In opposition Wes Streeting showed more interest, understanding, willingness to learn and commitment to the NHS than any of the Conservative Health Secretaries he faced. He has been given a hospital pass of an NHS in the worst state it has been in in my twenty eight year medical career. His enthusiasm, despite this, gives me hope and this blog outlines some of my ideas and concerns about his plans.
He has made no secret of his intention to open the NHS up to commercial/private healthcare companies to reduce waiting lists for surgery as well as providing other new technologies and services. NHS waiting times are longer than ever and public satisfaction with the NHS is lower than ever, so it’s probably safer than ever to propose greater private sector involvement in the NHS.
The founding principle of the NHS is that people get care according to need, rather than according to their ability to pay. We are accustomed to people paying to be seen sooner in the private healthcare sector but expect that NHS care will not put some people ahead of others for any reason other than clinical necessity. People in the most deprived areas have the illnesses of people many years older in the least deprived areas and spend more of their shorter lives living with these diseases which are further complicated by mental ill health and the stress of material poverty. Consequently, relative to wealthier people they are more complex to treat and take longer to recover. NHS funding has yet to match this disparity in need.
But what risks are there if private providers take on NHS work?
Cream skimming is where the most straightforward, least complicated work is contracted out to private providers, leaving the NHS with a more complex, higher risk caseload. Cataract surgery is a case in point and the subject of a recent report by CHPI. Cataract surgery is high-volume, low risk and has a clear and predictable profit margin. Where it still takes place in NHS hospitals it helps fund more complex, higher risk services. For the private sector treating the least complex patients guarantees better outcomes and fewer complications than would be expected from performing the same procedure on sicker patients. Their outcomes cannot be compared with the NHS unless you adjust for case mix.
Up-coding is where procedures are coded as more complex than is standard and are paid at a higher rate even though they are in fact, not more complex. CHPI found that the proportion of complex cataract surgical cases increased by over 144% over 5 years when they were outsourced to private providers, and while they did not find evidence of up-coding, NHS England have raised concerns that the increase in the numbers of complex cataracts cannot be explained by changes in patient complexity.
Staff training. Training healthcare professionals within the NHS is rarely profitable and providing safe levels of supervision within NHS services is vital, and extremely hard under the present constraints. Private providers do not offer this, so trainee surgeons miss out on opportunities to develop their skills by doing lots of relatively safe cataract operations. You want a surgeon who has done hundreds of straightforward procedures before they try something more complex. This same issue is a serious concern in almost every area of the NHS, not just because of private surgical providers, but because of the policy of using less qualified (cheaper) staff to do the more straightforward parts of almost every clinician’s work. NHS eye hospitals are left with little respite from their higher risk cases that remain and trainees require even greater levels of supervision. Increasing private sector capacity requires medical staff who have been trained and employed by the NHS and will leave if pay and conditions are sufficiently tempting.
Private providers are not required to publish patient safety data to the same standards as the NHS and despite this being raised as a concern by CHPI in 2017, it remains the case. Even though private providers leave the NHS to manage the most complex patients, there are many examples of patients treated in private hospitals which do not have costly intensive care departments who have to be transferred to NHS ICUs when they become sicker than anticipated.
Diagnostic clinics. Psychiatry, always the Cinderella service of the NHS, presently has waiting times of years for ADHD and autism diagnostic assessments. The private sector has been quick to respond and there are an enormous number of rapid, costly diagnostic services for people who suspect they have these conditions. This is high-volume, low risk, low complexity, profitable work. Psychiatry is full of diagnostic uncertainty and the cost and time of providing psychiatric care comes from looking after people who are suffering. The relationship-building, crisis-managing, medication monitoring, ongoing support is largely left for NHS psychiatry and GPs. Similarly diagnostic services that charge for scans and other tests, leave the time-consuming, anxiety containing work of taking responsibility for the results to GPs.
NHS England has a very poor record of getting good value from the private sector. CHPI showed that during the COVID epidemic the government covered all the private healthcare sectors operating costs, in the expectation that they would support the NHS, but in fact they continued to treat private patients while providing negligible support or capacity to the NHS.
The overall risk of outsourcing NHS work to the private sector is that the NHS will be left with more risk, less money, fewer training opportunities, and more stressful working conditions. Wealthier patients with less complex needs will disproportionately benefit from quicker access to private services while poorer patients will have longer waiting times for an increasingly beleaguered service.
What should Streeting do instead?
The NHS can be and is very often extremely good value with experienced staff working above and beyond their contacts every day. Inefficiencies come from an excessive dependence on documentation, data gathering, monitoring and inspections and IT systems that are constantly failing under the strain. The answer is not just better IT but less data-gathering and surveillance. Following his 2013 review into Patient safety in the NHS, Professor Don Berwick in 2016 recommended a 50% reduction in mandatory measurements over 3 years and 75% over 6 years. Since then, the amount of time spent on form filling, mandatory training, CQC and other inspections has increased year on year. Patients’ experience of NHS staff is that they are too busy documenting to listen. Streeting’s stated intention of inviting tech entrepreneurs to trial new diagnostic and treatment technologies misses the point that what doctors are trained very well to do is diagnose and treat patients, and what we want technology to do is free us up from our computers so that we can spend more time with patients and colleagues. Roughly 90% of most diagnoses comes down to a clinical history and examination and expensive diagnostic technologies will only improve that remaining 10%.
Overall I am concerned that the NHS is in danger of becoming a poorer service for poorer people, but I am optimistic about our new Health Secretary. In his recent interview about his plans for General Practice he showed an awareness of the essence of primary care and stated a commitment to increase funding and support measures to improve continuity of care which will benefit patients and clinicians. He has shown that he listens to NHS staff and patients and genuinely cares about the NHS. The private sector will very likely be involved but it will need far better scrutiny for quality, safety, equity and value for money than in the past.
The Centre for Health and the Public Health was set up in 2012 in the wake of Conservative Health minister Andrew Lansley’s Health Act which set out to invite private companies to compete to provide healthcare while the NHS withdrew from provision of care to become a commissioning service. With the Inverse Care Law very much in mind we research instances where this has happened and publish reports with an emphasis on the values of Probity, Integrity, Transparency and Accountability (PITA) Value for Money and the founding principles of the NHS.. We depend on charitable grants and individual donations and you can support us at CHPI.org.uk
The availability of good medical care tends to vary inversely with the need for it in the population served. This inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced. The market distribution of medical care is a primitive and historically outdated social form, and any return to it would further exaggerate the maldistribution of medical resources. Julian Tudor Hart. The Inverse Care Law 1971
How Labour will open the NHS up to private businesses (inews.co.uk)
Out of Sight – understanding the hidden impact of cataract outsourcing on NHS finances | CHPI
Berwick review into patient safety – GOV.UK (www.gov.uk)
Era 3 for Medicine and Health Care | Institute for Healthcare Improvement (ihi.org)
A Better NHS 
Really clear and useful analysis – Have you emailed this to the health minister?
While the whole article is pertinent your comments on training particularly resonate ‘You want a surgeon who has done hundreds of straightforward procedures before they try something more complex. This same issue is a serious concern in almost every area of the NHS, not just because of private surgical providers, but because of the policy of using less qualified (cheaper) staff to do the more straightforward parts of almost every clinician’s work.’ We already regularly see the effects of this on doctors in training posts. If there is expansion of these roles and increased creaming of low risk work to the private sector the unintended consequences need to be considered and somehow compensated for.
Thanks for your thought provoking, as ever, writing.