Image: Care Quality Commission's assessment of the only fully privatised NHS Trust in the country, Circle Hinchingbrooke.
Last Friday private healthcare company Circle announced it was pulling out of its contract to run the Hinchingbrooke Hospital in Cambridgeshire, blaming a £5million loss and an NHS crisis including “unprecedented increases in accident and emergency attendances, insufficient care plans for patients awaiting discharge, and funding levels that have not kept pace with demand".
True enough - but the real reasons for Circle’s snap exit emerged later that day, when the hospitals inspector the Care Quality Commission (CQC) released its delayed report into Circle’s management of Hinchingbrooke Hospital.
It was damning.
Hinchingbrooke - the flagship of NHS privatisation - was given the CQC’s worst ever rating for ‘caring’. Both safety and leadership were also bottom of the heap. Circle’s cleverly branded ‘mutual’ model, far from ‘liberating’ NHS professionals to make grassroots-led improvements, had in fact replicated some of the worst hierarchical, bullying practices to be found in the NHS. And it had lost the caring and expertise that are the NHS’s strengths, principally as a result of poor leadership and financially-driven staff cuts to satisfy investors.
But Circle’s news management has always been its forte (as David Cameron knows - his health advisor used to be a Circle PR chief). By Friday afternoon, most journalists were packing up for the weekend, Paris-sickened. Their pieces were already published, based on Circle’s pre-emptive morning statement, which suggested the only real difference between the private Circle and the public NHS is how easily Circle can walk away from a hospital.
But that’s a long way from the full story.
Circle’s medical services were found to be delivering “poor emotional and physical care which was not safe or caring…people were not treated with dignity and respect… some patients were afraid of certain nursing staff”’.
Some of the examples witnessed by the CQC in their two-day inspection were chilling.
“We heard the staff member say to the patient ‘don’t misbehave, you know what happens when you misbehave’. We later asked the patient what they thought the staff member meant by this; the patient became withdrawn and was unable to provide us with an answer.”
“A patient on Apple Tree Ward, who required support during the night to go to the toilet told us that staff were ‘often too busy’. They said ‘they tell me to go in my bed and they will change me when they have time’.”
Other patients during the two-day inspection reported similar experiences, or were witnessed being left dirty and distressed, and treated rudely or roughly.
Inspectors found a patient with ‘challenging’ behaviour had been sedated without any record of a proper assessment of their mental state or best interest.
Circle’s junior doctors were often labelling patients “do not resuscitate” without discussing the decision with patients or relatives, and without any apparent oversight from senior doctors. Sometimes the failure to discuss was because the patient lacked mental capacity, notes often suggested - but the CQC “saw no evidence that a mental capacity assessment had been undertaken in any of the patient records we looked at”.
The CQC notes “We found many instances of staff wishing to care for patients in the best way, but unable to … prevent service demands from severely impinging on the quality and kindness of care for patients.” It found Circle lacking “sufficient appropriately skilled nursing staff”.
Though the details are shocking, the general picture is unsurprising to anyone except those who bought the ideological hype about private sector magic dust. Circle won the contract by promising what the Public Accounts Committee called an ‘unrealistic’ and ‘unprecedented’ level of savings - urged on by government officials. Circle’s Full Business Case said it would achieve this by altering ‘nurse-patient ratios’ but exactly how was blacked out of the plan when it was eventually published. Leaks suggested plans to cut 320 posts in total.
Within 6 months of taking over Circle had already scrapped 46 full time nursing posts, then Chief Executive Ali Parsa (an ex-Goldman Sachs banker) admitted.
Hinchingbrooke’s A&E department had over a quarter of posts vacant. Staff were particularly worried that A&E facilities and staff cover for children were unsafe, though some improvements have been made since the inspection.
“Patients were routinely triaged within the waiting room area with no consideration for their privacy and dignity…we saw patients getting frustrated that they were waiting extended periods for treatment and lack of information, however staff reported they wished they had more time to care.”
Circle loudly proclaimed its rapid improvement in the key ‘4 hour A&E waiting time’ target as evidence that privatisation had quickly turned Hinchingbrooke around’.
But the CQC discovered the hospital kept patients waiting too long in ambulances before they were allowed into A&E. And after they were seen in A&E, they then waited far too long - up to 12 hours - to be admitted to hospital. On this measure (so-called ‘trolley waits’) Hinchingbrooke had one in 5 patients waiting between 4 and 12 hours, compared to a national average of only one in 20 patients.
So much for key targets.
And whilst waiting in A&E, an unusually high number of patients (double the national average) left before being seen, fed up of waiting - and presumably unimpressed by the waiting-management computer system Circle had boasted was modelled on the Argos tills. (Circle’s senior management team had been hired from Argos, Avon, Faberge, Tesco and fashion-website Asos, bragged Ali Parsa in an article entitled “Government should not be running hospitals”).
There were pockets of good practice too. Maternity care and outpatients and diagnostics were rated as good, and the chaplain singled out for special praise.
But overall performance indicators are patchy at best - and there are enough shocking examples for the overall rating of ‘inadequate’ to be wholly justified.
Dangerously sloppy procedures were everywhere at privately-run Hinchingbrooke, the inspectors found. Incomplete patient notes, missing care plans, infected catheters, unwashed hands, broken clinical guidelines. Fluids were repeatedly out of reach of patients despite the inspectors’ intervention. On other wards, call bells were placed out of reach. Diabetic patients were left without food. Patients missed vital medication rounds. Lifesaving resuscitation equipment was not checked regularly. Many post-surgical patients were waiting over 30 minutes for a response to a call bell (Circle’s own figures claimed the maximum wait was 8 minutes).
Many patients were being moved between wards in the middle of the night. “One patient on the acute surgical and trauma ward said that they had been on seven wards in the first three days of admission, and had been moved at 12.45am, 3am and 5am on different days.”
The CQC was keen not to blame the permanent staff themselves - though it did note an over-reliance on bank and agency staff (a problem Circle repeatedly promised to fix) who were involved in many of the most worrying failings. “All nursing staff told us the trust had difficulty recruiting and retaining staff…one nurse told inspectors “we can’t keep staff”.
The report reflects the recent staff survey which found morale amongst the lowest in the country.
Staff told the CQC that shortages also meant little time for training. For example, “Staff at ward level were not competent in caring for people at the end of their life, because they had not received the training required to enable them to undertake this role.”
Of course there are similar incidents in NHS hospitals - all are operating in a difficult environment as Circle themselves point out. But many NHS hospitals are weathering the storm better than this experiment with privatisation, sold as a way of ‘saving’ a District General hospital.
As for the claim that Circle was replacing an outdated fixation on public ownership and ethos, with a supposedly more responsive, grassroots approach, the CQC report comprehensively trounces that suggestion.
The CQC report says “teams were not engaged nor felt enabled to raise concerns”. They found staff did not use Circle’s much trumpeted ‘stop the line’ process supposed to help staff raise concerns about patient safety. Staff said when they tried, “they were made to feel that they were to blame, and they have done something wrong” - a feeling shared by the CQC inspectors who witnessed this ‘blame approach’ when they ‘stopped the line’ themselves in response to serious concerns.
Whilst a few senior doctors were well informed, “senior nursing staff we spoke to said they did not feel involved in the decision-making process within the hospital.” The findings will not surprise those who have looked at other so-called “mutual” structures and found them of greater benefit to higher paid, higher status staff.
All in all, the gulf between the privatisation rhetoric and reality has never yawned wider.
But does that mean privatisation is dead?
No. Too many have staked their careers - and their fortunes - on it, for them to back off that easily.
No-one who understands the NHS has ever really expected the private sector to make profits from running full service hospitals with A&E departments.
Just as opponents to the Health & Social Care Act pointed out, what the private sector really want to do is cherry pick, taking the government money to run all the predictable and easy stuff - starving the rest of the NHS of funds as a result.
But the government had to pretend otherwise, to get through the Health & Social Care Act, and Ali Parsa's hyperactive hyperbole was very useful during those turbulent months.
“Forget the cherries - give us the potatoes” Ali Parsa told the Times in November 2011 on winning the contract. That years’ business plan set out grand visions of Circle taking over 20 or more hospitals across the country. Parsa even told Newsnight "We would love to run a major teaching hospital".
But Parsa left at the end of 2012 for pastures new - his PR job done. And with the Act secured, and former Vice President of US healthcare giant United Health, Simon Stevens, now at the helm of the NHS, private health companies see better profits (and less brand damage) than openly taking over full service hospitals, as Circle’s statement on Friday hinted:
“We fully support the vision of Simon Stevens’ (NHS England Chief Executive) 5-year Forward View, but these potentially exciting reforms are too far into the future…if reform in the region develops fast and a new role for us becomes clear, we are happy to play our full part.”
In other words, if the entire NHS needs to be reconfigured away from providing us with local hospitals towards easier, more profitable routes for the private sector (perhaps a hefty chunk of ‘care in the community’), well, bring it on.
If doctors running local Clinical Commissioning Groups won’t hand over the NHS cash, there’s various ways decisions are being quietly wrenched away from them, from ‘commissioning support’ and ‘personal budgets’ to ‘chain hospital networks’, ‘Kaiser-style integration’ and ‘prime contractor’ models.
All of this will help companies like Circle sort the cherries from the potatoes.
And if the tariffs paid for many treatments are currently too low to squeeze a profit from, well, it's only a waiting game til the cherry picking undermines the NHS to the point the private sector providers can start flexing their muscles and demanding more money.
It's already starting.
In nearby Bedfordshire, Circle recently won a huge ‘integrated’ ‘prime contractor’ contract for all musculo-skeletal services in the area - and promptly tried to sub-contract the undesirable bits back to the NHS on Circle’s own terms. As the local NHS hospital told the BBC, “Our concern is that if we don't have the planned work coming through, then with the way the NHS is financed, we don't know whether we will have sufficient money to provide the emergency service.” Recent reports suggest Bedford Hospital is now in severe financial difficulties.
A little further afield in Nottingham, Circle runs the largest Independent Sector Treatment Centre in Europe, having pulled off an eyebrow-raising deal to force the NHS to pay it £42 million to buy its clinic in the hospital grounds, then lease it back to it. Circle then continued to expand, recently successfully bidding to take over the hospital’s routine NHS dermatology services - to the disgust of the doctors who left rather than be transferred to Circle. Now, the local NHS hospital is closing its acute dermatology services too, because it can’t afford to provide only the more expensive dermatology services Circle doesn’t want. Patients will be forced to travel ever further afield for anything more complicated or less profitable.
And Circle-style ‘mutual’ models are still being quietly pushed, as the government encourages nine more hospital trusts to leave the NHS - and makes clear that it would like to see all of them follow - or perhaps just their profitable cherries, leaving the NHS with the underfunded spuds.
Authors note: We asked Circle for an interview for their side of the story, but they failed to respond.
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