve and can develop also less need of sheltered facilities, so reducing the outsourcing. When MHD can work closely in a cooperative way with patients’ stakeholders can also be reduced the need of outsourcing. Furthermore sheltered facilities are also work places in economic instability times. So the general balance need again long term retrospective analysis for a perspective expenditure forecast. A local exemple is the Ambito territoriale XXIV of Marche Region, where I work since 1998. There was a sheltered facility for adult autism (Montelparo) and in 2011 started the Coser “Fratelli Lepri” in Force, a sheletred facilty for physical and mental disabled persons. In 2016 started the Residenza Protetta “Don Rino Vallorani” in Comunanza for mental disabled persons, it has been the first economic investment in the crater of earthquake 206-2017. Faced with 32 residential places in Force and Comunanza facilities, patients coming from the Ambito territoriale XXIV are only 2, because MHD and stakeholders’ networks can reduce the need of inpatients’ places. The sheltered facilities are an investment for MHD needs of a catchment area wider as the Ambito XXIV, the outsourched budgetary resources can give work places for specialized professionals. So we come back to the need of long term evaluation of outsourcing, especially in mental health care management, if these resources help patients to have an acceptable life, if patients can develop and independent life with the experience in a sheletered facility, so the outsourced resources can be helpful.
Competing interests: No competing interests
Re: Margaret McCartney: Do we want an NHS that depends on outsourcing?
“Should there be no outsourcing in the NHS”
I have always supported McCartney and her comments but not today (Should the NHS rely on outsourcing, 24 February). What is important is that patients receive the best care at the most competitive price, irrespective of the provider.
I have worked in NHS secondary care for over 40 years. On occasions I have been both seconded and commissioned private care companies. It’s all about the details of the contract. There are still significant inefficiencies with hospital care. If these can be overcome without loss of quality of care, why shouldn’t a private company oversee a specific clinical service. One of the problems is the Dept. of Health in seeking contracts with the Private sector doesn’t involve Clinicians at an early stage. The contract may be so doctrinal and complicated that there is a built in advantage for business trained experts over busy hospital managers. After all it is a competitive exercise. The recurring theme is that clinical training for both students and doctors seems to be of minor importance when considering the business case.
Providing a carefully thought out service model is worked through with consideration to all potential stakeholders, the private sector may introduce practices that the NHS has not previously experienced with subsequently improved all round care.
Jonathan DS Goodman, Cons, Maidstone
Competing interests: No competing interests