The carnival of incompetence- why nobody actually knows how to privatise the NHS but are doing it anyway
William Goldman, the famous Hollywood screenwriter once said about motion pictures, that ‘nobody knows anything’. That ultimately nobody in the entire motion picture field actually has any idea whether a film is going to work or not. I’m pretty sure that if Goldman had watched the calamitous privatisation of our NHS in recent months he’d have been struck by a rich similarity between the Hollywood studios and our own embattled NHS.
Image credit: Left Futures
Forgetting the obvious issue that privatisation is a fundamentally less effective way to run a public health service, the below example of a privatisation in West Sussex is a perfect example of how nobody actually knows how to do privatisation.
Now all local NHS privatisations start with the government. If you were a government who wanted to pull to pieces a national treasure without a democratic mandate one of your first concerns would be to at least do it well. That’s the absolute minimum you’d probably want. If you were to list the special attributes that your new commissioners must have, ‘having no experience in large-scale commissioning’ probably wouldn’t be high on your list. However the government decided to give around £80bn to brand new groups of people who had never commissioned on this scale before (CCGs). Moreover they would ask them to do it during a time when inflation and cuts means that they would have to restrict local services. This is problem number one.
And so to Coastal West Sussex CCG. They took the decision that MusculoSkeletal services (MSK) needed to go out to tender. In the end two organisation put bids together for the contract, BUPA Central Surrey Healthcare and the local Trust. Bupa CSH was adjudged to have the best bid and they won a £235m contract for five years and the contract was signed in September last year. Now to problem number two. In the governments excitement to foist private healthcare into the NHS they effectively made it law that all services had to be tendered out or potentially face a costly legal challenge to defend decisions not to. The problem was that BUPA CSH didn’t really know how this contract would impact the rest of the services across the trust because they were bidding against the only people who probably really knew this, the Trust themselves. So their bid must have been a little light in detail. The CCG decided that this was okay anyway. Now the local council, who had a committee which scrutinises such decisions, and the Trust who lost out in the tendering process, said that this contract could destabilise other services, particularly A&E (for instance the Surgeons who carry out elective orthopaedic operations also carry out A&E work as do anaesthetists and other staff) and that there needed to be a clear impact assessment carried out. What the Government and CCG hadn’t thought about in their desire to allow BUPA CSH to cherry pick the profitable health services is that multiple different health services are inextricably interlinked.
So the CCG spent an awful lot of money (commissioning in the NHS costs £5bn per year, funnily enough, the amount that the NHS is annually considered to be underfunded) to hire PriceWaterHouseCoopers to do an impact assessment to tell them what everyone else already knew. That this contract would destabilise a range of services, pose a number of risks and put the trust into financial deficit. To be the fair the CCG couldn’t have known this could they? Well it just so happens that in Bedfordshire there was also a privatisation of MSK services to private health care firm Circle, the result of which showed that such a deal DID threaten trauma (A&E) services and made the Trust financially unviable. Indeed, Professor Tim Briggs, President of British Orthopaedic Association, called for a halt to new contracts while the impact of “bold experiments” like Bedfordshire’s MSK contract with Circle Healthcare is assessed thoroughly. However the remit of PWC was only to concentrate very narrowly on local impact and not on national cases where a very similar contract had negative impacts on a trust.
So that’s what they did and they found that the contract would, if unchanged, negatively impact other services remaining in the trust and that the “cumulative impact of loss of MSK services” would result in the trust falling into deficit over the next five years. Like in Bedfordshire. The CCG declined to release the report publically, instead providing a brief summary. This was considered the best course of action in the face of the fact that by now, thousands of local people across the region had signed a local newspaper petition to save their A&E. The senior members of the cabinet were by now starting to distance themselves from Lansley’s folly while robotically still mouthing their safety buzzwords of ‘inefficiencies’, ‘unviable’ and ‘aging population’ and the local conservative MP, Tim Loughton, was telling everyone not to worry because he was having meetings. Coastal West Sussex CCG chief clinical officer Katie Armstrong reassured the public that she was pleased because the impact assessment which she hadn’t asked for and which she had set an overly narrow remit on and which had found the contract deeply problematic had given them the opportunity to fully explore the financial and clinical implications of the contract award.
So at this point the typical narrative is to switch the focus to dastardly multinationals and private healthcare companies who bend our compromised and ideologically zombied politicians to their heinous will. Surely they are the ones who are deviously and knowingly cherry picking the best the parts of the NHS and snaffling health funding into the pockets of their shareholders? Well, not really and this is problem number three. Here the carnival of incompetence continues. Circle’s abandonment of Hinchingbrooke Hospital after struggling to be profitable is a perfect example. Of course they found it unprofitable. Private healthcare companies exist to provide shareholder return and the best way to do this is though discrete cherry picking. But Circle shows that very often they don’t really know where the cherries actually are. When private companies move from their traditional domain of more straightforward elective work of wealthier insured people to the more messy, complex, integrated experiences of running a public infrastructure, they implicitly let their shareholders down because there is no way to predict profits. Circle had no idea if it could run Hitchingbroke and wasted a great deal of public money and their shareholder’s money finding this out.
Here in Sussex, BUPA CSH think they have isolated the cherries to pick but the PWC report, the cross-service nature of patient care for often unpredictable patients, and the fact that they couldn't do an adequate impact assessment because their competitor held necessary information, suggest they didn’t either. Now they are bogged down in costly negotiations, mitigations and thousands of angry local people who don’t want them anywhere near their hospitals.
So where are we now? Well William Goldman could tell us where we are. In essence nobody knows anything. Nobody knows how to privatise a national health service that nobody wants privatised. To say that this situation is desperate is an understatement. All the while the NHS, with its all-time high public satisfaction of 92% in 2010, its status as the most efficient in world despite being chronically underfunded, is torn to shreds by people who aren’t actually very good at tearing public institutions to shreds. History will not judge the political classes of 2010-2015 kindly. But it may at least spare a sympathetic gaze at us if we vote them out of office.
- Dr Carl Walker, EPCA Task Force on Austerity and Mental Health & National Health Action Party