Memorandum by the NHS Consultants' Association
The NHS Consultants' Association is an organisation
of more than 600 consultants in clinical and public health medicine.
Its role is to support the principles underlying the National
Health Service and to comment on proposals for development with
the aim of ensuring that the NHS provides the highest quality
and most comprehensive care possible for individual patients and
the population of the UK as a whole. The NHSCA produces regular
reports on aspects of the NHS and provides information for its
membership on current issues.
There are major concerns about the increased
involvement of the private sector in capital development and provision
of care within the NHS. The NHS needs to increase capacity to
provide the quality of care appropriate for the twenty-first century
and it is accepted that it might take some years for this to be
achieved. During this phase, it seems reasonable to explore short-term
options to increase capacity, including the use of spare capacity
in the private sector. Information so far suggests that the use
of the private sector is almost invariably more expensive than
providing services within the NHS. It is also accepted that the
private sector may have a small, peripheral involvement in provision
of care in the long-term to guarantee that care will be provided.
However, the large scale involvement of the private sector in
the form of the Private Finance Initiative for capital developments,
the concordat with the private sector for provision of care and
public/private partnership in both is unproven, is likely to lead
to higher expenditure from tax-funded resources than the planned
development of NHS facilities.
Other individuals and organisations can provide
better evidence on the economic risks of current proposals and
this evidence is intended to give some information on early experiences
of clinical staff within the NHS. The evidence will be provided
in three sections, as indicated in the invitation for evidence.
3. THE NHS CONCORDAT
(i) This involvement is to be planned in
three main areas, elective surgical procedures, critical care
and long-term and intermediate care for elderly care and other
(ii) Elective surgery is one of the safety
valves for acute hospitals when capacity is short. If a portion
of this is moved to the private sector, then it is unlikely to
significantly alter the ability of NHS managers and clinical staff
to continue to run their services during times of pressure.
(iii) Already, many consultant surgeons and
anaesthetists are expecting to be paid enhanced rates if they
work within private facilities for NHS patients.
(iv) The acknowledged shortages of clinical
staff within the NHS can only be worsened if there is increasing
activity in the private sector.
Trust Managers in a west country hospital arranged
for a consultant surgeon and a consultant anaesthetist to undertake
an NHS list in a private facility eight miles from their base
hospital. Other surgeons and anaesthetists were unwilling to undertake
this activity unless enhanced payment was available. Due to travelling,
etc, the team was only able to undertake half its normal volume
of work during the sessions, which had to be arranged some weeks
in advance. Whilst working in the private facility, they were
not available for the ward and post-operative care of patients
in their base hospital, nor for the supervision and training of
As the lists were planned in advance, it was
not possible to predict that beds and theatre time were available
or not in the District General Hospital. In fact, they were at
the time of lists being undertaken, although other patients were
cancelled during the same week because of shortage of beds and/or
(v) In critical care services, the medical
staff caring for patients are also those who provide clinical
care for these patients in the NHS. They have to be immediately
available and in most areas this would not be possible on two
sites. In the majority of private hospitals, especially outside
London, Intensive Care Units are unable to provide the same complexity
and extent of care as in the NHS and often transfer patients into
the local District General Hospital for this sort of care.
(vi) For long-term and intermediate care,
there are real issues about the quality and quantity of beds available
outside NHS facilities. This varies hugely around the country
and evidence from the membership of the NHSCA shows that private
facilities are often inadequate for patients' needs. Rehabilitation
is almost non-existent, as there is no incentive to shorten patients'
stay. Although it is proposed that these facilities will have
the same degree of inspection as NHS facilities, the mechanism
of this is not clear. There are insufficient medical, nursing
and rehabilitation staff to provide appropriate care on a multitude
(vii) In all three proposed areas, private
companies will wish to charge the full private cost of care, rather
than the more appropriate marginal cost, which should be the case
if spare capacity is being used.
Reports from around the country suggest that
quoted figures for the use of private intermediate care beds are
up to £1,000 per day.
4. THE PRIVATE
(i) The NHSCA has produced a report on its
concerns about the Private Finance Initiative (Private Finance
in Health CareWhy Not?enclosed). More recently a
report has been produced for Scotland with the support of the
NHSCA concerning the proposals for down-sized hospitals(enclosed).
Both of these reports raise major concerns about the future of
the NHS and its facilities if this initiative is used as the main
source of financing capital development.
(ii) Experience so far suggests that estimates
of hospital size, including bed numbers, management efficiency,
and quality of build requirements are hopelessly inadequate in
many PFI developments.
(iii) There are already disputes in some
PFI hospitals where staff are required to accept worse terms and
conditions of service than they have enjoyed within the NHS, despite
assurances to the contrary. It is already acknowledged that one
of the difficulties in maintaining NHS services is the difficulty
in recruitment because of generally low pay rates and poorer terms
and conditions of service than for competing employers outside
the health service.
(iv) The long-term future of the NHS must
be threatened if capital assets are given up to private companies.
In a PFI development in south London, changing
a light bulb has been costed at £85 as the work is sub-contracted
and costed on an hourly basis.
In the same unit the change of use of a room
had to be negotiated with another Trust and these negotiations
could take up to nine months incurring a cost of about £68,000.
Facilities in this unit make it very difficult to provide adequate
care as they are often of inadequate size to accommodate the staff
One PFI development in the heart of England has
increased in cost from £35 million to £44 million since
agreement, although work has not yet started.
Other examples of the inadequate quality and
size of PFI developments are regularly reported to the NHSCA,
demonstrating that contractors have little understanding of the
needs of hospital buildings which will be used 24 hours a day,
seven days a week.
(i) Both the concordat and PFI represent
some aspects of the public/private partnerships proposed.
(ii) Other proposals suggest that private
management may have skills that can make some parts of the NHS
function more efficiently. There is little evidence to support
this and the history of private managers working in the NHS since
the early 80s suggests that most struggle and fail when faced
with the complexities of NHS management. The NHS needs to be managed
as a whole locally, with co-operation with social services and
other agencies for maximum efficiency and effectiveness. To remove
easily managed sections of care from the NHS to private management
only makes the NHS more difficult to manage.
There is no evidence so far that suggests that
greater involvement of the private sector in NHS care provides
improved quality, greater efficiency, or greater value for money.
In the absence of this evidence, further involvement should be
viewed as short-term whilst NHS facilities are developed. In the
longer term, the future of the National Health Service is threatened
if there is a gradual transfer of work into the non-NHS sector,
which contradicts much of the Government's NHS Plan, published
in July 2000.