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Self-Serving Nhs Trusts Inhibit Better Patient Care

Closed-shop ‘NHS family’ freezes out other healthcare options to leave patients waiting

Patients are being denied potentially better, more timely treatment because of an NHS culture that demands loyalty to the family of NHS hospital providers, according to a new report.Refusing Treatment, by independent think tank Civitas – based on a one-year study into the relationships between acute trusts and their commissioners – concludes that existing NHS providers use their muscle and connections to keep providing services even when faster, higher quality care is on offer elsewhere.

The results are that the benefits of a decentralised and innovative NHS are being denied to patients who have to wait longer for treatment and fail to access the most appropriate services.

Surgeons – still the ‘kingpins’ in NHS hospitals

The report found evidence that surgeons working in both NHS hospitals and independently run centres often work more effectively in the latter, delivering a more reliable and punctual service to patients. But inertia in NHS providers, where surgeons can play the ‘clinical’ and ‘NHS family’ cards, keeps better working practices from spreading. One medically qualified executive commented:

It’s a question of having the will. Four surgeons didn’t turn up for work here yesterday, blaming the snow. In the private sector they’d all turn up… In the health service there just isn’t the will to work too hard, because you won’t get fired and you’ve got your pension.(p.83)

One private provider executive revealed:

I know for a fact that a surgeon in an unnamed NHS trust takes 2 1/2 hours to do a hip replacement that he does in 45 minutes at [one of our hospitals]. (p.84)

‘NHS family’ nurtures closed-shop mentality

The study suggests that loyalty to the ‘NHS family’ too often has a stronger impact on organisational decision-making than the needs of patients do. As one NHS provider executive explained:

[There is] a fundamental problem in current market policy: the DH [Department of Health] promotes competition and devotes substantial resources to its implementation, yet it also advocates the cultural sanctity and historic importance of the NHS… I do not believe many people have bought into the idea that the NHS is the organisation that procures health care for the public and where that health care is delivered should not matter. (pp.85-6)

Instead, there remains a culture of supporting local NHS providers, often regardless of the quality of other organisations: NHS, voluntary or private. One private provider executive explained how, despite patients being seen an average of 1.2 times before being given a diagnosis at his organisation compared to the local NHS average of 2.8 times (producing a 24 per cent cost saving) (p.35), ‘the [NHS] acute providers immediately formed a cartel and refused to let their consultants work at the clinic’.

Another participant described how:

NHS doctors ignored the private healthcare clinic staff at local meetings, barred them from training courses, and made it extremely difficult for them to integrate into the medical community, which may have an adverse effect on quality of care. Some NHS physicians walk out of the room when they enter. (p.87)

Summing up the situation, one DH official said the market has been blocked ‘by most people in most places’. (p.xv)

NHS trusts keep the heat on PCTs

NHS trust and foundation trust hospitals have used the guise of ‘defending the NHS’ to bully PCTs into preserving the status quo when better options were available. This has often happened with the support of local politicians and media. One executive reported:

PCTs are scared of the providers’ political power. They are afraid of putting services out to tender and angering the hospital providers. They are afraid that the hospitals will then go and do something to retaliate that will cause the PCT managers to lose their jobs.(p.73)

Hospitals were also found to have engaged in predatory pricing by shifting their overheads around to remove costs from services where they want to win competitive contracts, offsetting them onto other services where there was no competition. This practice prevents fair comparisons between healthcare providers, short-changing patients who may then end up with a lower quality, more costly, service.

Some success stories break the protection racket

The authors conducted a year-long inquiry into the market structure of the NHS, interviewing 46 senior managers and clinicians across three health economies in England. They found isolated examples of the market for provision having significant positive effects:

i. Faster treatment, continuity of care. One medically-qualified executive commented:

Back when I started people waited 18 months for an operation and had no idea what was going on. Now the same [physician] sees them throughout, and they are turned around in 18 weeks. It’s fantastic for patients… (p.35)

ii. Helping patients. A provider executive said:

NHS staff don’t like the word ‘customer’… the NHS has always dealt with vulnerable people. But I have seen a growing emphasis on promoting the little things, for example, are staff approaching people who look lost in the corridors?(p.27)

iii. Improvements in quality of care. One commissioner said:

We have certainly brought in new providers as a deliberate move to improve performance [in areas such as dentistry and sexual health] and I believe this has worked as an incentive for others to increase quality. (p.33)

iv. Increased value for money. One senior clinician commented:

[The trust being a business] makes us think in a lean fashion. For example, we recently streamlined prosthesis and implants. It wasn’t our preference, but doing it saved money without adversely affecting patient care. We have to be making money in our own patch. If we’re not, we have to ask ourselves why, because other hospitals can make money on the tariff… You can’t lose money this way in the real world, and you shouldn’t be able to do it in the health service. (p.34)

However, by and large, the ‘NHS family’ has successfully broken competitive, lower-cost and higher-quality alternatives, keeping the benefits of innovation and accountability limited. The NHS market for secondary care is yet to have its intended impact on providers and bring about the anticipated benefits on any meaningful and systematic scale, the authors conclude.

Co-author James Gubb said:

‘The Coalition Government has put a lot of faith in the power of the market to meet the NHS’s unnerving productivity challenge. The problem is the Coalition isn’t addressing the real issues as to why the market currently isn’t delivering: the overwhelming power of hospitals and the closed-shop “we can do it alone because we’re the NHS” attitude so prevalent across the organisation.’

Commenting on the report, Lord Warner, a former Labour health minister, said:

‘As the interviews in this report reflect, too many NHS personnel are too comfortable or frightened to create the discomfort and public angst that a properly functioning market would bring.’

The existing evidence that secondary care competition can bring the intended benefits in the NHS will be an important guide for future policy as the NHS embarks on major reforms over the coming years.

For more information contact:

James Gubb on: 079 3024 3570

Civitas on: 020 7799 6677 or

Notes for Editors

i. Refusing Treatment can be purchsed from Amazon, or directly from Civitas (020 77996677).

ii. James Gubb is director of the health unit at Civitas, a post he has held since 2007.

iii. Civitas is an independent social policy think tank. It has no links to any political party and its research programme receives no state funding. Civitas’s health policy research seeks to take an objective view of health care in Britain. It aims to offer an improved perspective on how best to deliver equitable and high standards of health care for all.


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