Published: 20/01/2005, Volume II5, No. 5939 Page 3
Not one of the respondents to HSJ's survey of over 100 chief executives said using the private sector to help meet NHS demand was a bad idea (news, page 7). A significant number also supported the theory that the introduction of independent treatment centres would have a positive effect on the performance of local health economies.
However, almost without exception, both primary care and acute trust chief executives said the ITC programme was being undermined by its execution.
No other issue among the avalanche of reform which has hit the NHS in the last five years has caused such consternation among senior health service managers.
Over the last few months, HSJ has received more 'angry and alarmed' calls about ITCs than all other issues combined.
The concerns fall into two categories: the first is the heavy-handed way in which the Department of Health has implemented the programme. One manager from the north of England rang in a cold fury after reading DoH director of delivery John Bacon claiming in HSJ that it 'was for individual PCTs to take the decision' on the use of private sector capacity (news, page 8, 16 December 2004). 'Rubbish, ' she said - and it seems that many agree with her.
The DoH's 'macho' commercial directorate comes in for very strong criticism, while the efforts of some strategic health authorities to follow the same hard-line approach is damned as an attempt simply to win 'brownie points' with the centre.
All this could be dismissed - if you were so inclined - as the teething troubles of a major policy shift, but it is the second category of concerns which illustrate the real dangers of the government's approach.
Central to chief executives' concerns is what one calls the 'fundamental policy contradiction' between the volume guarantees given to ITCs and the choose and book policy being rolled out across an NHS operating under payment by results. Many respondents to HSJ's survey painted a picture in which ITCs will be paid for work they do not carry out as patients choose to stay with the NHS. Alternatively, they suggest ITCs will be made artificially busy either simply by channelling any growth towards the private sector or because of the failure of NHS organisations operating under a more onerous financial regime. In either case, this is hardly the pluralistic market championed by the government in which patients shape provision by choosing on the basis of quality and timeliness of care.
But it is not only the introduction of choice that is threatened by the ITC programme. Respondents point out that practice-based commissioning, foundation trust applications, private finance schemes, the transfer of treatment from secondary to primary care and the separation of emergency and elective care through NHS treatment centres and day care centres are all at a risk.
Many in the DoH know that it has made a mistake. Trying to shoe-horn 500,000 private sector finished consultant episodes into an NHS whose growth plans were well established, while creating a commercial environment attractive enough to entice an understandably cautious private sector was a recipe for trouble.
In originally defining the growth of independent sector capacity in terms of elective care and failing to recognise the implications of differing geographic need for extra capacity, the DoH then stiffened the rod it had made for its own back.
Richmond House is apparently now adopting a more pragmatic and flexible approach. This would be welcome, but our survey suggests there is little evidence that this new approach is being felt on the frontline - even at chief executive level.
There are plenty of vested interests in the NHS that would be happy to see the ITC programme fail. PCT and acute trust chief executives are not among them, and the DoH would be wise to listen to their views and give them greater discretion about how the independent sector is used locally. No other approach will be sustainable in the long run.
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