Patient choice 'gaming' leaves NHS beds empty

Patient choice is leaving NHS beds empty as consultants use the scheme to refer patients to private practice and chief executives hang on to patients for economic reasons, senior managers have told HSJ.

Their comments came as health secretary John Reid attempted to refocus patient choice around NHS capacity as he launched guidance putting primary care trusts in the driving seat of the policy. By the end of 2005, all patients will be offered choice at the point of GP referral, and four or five different treatment options.

But University College London Hospitals trust chief executive Robert Naylor told HSJ that while he was 'totally and absolutely in favour of patient choice' in many places it is creating problems for the NHS. Projects to pilot cardiac choice in 2002 saw large numbers of patients referred to the Heart Hospital, acquired by UCL Hospitals in 2001. But with the national roll-out of the scheme, consultants instead use the scheme to refer patients to private practice funded by the NHS.

Mr Naylor said: 'One trust referred 200 patients to us in the pilot. That dried up to 15 when national patient choice came in because the consultants referred instead to private practice.'

And he said the NHS was paying more than twice over: 'We are paying to create the beds in the first place, then we are paying the private sector to do the operating and paying them a premium.'

While cardiac surgery is a relatively small specialty, others coming on line for patient choice such as orthopaedics and ear, nose and throat services are not. Mr Naylor said: 'We do not want to be ploughing millions of pounds into the private sector just by giving patients choice.' And he claimed that chief executives were reluctant to refer patients to another trust as they lost revenue and training accreditation by doing so.

At UCH, Heart Hospital and the Middlesex diagnostic and treatment centre currently have empty beds, he said. Other London DTCs are reporting similar difficulties. Mr Naylor has raised his concerns in writing with the Department of Health several times in the last few months.

Derek Smith, chief executive of Hammersmith Hospitals trust, which includes Ravenscourt Park orthopaedic DTC, said patient choice had not taken off as fast as it should. Consultant referral to the private sector was a minor factor, he said. 'It is more a simple business of economics. The income of a large hospital depends on volume.'

Rebecca Chalmers, project manager for a First Movers pilot at Central Middlesex Hospital's ambulatory care and diagnostic centre, identified similar difficulties. Consultants and trusts around London were initially so reluctant to transfer their patients to the unit that the team had to go outside London for referrals.

'A common concern we heard from trusts was that we were going to take the easy and lucrative work and leave them with the expensive and difficult stuff.'

Both Mr Naylor and Ms Chalmers agreed that shifting patient choice to GPs at the time of referral would solve some problems. Mr Naylor said: 'The difficulty arises when we have to winkle patients off existing lists.

Giving patients choice at the time of referral would overcome all the vested interests of consultants.'

But the NHS also needed clearer guidance on the use of private practice as well as better developed commissioning by PCTs, he said.

Sally Taber, head of operational policy at the Independent Healthcare Association, was sceptical about claims that consultants were making money out of the policy: 'While there are occasional examples of consultants referring to the private sector to earn extra money, it doesn't happen on a large scale.'

In other areas, managers are concerned that newly developed independent DTCs, designed to create capacity to deliver patient choice, will take their 'high volume, low complexity' work and leave them with additional capacity to fill.

Barnsley District General Hospital trust chief executive Jan Sobieraj said that while contracts with the new DTCs would be additional to PCT contracts with trusts, there were long-term questions: 'It may be that hospitals will be able to bring down bed occupancy and deal more effectively with emergencies. It may equally end up with hospitals with capacity gaps because patients are choosing to go elsewhere.

Ultimately, choice has a cost.'

A DoH spokesperson said all choice programmes employed patient care advisers to support patients and make sure their interests are put first.

He added: 'The DoH has been working to ensure all trusts are aware of any spare NHS capacity, so the widest range of options are available to patients.' To date, 2,549 cardiac patients had been treated under the programme and the NHS was on course to ensure no-one waits more than six months by the end of the year, he said.