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.
Independent sector and the NHS -
from concordat to free choice
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.
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.
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