One evening at dinner I overheard a young woman describe how, bleeding profusely some days after an operation, she was advised by the NHS 24 ‘call handler’ (not a nurse or doctor) that her call was not in the ‘urgent’ category, but that a doctor would call her back within 90 minutes. Luckily a doctor called sooner, and she was taken to hospital immediately, where she collapsed in the hospital car park and required four pints of blood on admission.
I suggested to NHS 24 that the computer ‘algorithm’ it uses for bleeding should be reviewed urgently, but was told that this was not possible because the ‘algorithms’ are the property of Capita Clinical Solutions. Commercial confidentiality appears now to have over-ridden the possibility of saving lives; and the outcome for patients now depends entirely on a series of questions of unpublished provenance posed by a ‘call handler’ with no medical insight.
On another tack, the Scottish Government has decreed that all patient accommodation in new or substantially rebuilt hospitals must be in single rooms. Alex Fergusson MSP observed that the policy emerged ‘without parliamentary discussion or consultation with patients’ representative groups – an omission that seems strange in this day and age’. The policy was said to be based on ‘available literature and evidence, a public attitude survey’ and various reports from ‘experts’. But surveys (including the government’s own) show that only 40% of patients strongly prefer a single room. And providing single rooms for 50% of patients with the remainder in four-bed bays is sufficient for infection control and would cost some 15% less to build and run.
So what can be the reason for the government’s insistence on 100% single rooms in spite of representations from the public and some clinicians, MSPs and board members? Could financial backers (a modified Private Finance Initiative called ‘Non Profit Distribution’ in the case of Dumfries and Galloway Royal Infirmary) be calling the shots – maybe seduced by the possibility of attracting greater numbers of private patients to Scottish hospitals? Private patients may now contribute up to half the revenue of foundation hospitals in England.
Feedback from users and staff is fundamental for service improvement. But complaints and even constructive comments are now channelled to defensive formal processes with the aim of rebuttal. On 15 January 2013 Scottish public service ombudsman Jim Martin told the Scottish Parliament’s health and sport committee: ‘The NHS unfairly rejects more than half of complaints made – leaving patients feeling ignored. This reluctance to accept criticism prevents the clear identification of problems and makes it more difficult to implement solutions’. He ‘strongly recommended’ corrective action.
Despite this dismissive response to complaints, the Scottish Government passed a patient rights bill, resulting in the employment of patient rights officers to encourage and help patients to complain. But the public is beginning to realise that complaining is as futile as ‘consultation’ exercises and surveys of opinion. Genuine public representation and effective scrutiny have been eroded to virtual extinction, whilst at the same time creating bureaucracies to try to convince the public of the opposite.
So what exactly is going on behind the rhetoric of government and its associated quangos? The recently published ‘NHS SOS: how the NHS was betrayed’ describes how (in England) ‘both commissioning and the provision of services will be in the hands of private providers, concealing from public scrutiny the way the health budget is spent and distancing the Secretary of State from responsibility’. It suggests that the NHS will be reduced to little more than a fund of taxpayers’ money through which services are purchased from a variety of providers, with almost every decision taken without regard to the views of local people.
The evidence presented above strongly suggests that similar influences are at work in Scotland, although more surreptitiously. Capita Clinical Solutions is a multinational company ‘delivering healthcare to over 100 million people’ and ‘nurtured’ by Balderton Capital, ‘the leading venture investor in the EU’. Having established itself at the heart of NHS 24, Capita and its associates will clearly be making inroads to other aspects of the NHS and other public services in Scotland – including building and telecommunication provision in hospitals. It is even possible that large corporations may in the future have a say in determining entitlement to free health services.
At the very least the public should be made aware of what is going on, and the pretences of ‘transparency’ and public involvement should be exposed for what they are. For a start the following facts should be made widely known and questions answered:
The least complex and most profitable public services are being progressively replaced by an industry dominated by multi-national organisations to the virtual exclusion of small, efficient innovative providers.
The boards of these organisations meet in private and are not subject to the Freedom of Information Act. Contracts appear to be set up in ways that make comparison of outcomes with traditional providers difficult or impossible.
It will no longer be clear who is accountable when things go wrong. Private companies are not accountable to NHS management or directly to government.
As illustrated by the NHS 24 example above, response of private companies to observations and complaints is sluggish or ignored. Continuous improvement based on feedback from patients and staff is therefore impossible.
In England even cash-saving reconfiguration of services is investigated as commercial transactions by the Co-operation and Competition Panel to ‘promote choice’ in health services. Also there was pressure to give contracts to private companies even where there was a perfectly acceptable local NHS service. Are these statements true for Scotland?
Is it true that EU competition laws ensure that once any service is privatised the state is unable to take it back into public ownership?
Is the government willing or able to monitor the efficiency, effectiveness and probity of private providers? Have civil servants the necessary specialist knowledge and skills to draw up and monitor contracts effectively – including outcomes for patients? If not, who will ‘blow the whistle when things go wrong’? This will be a considerable challenge for the new chief executive of NHS Scotland.
Who are the financial backers of new-build hospitals such as the Southern General in Glasgow and Dumfries and Galloway Royal Infirmary? How does the Non Profit Distribution (NPD) version of the Private Finance Initiative differ from the original? Is the public aware that around 70 PFI contracts are owned by companies based off-shore, and therefore not liable to UK taxes?
Encroachment by international businesses however is not the only problem for our NHS. There are many quangos of no perceptible benefit (except to those employed in them), and the many wasteful organisations and activities in government and health boards that emerged around the turn of the century still abound, including the perhaps excessive time now allocated for non-clinical work.
Chris Ham, chief executive of the King’s Fund, writes of the need to ‘see prudent stewardship of scarce public resources’ as a key part of the doctors’ role, and to engender a ‘culture of commitment rather than compliance, focusing on variations in clinical practice and reducing waste’. But that’s another story.
