Independent sector and the NHS - from concordat to free choice

Independent sector and the NHS - from concordat to free choice

The NHS Plan and the independent sector

As mentioned in Chapter 1, The NHS Plan was published in July 2000 and it created the platform for significant reform both within the NHS and between the NHS and the independent sector. The document set out challenging targets to reduce NHS waiting times. As part of the plan to meet those targets the document proposed that there was a need to engage more constructively with the independent sector in order to use extra capacity to benefit NHS patients. This approach has been termed the ‘plurality’ of service provision.

Before The NHS Plan the NHS had procured services on a local basis in an ad hoc manner, using a range of independent providers including hospitals, nursing homes and hospices. In 2000 the consistency, quality and value for money of service delivery by the independent sector were not monitored nationally. Reform was required to ensure that the £1 billion of public money being spent in the independent sector at that time was being used effectively and patient safety could be assured.

The NHS Plan described the creation of a concordat between the NHS and independent providers that would make better use of facilities, so long as value for money and standards of patient care could be demonstrated. Therefore the independent sector was required to comply with NHS standards in addition to compliance with the National Minimum Standards published in 2002.Furthermore, from 2002 the independent sector was required to move to a single approach to pricing procedures based on the national NHS tariff, published and revised annually by the Department of Health.

Fundamental to the new partnerships was that the core principle of the NHS would not be compromised, namely, that healthcare should be available on the basis of need and not ability to pay. In addition to the quality and safety principles another key requirement of the independent sector was that they should augment the clinical staff pool rather than rely on those same clinicians who deliver services in the NHS. It was recognised that full utilisation of existing and new capacity in the independent sector could not be realised if the procedures were delivered by the same NHS consultants; thus ‘additionality’ clauses were added before contracts for services were awarded.

Treatment centres – NHS and independent sector

The imperative to reduce waiting times in the NHS provided the impetus for the development of new treatment centres run by the NHS (NHSTC) or the independent sector (ISTC) for treatment of NHS patients. Treatment centres were designed to offer choice to patients and to provide streamlined, safe and effective surgery and diagnostics tests for prebooked patients. Treatment centres were often, although not exclusively, designed to manage procedures from one specialty, for example orthopaedics or ophthalmology, where waiting lists had traditionally been long.

In 2003 central contracts, which included national key performance indicators (KPIs) to support clinical and financial governance, began to be awarded to international independent healthcare companies who were able to offer ‘additional’ staff. New ISTC capacity initially became available towards the end of 2004. NHS patients treated by the independent sector are not private patients but remain NHS patients and they have access to all NHS services. To ensure patients are not confused, the ISTCs are required to comply with NHS branding requirements.

Two supplementary contracts were also established with the inde-pendent sector in 2004 to ensure that there was a timely reduction of waiting lists while further treatment centre contracts were agreed and building projects established. These contracts made use of existing spare capacity in independent hospitals already established in the UK, for example Nuffield Hospitals (now Nuffield Health) and Capio (now Ramsey Health Care).

The ISTC programme was designed to allow the independent sector to work in partnership with local healthcare economies to provide solutions that met local requirements. Another aim was to stimulate innovative models of service delivery and drive up productivity. The ISTCs provide care for elective surgical patients, not unplanned emergency care. This results in a streamlined process for patient care informed by preassessment and following defined pathways of care, including the discharge process. Many of the ISTCs are day case facilities and therefore patients with low risk and fewer or no comorbidities are selected.

Use of ISTCs has not been without criticism, both in the press and from politicians, with claims of higher costs for cases in ISTCs and limited contribution to waiting-list reductions. However, from the evidence that out-sourcing to the independent sector was already significant it seems that more capacity was essential and these possible inefficiencies are inevitable when a significant growth over a very short timescale was sought, with the very clear goal of greatly reduced waiting times. Furthermore, it was potentially difficult for providers to voice criticism of purchasers when in tendering situations. However, there was a general concern in the independent sector that the cumbersome contractual processes developed by the Department of Health did not support the initial intentions and innovative approaches that could be gained from working with private business.

Pharmacy service provision to ISTC will vary depending on the model of care and the procedures undertaken. There may be an on-site pharmacy providing products and services in a similar manner to any acute hospital pharmacy service. In should be noted that the base pharmacy department may be remote from the ISTC and may be provided by a subcontractor hospital-or community-based. The innovation and productivity aims of the ISTC programme mean that pharmacy providers have also had to come up with ways for effectively supporting the programme, for example protocols for medicines from admission to discharge.