The government's scanning contract with Alliance Medical was intended to overcome the shortage of staff and equipment in the NHS. But it has not been a smooth ride so far, as Sally Flood explains

When the government announced in June 2004 that a private company would carry out more than 120,000 scans a year for NHS patients, health minister John Hutton promised the service would cut waiting times for diagnostic tests and cost less than half the equivalent NHS price.

A year later, many in the healthcare sector believe the scanning service provided by Alliance Medical has actually created longer waiting times and cost the NHS money.

'The contract is not working, ' argues John Lister, information director of the pressure group London Health Emergency. 'Even where the number of people waiting for scans has gone down, we have questions about whether the service they're delivering has gone downhill, too.' London Health Emergency argues that investing in private suppliers diverts resources from NHS staff and facilities, and distorts the service by directing funds to lucrative markets rather than to patients with the greatest need.

'The government should abandon the idea of centralised contracts that give NHS professionals no control over how funding is allocated, and start thinking about how to use resources to recruit and retain qualified NHS staff, ' says Mr Lister.

Alliance Medical signed an£80m contract with the government last year to provide 635,000 scans over five years to NHS patients. The idea of the contract was to use private operating staff and radiologists to overcome the current shortage of staff and scanners in the NHS. Recent figures show that three-quarters of vacancies for radiologists take more than three months to fill.

The Alliance Medical contract should address this problem by using non-NHS staff and therefore boost overall capacity by 15 per cent.

Appointing a private contractor to deliver services to NHS patients is not a new idea, argues Alliance Medical group medical director Dr Andy Dun. 'We have been providing scanners and radiographers to the private and NHS sectors since 1989, ' he says. 'We have a 15-year track record of working with the health service, and That is why we were appointed for this contract.' Dr Dun is not surprised that the NHS cannot meet demand for high-tech services such as magnetic resonance imaging scans. 'Demand has rocketed as technology has evolved, but there is a real shortfall in the workforce - the private sector is the only way to bridge the gap.' Alliance Medical provides a fleet of mobile scanning units and privately employed radiographers which visit hospitals for up to 12 hours a day, seven days a week. 'We offer a flexibility to meet demand that can't be matched by a fixed scanner, ' says Dr Dun. 'We are experienced in mobile scanning, and we are developing innovative working practices around technology and telemedicine to deliver even more value for money.' The Department of Health argues the Alliance Medical scheme has been broadly successful, achieving its aims of boosting capacity and reducing costs. 'This contract has achieved our objectives and secured value for money, ' says a DoH spokesperson. 'So far, over 45,000 patients have been scanned and it has helped every trust it has served by cutting their waiting times.' The scheme has proved convenient for patients, too (see box).

The DoH also believes that because Alliance Medical provides mobile scanning units it reaches more hospitals and more patients than investing in fixed scanners for a few individual trusts.

However, a recent letter from a consultant radiologist to colleagues at Kingston Hospital in Surrey was leaked to the press. In it, Dr Caroline Ward said that waiting times at the hospital had risen in the past year from 26 to 52 weeks, and could rise further to 78 weeks.

Dr Ward also claimed that a lack of funding meant the hospital's own MRI scanner was only used for emergency or private patients, because funding wasn't available to use it for other patients. The hospital had used Alliance Medical's services, but experienced delays of up to eight weeks in reporting scans.

Kingston Hospital is not the only NHS site where waiting times haven't reduced as a result of the Alliance Medical contract. While the DoH says that waiting times for patients in Ipswich have fallen from 30 weeks to five, the hospital doesn't agree.

'We did query these figures when we saw them.

We are not sure where the reduction in waiting times has come from, because it hasn't been the reality for us, ' says a hospital spokesperson.

The hospital was visited twice by an Alliance Medical screening team, and some scans were performed. 'Everyone was grateful for the service, and generally very supportive, but there were problems - perhaps because It is a new service, ' says the spokesperson. 'People were being called to come in for scans at very short notice and then there was some delay in getting the reports back.' Cases that were not routine caused particular problems in Ipswich. 'We found that when a routine scan turned up something unexpected, such as a cancer, there were delays in getting the reports back to the right people within the NHS, ' says the spokesperson. 'Although cancer patients shouldn't really be seen by the Alliance Medical teams, sometimes it couldn't be helped.' Other healthcare practitioners agree that the external scanning service doesn't always meet expectations for complex or multidisciplinary cases. 'There really needs to be cross-sector agreement about what key investigations are triggered by particular symptom complexes, and incorporated into locally driven patient care pathways, ' says Dr Greg Tanner, a GP with cancer charity Macmillan. 'I think we should also have incentives built into the system to promote better communication between sectors and with patients and carers, ' he adds.

In April this year, the Alliance Medical service came under fire after it was revealed that some hospitals were experiencing long delays getting results from scans the company had sent overseas for analysis. The British Medical Association branded the project a 'complete disaster' and complained of mistakes and delays in diagnoses.

The delays were caused by the fact that the company sometimes beams scan images abroad to Belgium, Spain and South Africa for analysis by radiologists because the company is not allowed to use NHS staff. In one case highlighted by the BMA, it took four weeks for Alliance Medical to report on the scan of a patient with a potentially fatal brain condition.

The DoH and Alliance Medical admit there have been teething problems with the contract.

One of the biggest challenges has been developing standard ways of working with different NHS trusts, all of which have their own protocols and practices. 'The biggest challenge is misunderstanding and the misinformation that can flow, ' says the DoH. 'If there has been a weakness it is in not getting the message out clearly and strongly enough about the clinical standards guaranteed in these contracts.' Alliance Medical, meanwhile, admits that communicating more effectively with local NHS staff upfront could have reduced delays and improved working relationships between private and public sector practitioners.

'The key lesson we have learned is around communication between all the stakeholders, from the DoH to local NHS staff, clinicians and ourselves, ' says Dr Dun. 'We could have done better in terms of communicating what We are doing with people on the ground, and integrating our work into existing patient care pathways.' The Royal College of Radiologists was appointed to oversee the Alliance Medical contract, and is now at the centre of efforts to address the problems. A recent report by the college expressed concerns about the contract. Although standards of service had improved significantly by the end of 2004, problems still remained.

The college is currently working with the DoH to address the remaining problems - in particular, the variation between work undertaken in the NHS and the private sector, and the need to provide an integrated, uniform, high-quality service for all patients, whether they are imaged in the NHS or the private sector. A spokesperson for the college said they expected to come up with a number of initiatives in 2005 that would help Alliance Medical and the DoH to further reduce waiting times, including making better use of existing NHS facilities.

The DoH acknowledges there have been problems in the contract's first year, but believes this is inevitable in any large project of this kind.

'The contract has only been fully operational since December and we believe it is now delivering according to expectations, ' it says. 'We have to be prepared to adapt to new methods in the interests of getting patients their treatment more quickly.' Former health secretary John Reid was critical of some NHS staff, whom he argued were opposed to private service provision on principle, referring to a 'culture of resistance' in some parts of the NHS. The DoH feels this culture can only be overcome by providing professionals with more experience of working co-operatively with the private sector. 'All change is difficult, but from our experience on the ground NHS staff always put the interests of the patients first, ' says the spokesperson.

The government is committed to extending the use of private-sector companies for diagnostic testing. In February 2005, Mr Reid announced that an extra£1bn investment in private-sector provision would allow the NHS to reduce waiting times for scans to just three weeks within five years. The contract is still in the tender process.

In the shorter term, the DoH is committed to the Alliance Medical contract: 'We have paid for 600,000 scans and we intend to use them all, ' says the DoH spokesperson.

However, campaigners believe that some things need to change. 'Ministers are dismissing anyone who criticises this contract as being opposed to private-public partnerships on principle, ' says London Health Emergency's John Lister. 'The only people I see arguing on a point of principle are the ministers who keep insisting this is a better option in spite of all the evidence to the contrary.' l