Recovery Watch: Is the NHS making best use of private sector capacity?

NHS England chief executive Amanda Pritchard told a King’s Fund conference last week the amount of elective activity the NHS was sending to the private sector was “higher than it was pre-covid”.

Given the critical role the private sector will play in helping to clear the NHS’s spiralling backlog, this statement needs unpacking. And not least because NHS England’s most up-to-date, publicly available, major elective data set – the referral to treatment figures – suggests this was certainly not the case for the six months to the end of September, certainly not for the main RTT “clock stops” measure, at any rate.

As our analysis shows, the total number of RTT “clock stops” across admitted and non-admitted pathways recorded by independent sector providers was down by 4 per cent over the six months, compared to pre-covid levels. They dropped from 648,576 in the first half of 2019-20 to 625,874 for the same period in 2021-22.

But NHSE is adamant Ms Pritchard is correct. It has referred to unpublished “weekly activity returns” data for November, which apparently show activity at 113 per cent of pre-covid levels.

There are several red flags to note here. Firstly, RTT clock stops are NHSE’s main activity measure mentioned in the H2 planning guidance for the second half of 2021-22, so it is interesting that they are now pointing to another way of tracking progress.

Secondly, if there is an undercount in the RTT data recorded for 2021, that would also apply to the 2019 data and should therefore have limited bearing on the percentage change in activity, which is what the debate is about.

Thirdly, NHSE has refused to publish this data, so it’s very hard to independently verify this claim. And finally, the RTT data only goes up to September, and the unpublished data NHSE said Ms Pritchard was referring to about activity levels in November. So we need to be careful we are comparing like with like.

Private providers: “Available capacity [is] simply going unused”

NHSE may well be confident their internal data (which hasn’t even been shared with the private providers) demonstrates improvement, but the private providers apparently carrying out this “increased” level of activity are not.

The Independent Healthcare Providers Network told me the RTT data was a fair reflection of activity levels being sent the independent sector’s way. 

IHPN chief executive David Hare said: “HSJ’s analysis shows inpatient and day case activity in almost all specialties are down on pre-pandemic levels, which is clearly inadequate given the scale of the NHS’ backlog…[and] available staffed capacity in the sector is simply going unused”.

So, as well as disagreeing over which data set most accurately reflects activity levels (suffice to say neither dataset is perfect), the two sides’ rhetoric is also poles apart.

It all feels a long way from the “all in this together” spirit the two sides exuded when they signed a historic deal at the start of the pandemic for the NHS to block book almost the entirety of the private sector’s capacity back in March 2020, as we reported at the time.

And given the central role the private sector is supposed to be playing in recovering the backlog, the lack of alignment between the two sides is ominous.

It was already a tall order with everyone on the same page but will be worse if the NHS cannot work with the independent sector in a way to make optimal use of its circa 8,000 hospital beds (a good bolt-on to the circa 100,000 NHS acute beds) and rich array of facilities and equipment.

The alarming deterioration in surgical specialties sent private

The RTT data suggests an alarming deterioration in activity being sent private from the major surgical specialties.

The overall average for the first half of 2021-22 suggested a dip in activity when compared to the same peiod in 2019-20. However, in two of the six months, September and June, the number of clock stops was higher this year than the pre-covid period.

In September, for example, total clock stops increased by 5 per cent during the same month in 2021.

But independent experts said it was concerning that this rise was driven by a huge big hike in ophthalmology, while other surgical specialty activity levels were in fact lower.

In the September example, the overall rise was underpinned by a 57 per increase in ophthalmology, and a 32 per cent increase in dermatology activity.

Meanwhile, activity levels fell in major surgical specialties. Trauma and orthopedics, the largest specialty by volume in September 2019, fell 7 per cent (see table below).

As independent waiting list expert Rob Findlay told me: “While it is welcome that ophthalmology has benefited from extra activity in the independent sector, ‘extra’ is unfortunately not the same thing as ‘enough’, nor does it help in other specialties where independent sector activity has fallen and NHS activity is still constrained.”

The reasons why some specialties have risen while most have dipped, is in part down to logistics and the route into the private sector for some specialties being easier.

As Barry Mulholland, who works on waiting list management and recovery programmes with trusts, told me: “Once a patient sees a clinician in an NHS hospital, they tend to want to remain with that clinician rather than go somewhere else. Ophthalmology and dermatology pathways can often be sent straight to the private sector directly, without touching an NHS hospital.”

But is there something more to it than that?

Mr Mulholland, a partner at MBI Healthcare Technologies, added: “These specialties are therefore more suitable to refer privately than the more complex specialties.

“However, whilst they are more suitable than some of the other specialties, I am surprised there isn’t a lot more work from the other specialties being made available to the private sector. That suggests the problem is more an issue about contracting and commissioning.”

I asked both NHSE and the IHPN whether contracting issues were part of the problem. Both declined to comment, so make of that what you will.

NHSE did however point out it was extending the “increasing capacity framework’ under which independent providers offer care to NHS patients at nationally agreed prices by two years. New contracts worth up to £10bn under the framework will run from April next year until December 2024. 

Whether this helps remains to be seen. But it would certainly be fair to conclude it will need more than a new framework agreement to fix the complex array of problems which ultimately mean the NHS is not making optimal use of private capacity when, arguably, there has been no time in the service’s history it has needed to do so more.