Memorandum by MSF (PS16)
1. ABOUT MSF
1.1 MSF has over 65,000 professionals employed
in the NHS throughout the UK. We are therefore the third largest
health service trade union. MSF is the major trade union for healthcare
scientists organising, biomedical scientists, clinical scientists,
physicists, pharmacists, radiographers, medical technical officer
and medical laboratory assistants. We are the major trade union
and professional body for community nursing organising health
visitors, community psychiatric nurses, district nurses, school
nurses, practice nurses and community nursery nurses. We are a
significant union in therapy organising, speech and language therapists;
art, music and dance therapists. We are also a significant union
in mental health organising child psychotherapists, clinical psychologists
and counsellors. We have a number of specialist sections that
organise healthcare chaplains, general practitioners and hospital
doctors, advisers in sexually transmitted diseases and complementary
practitioners.
1.2 MSF has a tradition of both organising
around labour relations and professional issues. All professions
have autonomy over professional issues that directly effect their
occupation. As a result we believe that we produce an informed
approach to issues that squares the circle between the need to
give security to professions working in the NHS but also focuses
on improving clinical practice.
1.3 MSF believes that we are organised in
key areas for the modernisation of the NHS and the delivery of
healthcare in the 21st Century.
2. THE INQUIRY
2.1 Your Inquiry is very welcome because
the current debate on this key issue is confused and bordering
on the unproductive. A three dimensional issue is being debated
at a two dimensional level.
2.2 This is partly caused by confusion over
the terms being used by those involved. The Prime Minister in
his undelivered speech to the Trades Union Congress accused some
of setting up "Aunt Sallies" which they then knock down.
There is much truth in this statement. But then the Government
itself has partly contributed to this process by not being sufficiently
clear about how the private sector can productively be involved
in the NHS, whilst retaining the public sector ethos that has
sustained the unique character of the NHS. It has thus caused
unnecessary alarm and concern.
2.3 For clarity there should be agreement
on the terms being used. The following terms derived from the
Institute of Public Policy Research (IPPR) Commission's Report
provide useful definitions:[1]
Market testing:
Competition for the purpose of comparing the
viability (in terms of cost and/or quality) of in-house work with
that of alternative external contractors.
Private Finance Initiative:
Arrangements whereby a consortium of private
sector partners come together to provide an asset-based public
service under contract to a public body.
Privatisation:
The full transfer of assets from government
to the private sector.
Public Private Partnership:
A risk-sharing relationship based upon a shared
aspiration between the public sector and one or more partners
from the private and/or voluntary sectors to deliver a publicly
agreed outcome and/or public service.
2.4 MSF has members in both the public and
private sectors. In that sense we are a public private partnership
in our own right. We recognise that the private sector has for
many years played a major role in the NHS. We support this not
to promote the commercial interests of the companies in which
our private sector members are involved, but because this reflects
the current situation in the NHS. The NHS as an almost monopoly
supplier of healthcare in the UK has a myriad of relations with
the private sector primarily through the provision of services,
equipment, technology and more general supplies. The NHS has never
been a public sector island in a private sector sea.
3. MSF POLICY
3.1 The policy below on the NHS was unanimously
agreed by the MSF NHS National Advisory Committee (NAC), representing
members in over 80 occupations in the NHS on 23 July 2001. It
has also been endorsed by the National Executive (NEC) of MSF.
It is our definitive position.
3.2 For the first time ever all major parties
at the last election spoke in support of the principle of a National
Health Service. The Government made promises in its manifesto
to provide a quality Health Service focused on the patients need
and this had to be done with the active involvement and co-operation
of the staff. It has also been suggested that the involvement
of the Private sector can generate investment and manage change
in ways not available in the NHS.
3.3 MSF has a proud record of support for
the NHS both as a provider of healthcare free at the point of
use, and of a public service providing employment opportunities,
which reflect the high professional standards adopted by our members.
3.4 After extensive discussions at the highest
level with government, we believe that the aspirations of both
government and MSF can be met.
3.5 Elements of government still believe
that the private sector can increase NHS spending. The recent
IPPR report proves conclusively that this is not the case. Some
in Government understand this. The second area to be improved
by private involvement, is in introducing innovative techniques
and the management of change.
3.6 This is more difficult area to refute
because we all acknowledge that the management of the NHS at National,
Authority and Trust level often leaves a great deal to be desired.
On the other hand we have many examples of the inadequacies of
private management. The truth is that change cannot occur without
the participation, professional guidance, initiative and drive
of the workforce. Without wishing to comment on the ability of
other unions and their members to adopt change, MSF believe their
members are in a unique and authoritative position to improve
standards in Health Care for the UK population.
3.7 With a supportive management, MSF members
in a number of areas have already demonstrated better use of resources
to deliver a better service to the patient. Preservation of public
service and members employment prospects in North Manchester are
an example of working in partnership for change. We are able to
do this because we are not just producers of healthcare but consumers
as well. We understand the need for change and are determined
to produce it. The breach of glass ceilings and involvement of
all staff in the development of new and improved services is crucial.
The status quo is not an option. If the manifesto commitments
are not in place by the end of this parliamentary term we shall
all be faced with a government who really believe in the privatisation
of health care.
3.8 MSF can demonstrate that well lead and
organised staff can push aside the barriers of old style management
and the false promise of the private sector to introduce radical
change into the NHS, without compromising our deeply held principles
of free and comprehensive health care.
3.9 The professionalism of MSF members ensures
they will take a responsible role on proposing the introduction
of innovative change to improve the service for the patient. MSF
can lead the way in our areas of work if the government provides
the incentive of maintaining the high standards of the NHS and
obliging management to act in partnership, following the example
of Scotland.
3.10 We set down only four principles, which
we are not prepared to see breached:
(1) The concept of profit shall never come
between provider and patient.
(2) Training, staffing levels and grades
are determined by patient need not cost.
(3) Service improvement to the patient will
take precedent over cost reduction.
(4) Effective change can only be achieved
through partnership.
3.11 Since we developed the policy there
have been a number of developments.
— The Prime Minister has more closely
defined his intentions, thus removing some of the more contentious
areas.
— The Prime Minister, in his recent
speech, acknowledged and welcomed the pioneering work which MSF
and its NHS members were already carrying out to improve flexibility
and service delivery.
— The Department of Health has developed
and we have discussed with them the "Retention of Employment
Model" whereby any private sector involvement would retain
NHS staff in the NHS. MSF made clear that Private Sector scientific
management of the Pathology service was unacceptable.
— MSF has put to the Secretary of State
a number of proposals for consideration which would improve delivery
of service to the patient whilst excluding Private Sector involvement.
4. PRIVATE FINANCE
INITIATIVE (PFI)
4.1 The financial arguments over whether
PFI schemes constitute value for money have been well rehearsed
and we have nothing to add to this debate. Figures from the Health
Policy and Health Services Research Unit of the School of Public
Policy, University College London questioning whether there is
value for money from existing PFI projects appear robust and have
not been adequately challenged by the Treasury or independent
think tanks. Indeed the IPPR Commission[2]
report has specifically accepted these arguments. The Inquiry
needs to start drawing a conclusion on this vexed issue in order
that we are able to proceed in a more rational and productive
way.
4.2 At the same time you should dispel the
so-called "free lunch" argument put forward by some
Ministers. The argument that without the private sector these
hospitals would not have been built is becoming less and less
credible. Ministers who continue this line of argument are being
disingenuous and insulting the intelligence of many NHS workers.
Ministers also claim that this is no different from taking out
a mortgage—which is correct except in one crucial respect,
the Government does not end up owning the asset!
4.3 Treasury Ministers should be asked to
justify their reasons why they wish to finance major capital investment
requirements through these means when it is more expensive, when
the Department of Health is under-spending within its expenditure
limits and all PFI projects could be easily swallowed up in the
PSBR.
4.4 We are also concerned that this method
of funding, stores up tax liabilities for future generations as
the funding streams for PFI projects have first call on NHS funds.
At a time when younger employees are increasingly been asked to
make provision for their retirement we cannot support further
additional fiscal burdens. This is not a "joined up"
government approach. If the NHS is modernised today and funded
through taxation, this must be raised from today's working generation.
4.5 The other reason that Government seeks
such arrangements is that they believe the private sector would
bring in more effective change management and innovate, thereby
modernising the service. Once again the arguments in this area
have been well rehearsed by others. The Government argues that
we cannot afford to be driven by dogma and that there is an absence
of management capacity in the NHS. MSF's campaigns[3]
in a number of areas lends us to partly concur with this analysis.
However, our members suspect that there is a covert preference
for private sector projects and change driven in this manner,
reveals an abstinence of management rather than an absence of
management.
4.6 We believe that there are both good
and bad public sector organisations and good and bad private sector
organisations. In the age of the Marconi debacle we do not need
reminding that the private sector is not always best as investors,
which our members have discovered to their cost.
4.7 In the absence of a more rational and
acceptable explanation of the Treasury's preference for funding
capital projects through PFI, MSF remains implacably opposed to
its use.
5. UNION RESPONSE
TO DATE
5.1 MSF is party to the Department of Health
contact group which discusses matters of concern and has developed
guidelines on PFI and market testing. We welcome this open partnership
approach. These have ameliorated the effect of the worst schemes
but have not prevented moves into the private sector. Further
protection for our members is affordable by legislation (TUPE
etc).
5.2 The Retention of Employment model [See
outline letter to the Service: Appendix One[4]]
has been proposed by the Department of Health in response to the
Staff Side view that PPPs or market testing of services creates
a two-tier workforce ie colleagues working side-by-side on different
terms and conditions of employment. However, the logic of this
approach is that once this is agreed staff objections to the greater
involvement of the private sector will be removed. This is not
the case as the model does not address whether the involvement
of the private sector improves patient care and gives real value
for money. This is the substantive question that we believe should
be addressed by the Inquiry. Besides some staff side organisations
and contractors are also stating some major reservations about
the terms of the model. However, MSF is committed to ensuring
agreement on this model and we believe that this a major step
forward that will address many of the concerns of Staff Side organisations.
A more detailed brief on negotiations around this model is available
on request.
5.3 The model as first proposed took a simplistic
view of NHS workers being a defined group with a supervisor who
alone would be transferred to the Private sector. Such a policy
would be entirely inappropriate where the contract covers more
complex areas such as pathology laboratories. Here the clinical
nature of much of the work and the supervisory responsibilities
of almost all layers of staff means that such proposals would
be inoperable.
5.4 MSF has been at a series of meetings
with the Prime Minister and the Secretary of State where the latest
initiative to involve the private sector has been fully discussed.
Once again MSF very much welcomes this approach and a full and
frank exchange of views.
6. PUBLIC PRIVATE
PARTNERSHIP (PPPS)
6.1 The NHS Plan made a reference to looking
at PPPs in Pathology and Imaging. MSF sought clarification regarding
this reference. Subsequently the Department organised partnership
forums involving MSF and other trade unions, professional bodies,
the private sector and civil servants. Senior MSF officials and
working members have had meetings with the Secretary of State.
MSF again welcomes this discursive approach and we believe are
close to coming to an understanding on the way forward.
6.2 These Services are clearly considered
to be clinical, even by the Department of Health's own definition
contained within its PFI and draft market testing guidelines.
The Prime Minister has given a commitment on non-privatisation
of clinical services. However, this does not preclude private
sector involvement or PPPs. This approach over emphasis the contribution
that the private sector can make to modernising the service and
minimises the contribution staff can make to the very same objective.
6.3 Whilst we understand the imperative
of the Prime Minister and the Secretary of State to "deliver"
in this Parliament there has been no real or sustained attempt
through partnership to involve the staff in service modernisation.
This was lost opportunity of the first Parliament and this has
been recognised by the Department of Health. Therefore, our members
are at a loss to understand why market mechanisms are being considered
before this has taken place particularly at a time when significant
extra resources are now coming into the NHS.
6.4 The prime advantage of modernising the
NHS "in-house" is that the benefits accrue to the NHS
and its patients rather than the private sector contractor. Key
to this issue is the need for investment. The NHS Plan and the
last two Budgets have addressed this issue in a significant way.
MSF is seeking to create a virtuous circle where extra monies
allocated by the Chancellor are invested to modernise the service
and in turn the benefits derived are reinvested to provide further
improvements.
6.5 So what do we mean by modernisation?
It means service improvement rather than cost cutting. It means
skill mix of professional staff rather than cutting salaries through
grade mix. It means upskilling the workforce through training
and education not seeking to cut costs through a higher proportion
of lower grades. It means deploying science and technology to
its maximum potential. It means squaring the circle between demands
for longer service provision (the 24 hour and seven day a week
service) and staff demands, particularly carers, for more flexible
and shorter working hours. It means more effective and transparent
regulation of professions in order to improve clinical performance.
It means greater public accountability, which is denied by private
sector involvement.
6.6 Where this approach is being adopted
MSF has been fully involved. For example the new HR strategy for
Professions in Healthcare Science[5]
positively addresses professional issues including the status,
registration, continuing professional development and career development
of a sadly neglected section of allied health care professions.
However, the fact of the matter is that the involvement of the
private sector through a PPP in this area will cut across this
policy before it has even begun to be implemented across the Service.
6.7 MSF is fully prepared to welcome guidance
and advice from the private sector where it can better inform
the NHS. The use of management consultants may well be a better-controlled
route to modernisation and improvement than wholesale acquisition
of important and previously integrated sections of the NHS.
7. REDEFINING
THE DEBATE
7.1 So can there be a role for the private
sector? The NHS has numerous commercial relationships with the
private sector. The problem with this debate is that we believe
that they are focused on the wrong issues or the Prime Minister's
Aunt Sallies. If the wrong questions are asked the wrong answers
are inevitable.
7.2 MSF believes that we cannot afford to
take an "Albanian economic approach" to modernising
the NHS. Delivery on public services is the great challenge of
this Parliament.
7.3 Therefore, the focus of the debate should
be conducted around the boundaries between the NHS and the private
sector. In turn, the main determinant of these boundaries should
be clinical factors: ie on a fair comparable basis does this improve
patient care.
74. In order to avoid to be contradictory
or misquoted we will give details of one example where we believe
a positive relationship take place.
7.5 MSF has a very large membership amongst
scientific and technical grades. One evolving healthcare science
is genetics which we believe will revolutionise healthcare: genetic
identification assisting the design or selection of drugs to suite
the individual; developing methods of modifying genetic make up
to resist disease or change the persons response. The vast majority
of research in this area is being conducted in the private sector.
The fact of the matter is that the R&D budgets of the pharmaceutical
companies in the UK outstrip the total public sector budget many
times over. This is an area where a genuine increase in health
care expenditure could be funded by the private sector. If the
NHS is seeking to take advantage of this science it will have
little option but to work with the private sector.
7.6 Will this be a parasitical relationship
with companies merely selling their diagnostic tests or cures,
still many years off, to the NHS? Or should we instead develop
a proper partnership to the mutual benefit of the NHS and the
companies concerned? If we believe in the latter then how can
such a partnership be founded?
7.7 The NHS has a massive opportunity to
act as a conduit for the data necessary for development work for
the clinical tests which would follow and in this way accelerate
the use of new tests through the Service. This would further improve
health-screening programmes and add to an evidence based approach
to medicine. The new tests will obviously create a commercial
opportunity for the companies concerned.
7.8 Likewise the NHS can work together with
suppliers on new specifications on tests or equipment to improve
their effectiveness. Such partnership can make them more user
friendly so that nursing and laboratory assistants can take the
tests, thereby freeing up the more skilled scientific staff to
undertake the interpretative work requiring clinical judgement.
The NHS can use its advantageous position to reduce costs in much
the same way recent innovations in manufacturing have forced closer
working relationship between manufacturers and their suppliers.
The successful suppliers will be those that are able to meet the
demands of the NHS for continuous improvement.
7.9 It has to be said of course that none
of this co-operation should proceed without the most stringent
confidentiality and security controls in place.
7.10 The view of our members is clear that
the clinical border between the NHS and private sector are well
established. But this does not prevent us looking at new ways
to take this relationship forward in an evolutionary fashion,
both growing the capacity of the NHS to deliver healthcare more
effectively and efficiently and creating new commercial opportunities
for the private sector.
8. REFOCUSING
THE DEBATE
8.1 However, if we are true to our word
and honest advocates of partnership, modernisation is where we
should focus our attention. Often staff organisations can think
of many reasons why change should not take place and few reasons
why change should take place.
8.2 MSF realises that this is in part a
resource issue but this position should be greatly improved after
the last two Budgets. MSF also understands that these resources
will only be made available contingent upon being used to implement
the modernising agenda.
8.3 MSF has responded positively to this
approach and has to date submitted a series of memorandum[6]
to the Secretary of State on how we believe that acute and community
services can be modernised detailing service improvements and
efficiency savings. We are continuing this work. MSF recognises
the need for change and our role in both identifying change and
becoming a champion of those changes which will improve the quality
and quantity of patient care.
8.4 MSF has also negotiated directly with
Trusts on service modernisation. Our biggest obstacle is the seeming
lack of commitment by local Boards of trusts to openly engage
in partnership style discussions on service modernisation. Often
MSF has to intervene nationally with the Department of Health
or the Secretary of State in order to get Trusts to discuss locally
with our members their plans for the future. MSF believes this
a wasted opportunity and a waste of a valuable resource—our
members knowledge and commitment to the NHS. There is a subsidiary
issue that Trusts are also not willing to take on "vested
interests" and allow our members to take an enhanced role
in providing a service. These unhelpful demarcations have no clinical
resonance whatsoever. We reproduce our brief to the Secretary
of State giving exemplar models of how we have been engaged in
service modernisation in Pathology (Appendix Two).[7]
1 Building Better Partnerships: The final Report of
the Commission on Public Private Partnerships-IPPR 2001. Back
2
Ibid. Back
3
The 29 Steps: booklet on the implementation of HR policies in
the NHS: MSF 1999. Back
4
Not Printed Back
5
Making the Change: A Strategy for the Professions in Healthcare
Science: Department of Health-February 2001. Back
6
MSF Briefs to the Secretary of State Nos. 1-5 (Number 6 on Imaging
and Radiography in draft form)-MSF 2001. Back
7
Not printed. Back
| 
