Bupa’s Spanish subsidiary’s example of public-private health services is arousing interest in the UK, says Daloni Carlisle.

November’s news that a private provider - Circle - is to be given a franchise to take over troubled Hinchingbrooke Health Care Trust sent a frisson through the NHS management hierarchy.

It is a radical move for the NHS - but not so bold when compared with the Spanish experience, where not just acute hospitals but health services for an entire region are now managed on behalf of the public by a private company.

The company is Sanitas, the Spanish subsidiary of Bupa, which now not only provides acute care but also primary care and intermediate care to 197,000 people in Manises, Valencia.

The public-private partnership model is creating widespread interest in the UK - Sanitas director Iñaki Peralta spoke at the King’s Fund annual conference in 2010 and a number of NHS management teams are planning study tours.

Sanitas receives a per capita allowance of just over €600 (£516) for each of the 197,000 people under its care, compared with around €850 in the pure public sector. For this, the company provides primary care at 20 GP surgeries, acute care at a new state-of-the-art 220-bed hospital and two specialist hospitals and intermediate care for people with mental health problems and those with long term conditions in 137 dedicated beds.

People receive their care free at the point of delivery and can choose where to have acute care.

Each year, Sanitas agrees targets with the regional government, with which they can track the care provided. Typically, these concern patient safety, rationalising prescribing or implementing clinical guidelines as well as adherence to public health programmes.

More for less

There are several important points about this model, says Mr Peralta. First, Sanitas is doing more for less - including paying for the €100m investment made in the new hospital.

Second, consumer choice means that there is a risk for Sanitas if services are not perceived to be high quality and people choose to go elsewhere - with financial penalties.

Mr Peralta says: “The risk is transferred by the government to our company for providing efficient, high quality care.”

Third is that integrating primary, intermediary and secondary care puts the onus on Sanitas to provide preventive services.

“It is very important that we focus on prevention,” he says. “We have an interest in increasing the health of the population.”

So where are the savings being made? Mr Peralta is very clear: pay is a major factor. Although many of the primary care staff remain employed by the public sector and are managed by Sanitas, 60 per cent of the 1,400 workers are direct employees. Not only does Sanitas employ fewer people than the equivalent public structures - partly because of the integrated model - it also pays them less.

Mr Peralta says: “The capacity to run the staff is a key point to reduce cost.”

There is more to it than this, though. As a Bupa spokesman points out, Sanitas has been able to introduce private management principles into public services.

For example, the acute hospital has state-of-the-art IT systems that create not just a clinical record for each patient but also a parallel economic record. By keeping track of the costs, the hospital management and clinical staff can examine ways to streamline care pathways, implement preventive programmes or develop targeted care packages to prevent readmission of patients with long term conditions.

Sanitas believes the public-private partnership is delivering beyond its targets - see box below. Primary care and acute care records are now integrated electronically, allowing clinicians and managers to standardise care for common conditions - in other words, achieving the much vaunted goal of removing unwarranted variation in care.

It has not been an easy journey politically. Manises is not the first area to implement public-private partnerships in Spain but has gone the furthest with the integration of primary care into the model.

“It is politically difficult, yes,” says Mr Peralta. “Not everybody was happy with it but I think it has been a success. It is true that the people in Manises have got fantastic infrastructures that they could not have had using public money and our quality standards are as high as in the public sector.”

The 64 million dollar question, though, has to be whether Sanitas has made a return on its investment in the new facilities or made a profit on its contract, which was first signed in 2006 but went live in 2009.

Not yet, admits Mr Peralta, although he says this with enough of a smile to indicate he has a degree of confidence.

The Sanitas model is a long way from the Circle franchise and indeed would not be legal in the UK under current law.

But Bupa medical director Dr Andrew Vallance-Owen believes it is worth looking at in the UK context - particularly by commissioning consortia that want to drive integrated care.

“As a private hospital, we are usually trying to maximise our throughput,” he says. “The whole point about Manises is that it is capitation based and integrated. We do not want our people using the hospital [because they want to promote prevention] but we want the hospital to be good enough to attract people from outside the area because it makes money.”

SANITAS MANISES: Some targets

During the first half of 2010:

  • 96.27 per cent of 15 month old children have received the first dose of MMR vaccine, making this the first department of the Valencian community region that meets this indicator and satisfying the requirements of the childhood vaccination schedule of the Valencian community
  • 54.72 per cent of adults over 45 years old (100 per cent of the set target) have controlled their glucose in the last three years. This enables efficient mechanisms of prevention and control for diabetes
  • 6.9 per cent (100 per cent of the set target) of low risk pregnancies undergo caesarean section
  • It is leading in surgery that does not require hospitalisation, improving the quality of life of patients.

Source: Bupa, Sanitas