“No privatisation of the NHS on my watch,” said Matt Hancock, Secretary of State for Health, shortly after taking up his post. But this week the Health Services Journal (HSJ) revealed that “Providers offered control of NHSE budgets worth billions” (paywall). The article is explicit that the private healthcare sector is central among those now being offered control of at least £2billion of mental health cash.
We’ve got used to privatisation of a lot of NHS services in recent years – everything from ambulances to cataract ops. The latest move – giving private companies responsibility not just for providing NHS services, but decision-making powers over commissioning budgets worth £billions as well – takes privatisation to a whole new level.
‘Commissioning’ means deciding who gets the money to provide NHS services – NHS Trusts, charities or private companies. It means deciding what services those organisations have to provide, who will be allowed to access them and what standards they have to be delivered to.
The HSJ reports that “NHS England has invited providers to take on specialised commissioning powers across the country, in a major expansion of its mental health new care models programme.” There is a “new target for setting up “provider collaboratives” - which are expected to take on the responsibilities and budgets - across the whole of England by 2022, and in 75 per cent of areas by 2020. They will have a lead provider which will coordinate services. It will involve substantial input from private organisations which are major providers of inpatient mental health and learning disabilities beds”.
So it seems important to ask at this point, what kind of role the private sector is already playing in the delivery of mental healthcare for the NHS – and what kind of standards of quality and access has it demonstrated so far?
Often not very good ones, it would seem.
Mental healthcare and private providers
The Care Quality Commission (CQC) issued a report on mental health rehabilitation in March 2018. They found that placements of NHS patients in the private sector were nearly twice as long as similar placements in the NHS. They were more than three times as far away from patients homes and social support – and twice as expensive. And managers at private providers were half as likely as NHS providers to know who was going to be responsible for after-care, post-discharge.
There have been scandals and indeed calls for private providers to lose their NHS contracts after episodes of unacceptably poor care. In one case a 17-year-old girl committed suicide. The coroner who ruled on the case said her anxiety had been exacerbated by her unacceptably prolonged stay at The Priory one hundred miles from her home in Scunthorpe.
Mental health is not given the priority that it needs regardless of promises from all parties to give it parity of esteem with physical health. All mental health patients, regardless of age, risk being sent long distances from home for in-patient treatment. The majority of locked rehabilitation centres are provided by the private sector.
By giving commissioning responsibilities to private firms there is clear potential for conflict of interest that the money will find its way into private pockets, and that contracts will be designed to suit the private companies who want to bid for them.
Essentially, there are two ways the private sector can win big from the NHS. They can win by getting government contracts and cash to provide services and facilities to NHS patients or other NHS bodies, when directly provided NHS facilities are cut or closed down. And the private sector can also win by providing services to patients who can pay, if those services simply aren’t made available to NHS patients.
And commissioning decisions – that the private sector has just been offered a huge role in – are absolutely key in both cases.
Public cutbacks, private opportunities
Looking again at specialist rehab centres, we can see how things are already beginning to play out, even before the role of the private sector is further extended into commissioning.
In its recent report the CQC recommended that every Clinical Commissioning Group – the organisations currently responsible for buying the services the NHS needs - should provide specialist rehabilitation facilities. NHS England has responded by saying that it is implausible for them to do so.
But the NHS did used to directly provide rehabilitation services. These were cut from 130 in 2009 to 82 by 2015. The private sector has been the direct beneficiary of these cuts.
In January 2016 The Priory Group was sold for £1.3billion by the US Private Equity Firm Advent International to Acadia Healthcare of Tennessee, a substantial increase from its sale value of £289 million in 2002. Last year, Channel 4's Dispatches programme included a senior figure at Acadia Healthcare who was explicit about some of the business opportunities offered by the NHS’s cutbacks to its mental healthcare facilities:
"What we would look forward to, or hope does occur, is that the NHS continue to close beds and have a need to outsource those patients to the private providers. We think, that or are optimistic, that if the NHS closes more beds and outsources those, we would be the big winner there."
The US owned Priory Group is listed in the HSJ story as one of the private sector companies which will be involved in the new budget holding ‘provider collaboratives’. The others include Cygnet Healthcare, a subsidiary of Universal Health Services which is an American Fortune 500 company and one of the largest hospital management companies in the United States and Elysium Healthcare, which is backed by BC Partners, an international investment firm.
The wider context – not just mental health
Understanding the Byzantine changes that are being made to the NHS isn’t made easier by the endless changes of names given to the same processes. But the mental health announcement should be understood alongside a wider move to create Integrated Care Providers (ICPs) across the whole NHS. These are also ‘provider collaboratives’ with responsibility for commissioning as well as service provision. The plans have been of considerable concern to NHS campaigners of late, who have been warning that such moves mean the private sector will become embedded in the structure of the NHS with potentially serious consequences for the care we all receive. There have even been judicial reviews taken by campaigners on the issue, including a very high profile case involving the late Prof Stephen Hawking.
But til now, campaigners’ concerns have been met by rebuffs – and by repeated reassurances that Integrated Care contracts, giving control over billions of pounds of spending, would not be awarded to the private sector.
Move on, nothing to see here
For example, the House of Commons Health and Social Care Committee’s report on integrated care (June 2018) found that the prospect of a private provider holding an ICP contract was “unlikely”. The NHS Long Term Plan also restated the “expectation that ICP Contracts would be held by public statutory providers”. Andrew Selous MP, member of the Health and Social Care Committee speaking in the NHS privatisation debate quoted Professor Chris Ham of the King’s Fund. “If you look at what is happening in the partnerships—places such as Salford, Northumbria, Wolverhampton, Yeovil and South Somerset—there is absolutely no evidence of privatisation”. And fellow Committee member Ben Bradshaw MP told his colleagues, “The other advocates of these integrated models are not just people such as Chris Ham but people we have spoken to on the ground, trying to deliver a service for their local population….. it makes it less likely that they are going to be private contracting.”
Such reassurances have been going on for some time, of course – with David Cameron insisting in a BBC interview that there would be "no privatisation of the NHS", and Theresa May answering concerns about US private health firms involvement by telling parliament “The NHS is not for sale”.
And they continue at the highest level. Earlier this year there was a decidedly awkward moment in front of the House of Commons Health & Social Care Select Committee after Simon Stevens, the NHS England CEO, tried to deflect repeated questioning over this key issue of ‘non-NHS bodies’ running NHS budgets.
Choosing his words carefully, Stevens said “we are suggesting that the integrated care should be from public providers”. Then – impatiently - Secretary of State Matt Hancock stepped in with his bravura statement. He said: “I am going to be much more concrete. There is no privatisation of the NHS on my watch, and the integrated care contracts will go to public sector bodies to deliver the NHS in public hands.”
In the face of such insistence, even some campaigners found it difficult to understand why the private sector would be interested, especially as there have been some spectacular failures of private sector contracts. Indeed, one of the pilots for a mental health ‘provider collaborative’ for Kent, Surrey and Sussex was quietly withdrawn without explanation at the end of last year. It contained more private sector providers than any of the other planned groupings.
But they are interested - and they are being awarded a part in the contracts, because they are already an integral part of the provider network. And NHS England has made clear that it will continue on its path regardless of evidence that it’s not in the interests of patients.
Already these private sector companies are providing some ‘backroom’ services. The word ‘backroom’ conjures up images of clerical work of little importance but it turns out to mean, amongst other things, advising and drawing up specifications on tendering processes for contracts worth £millions. Another key player in ‘backroom’ services is Optum, subsidiary of US health giant UnitedHealth (the organisation that formerly employed NHS boss Simon Stevens himself). Optum already provide a variety of back office services to the NHS, and according to US magazine Healthdive, the company has been on an acquisition spree to position itself as a leader in Integrated Services. It is working closely with organisations like Modality, the GP Super Partnership based in the West Midlands, who’ve just been awarded ‘custodianship’ of funds for bank and ‘back office’ services for Primary Care Networks, one of the new models for GP provision.
All of this should be a hot topic in England, knocking even the loss of GPs off the top news slot and sending shockwaves through the NHS. The private sector, including US-owned companies, looks like it’s about to be embedded in greater positions of power.
How much of the NHS must be controlled or heavily influenced by private interests before backbench MPs from all sides of parliament wake up and realise they have an awful lot of explaining to do to their constituents? Or, like ‘backroom’ and ‘outsourcing’ will ‘provider collaboratives’ just become more words for ‘move on, nothing to see here?