Case Studies on Competition in the NHS

SheffieldWhen I arrived in Sheffield in 2004, my first task was to "kill" the ISTC (Independent Sector Treatment Centre) that had been "imposed" on the South Yorkshire SHA by the Blair government.

The local Chief Executives, of the PCTs, of the Teaching Hospital, Children's Hospital and Mental Care Trust, and most of the surrounding Trusts, couldn't see the point.  I went  about it in my usual diligent way, talking to people who knew about ISTCs in the Department of Health, in private healthcare providers, barking to a few dogs ("talking to everyone and their dog"), doing the numbers, working it out for myself.  It's not that I'm suspicious, just that I like to check for myself.  The numbers stacked up, I presented my report, and the ISTC was canceled before it left the drawing board.  Of the 38 originally imposed by the Blair government, 2 were canceled, 34 were terminated during the due diligence phase (at a cost to the tax payer of many £millions), and the remaining went into production.

An ISTC worked extremely well in the North West.  It triages patients and prepares them for operations, which are then carried out in NHS hospitals (at least, it did then).  It was brought in with the agreement of all parties, and filled a gap.  It was a success - but one size doesn't fit all! 

Reform of Urgent Care in LondonLondon Ambulance Service

I then did the numbers for a plan to overhaul Urgent Care in the capital - work which subsequently made its way into the Darzi review.  The political strategy this time was right, but it had still been formulated without a proper analysis and could easily have been as embarrassing as the ISTC debacle had been, and the Darzi centres were about to become.  This evidence justified the use of specialist heart centres, on the grounds that patient outcomes were better and ambulances responded to the right cases, even though some hospitals complained bitterly that they wanted the income from patient arrivals.  It made me ever so slightly sick, to think that some hospitals would rather get the fee for an A&E arrival, than let the patient get the best possible care in a specialist centre, care that cost the NHS exactly the same amount.

Lord Darzi in Jan 2009Coping with Darzi Centres

Firmly in the middle of front-line healthcare, I was involved in pulling together GP consortia, one to bid to run a Darzi centre (I think we were too honest about numbers and costs - the (private) company that won it already knew that they would buy in cheap doctors and understaff, on the grounds that no patients ever turned up), and the second to take over the activity of a Darzi centre once its 2 year lease had ended.  The local GPs didn't want anything to do with the centre, and ended up ignoring the building (exactly as the patients had done) but the service was provided cost-effectively in more appropriate and acceptable locations.

AWP, ACP, AQP

The current round of change and opportunities for GPs and the independent healthcare sector (the companies that Mark Britnell is encouraging to buy KPMG consultancy to join in) has gone through a number of titles, and there are subtle but important differences.

AWP - Any Willing Provider is a tacit term for "Anyone already in the NHS or already holding contracts with NHS".  Although anybody is supposed to be able to bid, in practice various reasons have been created to keep the services "in the family".  This upset Blair and subsequently Cameron, so they came out with a new title

ACP - Any Competent Provider was quickly morphed into AQP Any Qualified Provider after the usual round of "how do you know they are competent?"  It was rather inevitable.  However the change is important - basically AQP means that you (the supplier) has to be really determined to bid for a service, with all of the bid costs that entails, because this is about showing on paper that you are competent, not pointing to a track record.  In effect, the GP practices that "just look after our patients" find themselves excluded, and the aggressive for-profit companies can present the most convincing paper cases.  Almost a reversal of the AWP situation, and this is reflected in the legal cases brought by disgruntled losing companies against the commissioners of the services.

So why explain this?

It's important to understand where NHS is now.  The money may be "National", but the providers are in danger of becoming anything but - "International" might be a more appropriate description.

Is this necessarily a bad thing?  Not on the face of it, but small companies each providing their distinct part of the healthcare system can increase the cost of bureaucracy, reduce continuity of care for patients, and start an endless "blame game" when something doesn't work or a target isn't met.  I faced all of this when working with the group of GPs to take over a failing OOH and urgent care service - this is exactly why it was failing.

The NHS does have national standards, but every population is different, every network of healthcare providers is different, and the solutions must, necessarily, be different.  It wold be nice if we could simply take a template for healthcare out of a drawer and say "here is the solution", but just as a GP can't say to every patient with COPD "I don't care what else you have, take this drug to relieve your COPD", so those who make policy actually work have to tailor the solution to the need.

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