This is a story of my recent experience of how a private hospital is coping with a sudden influx of NHS patients, due to the recent changes to healthcare in England. The personal account comes towards the end so please bear with me…
We’re all too nauseatingly familiar by now with Jeremy Hunt’s ‘NHS is a disaster’ discourse with its characterisation of the whole service as one on the edge of collapse. According to this story A&E departments are in chaos, GP’s are lazy, hospitals are dirty, inefficient and badly managed. Waiting rooms are overflowing with people having to wait ages to be seen and nursing staff are dismissive of their needs. And the food’s terrible.
In contrast to this picture of medical Armageddon he paints a picture of private hospitals as clean, comfortable, well maintained places where patients are treated efficiently and with extraordinary care and attention; medical care is exemplary and they don’t have to wait around for ages to be seen. Oh, and the food is top quality.
On 1st April this year, as we know, new regulations came into effect as a result of the Health and Social Care Act 2012. Under this new regulatory regime NHS foundation trusts must comply with the terms of the provider licence. The licence replaces the terms of authorisation under which trusts were previously granted foundation trust status. The Act gives Monitor concurrent powers with the Office of Fair Trading to apply competition law in the health care sector in England and the terms of the new licences require health care providers to abide by a number of stringent regulations that are designed to ensure they don’t engage in ‘anti-competitive’ behaviour.
The government sees these licence conditions as powerful incentives for improving the quality of care provided to patients. This is an important point to note since running throughout Jeremy Hunt’s discourse on the NHS is his concept of care quality and how its NOT being achieved across the NHS with the implication that its the delivery system that’s ultimately at fault, with the corresponding implication that a different service delivery system – private healthcare – would produce better results.
When you read the licence conditions it becomes clear that the ONLY definition of ‘improving quality for patients’ that can be found within this document is ‘encouraging competition between providers’. Even when it talks of integrated care which demands different providers working together to provide a complete care package for patients, the need for these co-operating entities to maintain competition between themselves is still a licence requirement. This is clearly contradictory. The guidelines say this,
“With careful design therefore, many models for the delivery of integrated care can be implemented in a way that does not reduce competition between providers.”
“The licensee shall not:
a) enter into or maintain any agreement or other arrangement which has the object or which has (or would be likely to have) the effect of preventing, restricting or distorting competition in the provision of health care services for the purposes of the NHS, or
b) engage in any other conduct which has (or would be likely to have) the effect of preventing, restricting or distorting competition in the provision of health care services for the purposes of the NHS,”
It seems to me that it’s likely to need a hell of a lot of ‘careful design’ if different providers wanting to integrate their services by entering into co-operative contracts are going to avoid being in breach of their licence and thus at risk of the sanctions that Monitor can impose for such a breach – loss of that licence being one of them.
I now want to turn to another section of the licence conditions known as ‘Choice and Competition: Condition C1: The right of patients to make choices’. This is what it says,
“Choice and Competition – Condition C1: The right of patients to make choices This condition protects patients’ right to choose between providers by obliging licensees to make information available, to ensure that any information or advice provided is not misleading and to act in a fair way where patients have a choice of provider. This condition applies wherever patients have a choice under the NHS Constitution or a choice that has been conferred locally by commissioners. It also prohibits licensees from receiving or offering inducements to refer patients or commission services.
This condition prevents a licensee from entering into or maintaining agreements that have the object or effect of preventing, restricting or distorting competition to the extent that it is against the interests of health care users. It also prohibits the licensee from engaging in other conduct which has (or is likely to have) the effect of preventing, restricting or distorting competition to the extent that it is against the interests of health care users.”
Again it can be seen how the regulations once more conflate the interests of patients with the existence of competition between providers. In a fully public NHS you could imagine an element of competition based on quality of service and as a patient would want the ability to choose the best. However, in a climate of privatisation competition takes on a different hue. Providers are by definition businesses making profit and patients come with money. The whole ethos changes, the whole identity of ‘patient’ changes – we become customers and the whole raison d’etre of providers is to attract our custom. The government argues that this will both push up quality AND push down cost but that’s a rather naive and simplistic view.
We all know that real quality costs money. We all equally know the tricks retailers use to attract us into their shops and tempt us to spend more and more. We know the amount of money they spend on slick advertising and fancy packaging of goods that turn out to be the same old thing. And we’ve seen how this tends to increase prices, not bring them down. When the bottom line is profit not patients then its likely patients will be exploited to achieve that profit. And in this kind of competition it has always been the sharks and the big fish who win.
The Monitor regulations go on to stipulate,
“Clause 1 of the licence condition requires the licensee to notify and make information available to patients wherever a patient has a choice of provider under the NHS Constitution or a choice that has been conferred locally by a commissioner…The NHS Constitution also gives patients the right to access services within maximum waiting times, or, where this is not possible, the NHS must take all reasonable steps to offer patients a range of alternative providers.”
Now we’re getting to the whole point of this blog.
Despite blatantly false claims from the Prime Minister and Jeremy Hunt that they are pouring extra money into the NHS*, doctors have confirmed this week at their annual BMA Conference that the NHS is being cut back ‘beyond the bone’ including on the front line – something we were faithfully promised when the Health Bill first raised its ugly head would never happen. In fact, so certain were doctors of this fact that they unanimously gave Hunt a vote of no confidence.
* See (http://skwalker1964.wordpress.com/2013/06/09/smith-shapps-now-cameron-lies-to-parliament-on-nhs-stats/)
Derelict Ancoats Hospital
As hospitals are starved of cash they begin to miss targets and find themselves in breach of their licence (Monitor are already investigating three NHS hospitals for this)* and risk closure. As their waiting times for treatment get longer, if they want to avoid breaches for missing targets. and in order to comply with the Condition C1 shown above. they are sending their patients to private hospitals for their procedures and paying for this from their already stretched budgets. This is a zero sum game because by paying for more and more private treatment to avoid sanctions over targets NHS hospitals will eventually drain their budgets and be sanctioned anyway for going over budget – Poole Hospital NHS Foundation Trust is currently being investigated by Monitor for doing just that.
*Aintree University Hospital NHS Foundation Trust, South Warwickshire NHS Foundation Trust and University Hospital Southampton NHS Foundation Trust. Source: Monitor.
Beaumont BMI Hospital
Yesterday I saw for myself the way the new Monitor regulations are beginning to bite in my own NHS Foundation Trust. My partner, Neil, was on the waiting list for a minor surgical procedure and last week he received an unexpected letter from a nearby private hospital, The Beaumont BMI Hospital in Bolton. It informed him that he had an appointment with them for his surgical procedure at 12 pm on 25th June. It also reassured him that the treatment would be paid for by the Royal Bolton NHS Foundation Trust Hospital (RBH), and a family member would need to accompany him to take him home after the procedure.
So yesterday we duly arrived in time for his appointment. The hospital is an impressive old building set in its own large grounds and from the outside looks well maintained. The waiting room and reception area was small and comfortable, but not ostentatiously furnished. We sat down to wait for Neil to be called in for his appointment….And waited…and waited…
I read all four of the glossy magazines, Neil read the only newspaper provided, the Daily Mail, from cover to cover. During this time several more patients had turned up. I overheard one of them say loudly to the receptionist she couldn’t understand why RBH had sent her there. It transpired that the rapidly growing number of people filling up the small waiting area were all NHS patients. The receptionist was beginning to look flustered.
After we’d been been waiting for around 45 minutes an orderly approached the receptionist and began reading names from a list and telling her which rooms were being allocated to which patient. We heard him mention that Neil was down for room 19. He disappeared and returned ten minutes later and spoke to the receptionist again. This time he had Neil down for room 30. Meanwhile in the waiting area people were getting restless. A bored child was running around and this was obviously not making the receptionist happy. The orderly returned looking harassed and informed the receptionist of yet more room changes. This time Neil was allocated room 32 and finally we were asked to go with him up to the treatment floor.
Because I have difficulty with stairs due to a disability we asked to use the lift. He said this was fine but warned us the lift ‘played up, sometimes’ and needed some maintenance that never seemed to happen. Thankfully, it worked OK that time. We arrived at room 32 and the orderly opened the door to find it was still occupied by a patient. He apologised and said he’d find a nurse and see which room he should us in.
A nurse came along just then and the embarrassed orderly stopped her and asked where he should put us. Without even glancing at us she told him a tad tetchily that she had no idea and hurried off. The poor orderly apologised again and began opening the doors to other rooms until he found one empty. He went in search of someone else to check if he could put us in there and eventually it was sorted out.
By this time the orderly, who was actually a decent man trying to do his best for us, was visibly fed up and confided that they were finding it hard to cope with the influx of NHS work. As he explained the facilities in the room he also made a point of saying “I shouldn’t tell you this but be aware if you use the phone in here they put a massive charge on it and bill you for it when you leave”, the implication being that his employers were not averse to exploiting their customers.
It was now 1.15 pm. Last time Neil had this procedure done at RBH it was done within half an hour of his appointment time. He was looking a bit mithered because he always gets nervous on these occasions and all the waiting was obviously getting to him.
A few minutes later a woman from the kitchen came in with a menu. Neil apparently wouldn’t be discharged until he’d had something to eat and drink so he had to choose something from the menu. This was included in the treatment cost. The menu choice wasn’t spectacular but comparable to that I remember from a stay in the RBH a few years ago. Neil ordered a sandwich and coffee.
Two nurses came to do the paperwork and record Neil’s blood pressure etc. He asked them how long he’d be waiting for the procedure. They couldn’t tell him because the consultant doing the procedure hadn’t arrived at the hospital yet. He was still over at RBH finishing his list there. In the end it was 3.30 pm before Neil finally had his procedure. When I returned to pick him up he was eating his sandwich. It was a bog standard ham sandwich with the crusts cut off and with a few bits of salad leaves surrounding it. The only difference to an NHS ham sandwich was it was served on a posh plate. I also noticed that the cotton gown he was wearing was exactly the same as those used in the NHS everywhere. Ah well, there goes another myth exploded!
Royal Bolton NHS Hospital
The consultant came to talk to us afterwards to explain his findings and answer any questions. During the course of the conversation the consultant expressed his concerns about the NHS reforms saying that already doctors were finding the fragmented system was causing them huge problems with the continuity of patients’ records. He wants to see Neil again in six weeks and said he would insist this happened at RBH where he was able to conduct his clinic more efficiently.
I leave you to draw your own conclusions from this story. Its clear that some potentially disruptive changes are already afoot and private hospitals like the Beaumont are possibly going to see an increase in NHS patients coming through their doors. It was obvious even from this short glimpse that good as these hospitals may be, they are not equipped for large numbers of patients. This is one reason why they have been able to maintain standards. One potential positive outcome from this, given what I witnessed, may be that the Secretary of State will be forced to admit that the public sector model is not at the heart of our problems, since the private sector also struggles to cope with a sudden high demand.
A properly staffed and well integrated NHS with real investment behind it and years of collective experience CAN give us the quality healthcare everyone in this country deserves. I’m more convinced of that now than I’ve ever been.