CONFUSE AND CONCEAL! – the NHS and the independent sector treatment centres

GPs in Rugby protest against privately run polyclinics
GPs in Rugby protest against privately run polyclinics

THIS book shows that Independent Sector Treatment Centres (ISTCs) have been introduced to give contracts to private companies to provide care for NHS patients, in competition with NHS hospitals, in order to spearhead the setting up of a market in healthcare in Britain.

The authors conclude that the real nature of the project is to spend a growing share of the NHS budget on private, for-profit providers, and to shift a growing proportion of the NHS workforce to work for them.

All over the country, District General Hospitals (DGHs) are being closed down or losing departments. The government claims this ‘reconfiguration’ is in the interests of improving care for patients.

In reality, those that stand to gain are the large healthcare companies which are being given the contracts to run the new ‘urgent care centres,’ surgical treatment centres and polyclinics, which are to replace the lost DGHs.

Up till 2002, the NHS had a virtual monopoly of the provision of clinical care to NHS patients. The NHS plan 2000 of Tony Blair, set about ending this by introducing a market.

In 2002 the Department of Health (DH) invited in external providers to bid to provide elective operations and diagnostics for NHS patients in separate privately owned facilities – the ISTCs. They were invited to perform the more straight forward elective operations on the more healthy patients, or to provide diagnostic scans or tests.

Wave 1 was to provide 170,000 procedures a year over five years at a cost of  £1.6 billion. Most ISTCs belong to chains owned by a single company. The first wave providers were: Netcare, Capio, Mercury, Nations Healthcare, Interhealth, Clincenta UK Specialist Hospitals and Birkdale Clinics.

In January 2007, there were 43 treatment centres which in 2005/6 provided 186,355 procedures (some of these are NHS Treatment centres).

The DH not only subsidised the companies with start-up costs, they also gave these companies higher payments than the NHS. They were given five year block contracts guaranteeing them payment for certain numbers of procedures, even if they did not perform these. They were also given indemnity from prosecution for negligence at little cost for themselves as they were granted Clinical Negligence Scheme for Trusts coverage paid for by the NHS.

The public were told ISTCs were necessary to increase surgical capacity and bring down waiting lists. The staff were going to be ‘additional’ to NHS staff.

In the second wave of  ISTCs, the additionality rule was removed. NHS staff are allowed to work in ISTCs provided they are not in a shortage specialty, and consultants can work in them in their own time after hours.

The authors discovered that as of February 2007 approximately 25 per cent of all work carried out in wave 1. ISTCs were not additional work but ‘transferred activity’; work that could have been carried out by NHS trusts but was instead given to ISTCs and performed there by NHS staff.

In effect, elective NHS surgery is being forcibly shifted out of NHS hospitals into ISTCs.

In order to cover up their real purpose, government propaganda suggested that  ISTCs would increase  ‘choice.’ They were said to be innovative, increase efficiency, drive up productivity and be value for money.

Stewart and Leys dissect these claims by examining the evidence given to the House of Commons Health Select Committee (HC) enquiry into ISTCs in 2005/6.

They show that in fact ISTCs did not increase choice. PCTs are instructed to divert patients to ISTCs  taking work away from NHS hospitals. This threatens the continuance of local NHS hospital service, reducing choice.

PCTs are given no choice if they do not wish to give contracts to an ISTC. The authors give the example of West Oxfordshire PCT in which the DoH threatened the executives with removal if the PCT voted against giving a contract to an ISTC.

The PCTs are having to pay for the ISTC contracts, use coercive measure to make GPs refer patients into the ISTCs. If the patients choose the NHS hospital instead, the PCTs have to pay twice. Some PCTs have offered GPs incentives of £130 to send patients to ISTCs.

There was no apparent difference in innovation or productivity. There was no evidence that value for money was increased in the ISTCs. In fact, disgracefully, the Health Committee was deprived of any meaningful financial information from the DoH about ISTCs on the grounds of commercial confidentiality.

What did come out at the enquiry, was a body of evidence from leading doctors that the standards of care in ISTCs were not up to those in NHS hospitals. The British Orthopaedic Association claimed that orthopaedic surgeons had seen above average revision and re-admission rates for patients who had been treated in ISTCs.

Even the Healthcare Commission said that it could not assess the quality of care in ISTCs because the necessary information was missing.

A second wave of procurement from the private sector started in March 2005. It was to deliver 250,000 procedures per year plus a further 150,000 procedures a year by an ‘Extended Choice Network’ of private hospitals, costing £3 billion over five years. A further £1 billion was to be spent on two million private diagnostics.

The elective contracts went to BUPA (general) Netcare for Clinical Assessment Treatment Centres (CATs) in Cumbria and Lancs, UK Specialist Hospitals (Avon and Gloucester), Capio (general surgery Cumbria and Lancs), Clinicenta (CATs in North and South London), Nuffield (general W Midlands), Mercury Health ( general and rehab Essex), Netcare (CATs Greater Manchester), Care UK (CATs Greater Manchester), Partnership HealthGroup (General, Isle of Wight, Hants), Fresenius (haemodialysis England).

However it emerged that in 2007, more patients were to be cared for by the Extended Choice Network (ECN) than by ISTCs.

Alan Johnson, Health secretary, announced that the second wave of ISTCs, which was to have comprised 22 ISTCs, would be reduced by seven because these were not needed.

However, the investment promised to the private sector was not withdrawn. The authors make the point that the market required this level of spending to be sustainable.

Instead two ICATs (Independent Clinical Assessment Treatment Centres) were given contracts. Ben Bradshaw Health Minister reassured business that the privatisation programme would continue with more contracts in the primary care sector.

Despite the underperformance of the first wave of ISTCs, the government has used the ISTC programme to introduce all the infrastructure for the market and PCTs to commission contracts to the private sector for NHS patients.

This has forced the ‘incumbent” private sector hospital groups like BUPA, Nuffield, Health Care Group,  to completely restructure themselves. Instead of supplying high cost private care to a limited clientele of the privately insured, they have joined the competition for NHS patients. For example, the proportion of NHS patients treated in Nuffields Hospitals grew from 6.3 per cent to 20 per cent in 2005.

‘This has now resulted in an England-wide Extended Choice Network (ECN) of private hospitals and clinics able to compete with NHS trusts for NHS patients – officially at NHS tariff prices and not only for elective care.’

ECN was officially launched in may 2006. In August 2006 the DoH signed a £200 million deal with 14 independent healthcare companies to deliver an extra 150,000 procedures per year for five years.

They went to Netcare (owning the BMI hospitals. which got 44 contracts), BUPA, Nuffield, Capio, Centres for Clinical Excellence, Mercury Health, Nations Healthcare, and others.

The authors say ‘The ECN is thus a framework within which a steadily growing transfer of elective services to the independent or corporate sector is expected to take place…… corporate providers need to be assured that the balance of the £5.6 billion committed to the ISTC programme, which is now not going to be spent on new ISTCs, will be devoted to the ECN, providing a measure of security during the transition to a much bigger market.’

Government policy for 2008 is that every NHS patient should have a choice of any foundation trust hospital or ECN provider.

With the movement to coerce PCTs to outsource their commissioning to  FESC (the Framework for procuring external support for commissioners) the grip of the private corporations is increasing on PCTs funds. The favoured 14 contractors are; the four big US insurers and care managers; Aetna, Humana, Health Dialog services, UnitedHealth, and UK BUPA, Axa PPP and Tribal and the consulting firms KPMG and McKinsey.

These private commissioners will allocate themselves the plum contracts for polyclinics and GP health centres. With the gate keeper role of GPs in their hands, they will be in a position to  divert NHS patients into their own company ISTCs and private hospitals.

It is no wonder that the government seeks to confuse and conceal. They are pushing towards a massive takeover of NHS clinical commissioning and provision by private companies. They hope to keep all this quiet until it is too late.

This book plays a very useful role in exposing what is going on. It makes no recommendations as to what should be done about it.

Clearly the government is moving very fast to privatise the whole NHS. The trade unions have to mobilise mass action to  defeat this government, defend our hospitals and GPs and restore public ownership. Local residents staff and unions must, if necessary, occupy our NHS hospitals to  keep them open, and we must have a workers government in place of the Brown government.