Essential insight into England’s biggest health economy, by Ben Clover

Not going to Hackney

Lewisham and Greenwich Trust is having to outsource a lot of elective work at the moment.

Mainly vascular but also a significant backlog of orthopaedic patients.

How successful has it been in keeping the NHS pound in the NHS?

Not wholly.

The south London acute trust had originally looked at sending some orthopaedic cases to Homerton University Hospital Foundation Trust in Hackney on the other side of the river.

Homerton would certainly like the work – it is casting around for extra income at the moment and has a strategic goal of becoming a trust with a turnover of £400m. This, it is thought, would guarantee its continued independence from, say, Barts, whose experience of running a multisite trust is getting better but from a low base.

The Homerton and Lewisham hospitals used to be quite similar propositions, plucky holdouts against the vast organisations surrounding them (in Lewisham’s case, King’s College Hospital FT and Guy’s and St Thomas’ FT), and which won the contracts to run community services in their patches when the opportunity arose in 2011.

They and the Whittington Hospital Trust were looked at with interest by policy people to see whether a district general hospital serving one borough could stay viable.

Whittington and Homerton have done, the latter embarrassing far grander organisations with its stellar accident and emergency performance. Lewisham instead was tethered to the private finance initiative albatross of Queen Elizabeth Hospital in Woolwich, under the never repeated trust special administration programme.

This process unsuccessfully tried to strip Lewisham of its A&E. Had it succeeded it might have created the hotsite /cold site model beloved by Simon Stevens.

(Neighbouring King’s is now attempting this very thing to try to rescue the performance of its Denmark Hill site, sending a lot of routine activity down the road to Orpington. Could Orpington Hospital one day be south east London’s equivalent of the South West London Elective Orthopaedic Centre, rated outstanding by the Care Quality Commission? It’s slow going at the moment.)

So, where is Lewisham’s elective patient backlog being sent?

Not Hackney.

The trust said the distance from Lewisham to Hackney meant there had been a low patient take up (managers had planned on 20 cases a month). Sources at Homerton said they were told by Lewisham it was a clinical governance issue, something a Lewisham spokeswoman denied.

Patients awaiting hand procedures at King’s College Hospital FT have also turned down treatment in east London, with no one taking up the offer of a referral to Newham.

Part of Lewisham and Greenwich’s backlog of 666 vascular and general surgery patients are being sent to a BMI facility in Shirley Oaks, some way away in Croydon, and a smaller firm called Frontière Médicale.

Does this matter as long as patients get treated at tariff?

Yes, in an unexpected way.

It’s not accusing the private providers of cherry picking to say they get sent the less complicated work, to clear the backlog.

This makes sense when private hospitals tend to lack other specialties to help out if things go wrong.

But it has an implication for training.

The Royal College of Surgeons has concerns that outsourcing easier cases to the private sector en masse will leave only difficult patients that require senior consultants in the NHS – and the juniors therefore won’t get the practice they need to develop their skills on the routine stuff.

Hard to quantify but a legitimate concern.

Earlier this month, University College London Hospitals boss Marcel Levi approached the training/private provision issue from a different angle at a King’s Fund event.

The central London super specialist has long had a partnership with HCA on specialist haemotology work.

Professor Levi was straightforward about this, saying these clinicians were going to find their way to this private work and he preferred to have them working onsite rather than somewhere private where they couldn’t be contacted.

But NHS trainee medics, important to the running of these services, were not allowed on private floors because HCA had not contributed to their cost and Health Education England had. This isn’t insurmountable, but both issues are complications of using or partnering with the private sector – a sector that relies heavily on a specialist workforce trained at public expense.

Happily, NHS private patient units, often run with HCA and the like, are doing well.

Data from analysts Laing & Buisson released this week said roughly £1.5bn of private hospital work was carried out in London, £360m of it in NHS private patient units.

Better still, the report said these units were starting to take market share from the independent sector on work coming from foreign embassies.

This work is worth more than £318m a year (more than Homerton’s turnover) and the NHS has apparently benefited from appearing cheaper as the oil price slump enters its fourth year.

The NHS should of course make sure it actually gets paid for this work, as relations with embassies can be murky and not always as rewarding as they promise to be.