1. How does Earl Howe explain the comments he made at the Laing & Buisson Independent Healthcare Forum on 7 September (during the 3rd Reading) in which he informed the audience of private sector providers that there were big opportunities for them to make money by taking patients away from the NHS?
2. What safeguards are to be put in place to prevent private equity companies from taking a stake in NHS ex-employee buyout “social enterprises”, gearing them up [raising loans against them and extracting the principal, a standard asset-stripping manoeuvre], extracting the cash and dumping the remains once no more income stream can be extracted? i.e. the Southern Cross story?
3. There are sections of the Bill which pertain to property transfers (134, 299, 300 and Schedule 23), but none of them mention the value at which land and buildings may be transferred under their provisions. What safeguards are in place to prevent NHS land and buildings being transferred at undervalue? Can Earl Howe guarantee that these transfers will not take place for a nominal sum? The Bill contains no provisions for public scrutiny of such transactions involving the Secretary of State and “qualifying companies”. How will public oversight be arranged for this?
4. Several of the US companies which are hoping to come in to the NHS as either providers or commissioners have been in trouble for defrauding the US government. What safeguards will be put in place to stop them applying the same low business standards to their dealings with patients, GPs and the UK government?
5. One large company which has been lobbying for access to the post-reform NHS is a South African company [Netcare, parent of General Healthcare Group] which was found guilty of removing the kidneys of minors and selling them. What “fit and proper person” tests are to be applied for the new entrants to our state-funded health system? Will the general public be allowed to lodge protests against particular providers who seem to have demonstrated themselves not to be fit and proper persons to be involved in running services for the NHS? The Mirror alleges that GHG is under consideration for contracts to run transplant services in the UK: http://www.mirror.co.uk/news/politics/2011/09/06/organ-selling-firm-in-nhs-talks-115875-23399313/
6. Once NHS hospitals are required to make their money through selling services, they will have to balance their books or go out of business. Is it planned for those burdened by expensive PFI deals to be left to sink or swim, or is the government planning to force the taxpayer to take over all of the PFI deals so that such hospitals have a chance of survival in the new market-place? What efforts have been made so far to repudiate these deals and stop the PFI lenders and providers from continuing to fleece the taxpayer?
7. The Care Quality Commission has been running regulation on the basis of self-certification and has a track record of believing those assessments rather than inspecting in person; the Winterbourne View case demonstrated that self-assessments by profit-making, private-equity-funded suppliers are not to be trusted. For the last year the CQC has recruited no-one with any medical qualifications for any of its management or inspection roles. The reason appears to be systematic under-funding and management which fails to protest about the fact that it has insufficient funding to do the job properly. The Bill puts the responsibility for technical inspection on to the underfunded and underskilled CQC and mandates no extra funding. Can Lord Howe please elaborate on how the system will be changing to safeguard patients properly? For instance, how will the figure for an adequate amount of CQC funding be arrived at? What is the planned frequency of facility inspections by medical doctors?
8. What safeguards are to be put in place to stop GPs denying patients treatment under the NHS (and retaining the money saved, as would be permitted by the Bill) then offering to give private treatment for the same complaint (as also permitted by the Bill). None are at present included in the Bill.
9. What proportion of the referrals budget is expected to be spent on commissioning overheads and profits (of contractors to which the commissioning tasks are outsourced)? Is it reasonable to expect this to be in the 20%-40% range as applies to similar arrangements in the USA? What do your projections show for the amount of the budget given to GP consortia which will be consumed by the outsourcing of commissioning costs?
10. The Bill (s13) allows privatisation of secure psychiatric services; s35 allows the Secretary of State to nominate whoever he likes to approve people to section individuals thought to be a danger to themselves or to other people. The Bill states that the SoSH may or may not arrange compensation for this task. Clearly there is potential for abuse in this combination of changes. There has been a recent related abuse in the USA: http://www.nytimes.com/2009/02/13/us/13judge.html?pagewanted=all but in that case the scheme required bribery of judges and the sentences were for months only. In the NHS case abuse would not require any illegality, merely the possession of the right to lock people up and to be paid for doing so (under a contract) and the ability to approve people to section others (who as well as approval need the minimum qualifications specified under the Mental Health Act 1986); and the deprivation of liberty involved could be long-term or permanent. This seems to be a duty which should not be taken out of state supervision. What safeguards are to be put in place to protect the general public from being involuntarily admitted to profit-making secure mental hospitals which are paid by the number of inmates held?
11. What safeguards are in place to prevent inmates of secure psychiatric facilities privatised under s13 from being pacified with drugs which have serious permanent side-effects, or with ECT, in order to enable lower levels of staffing to be maintained and more profits made?
By Dr Lucy Reynolds.
Other articles by Dr Lucy Reynolds:
Provisions for competition in the Health Bill. Martin McKee’s blog 07.11.2011
Two issues with competition in healthcare BMJ 25.07.2011
For-profit companies will strip NHS assets BMJ 15.06.2011
Issues MPs and the media have missed in Lansley’s bill BMJ 24.05.2011