Select Committee on Health Minutes of Evidence


Memorandum by Royal College of Nursing of the United Kingdom (PS 23)

TERMS OF REFERENCE AND EXECUTIVE SUMMARY

"The Role of the Private Sector in the NHS"

  This inquiry focuses specifically on:

    —  the NHS Concordat with the Private and Voluntary Sectors;

    —  the Private Finance Initiative; and

    —  Public Private Partnerships.

  To date the RCN has taken a pragmatic "what works" approach to the role of the private sector in the NHS. The RCN's evidence reflects the reality of nurses' and patients' experiences of the role of the private sector in practice.

METHODOLOGY

  To gather information about experiences with these projects, the RCN developed two standard questionnaires. One was sent to each of the 16 operational PFI schemes in England and was completed jointly by RCN members and staff within those sites. The other was distributed to selected members of the RCN management and commissioning fora who have experience of working with concordat arrangements. A half-day workshop including RCN staff and members from both these groups was held to identify themes and issues arising from both questionnaires.

  As the Government has only recently announced extending PFI into new PPPs in primary and social care, there are no established practical examples of these arrangements. To date the most advanced example of this type of initiative that we are aware of concerns the redevelopment of two community hospitals in Herefordshire. These schemes have been examined.

FINDINGS

PFI

    —  There is a significant difference between the experiences of staff and members in the smaller PFI sites (less than £25 million) compared to the larger schemes (in excess of £45 million).

    —  The smaller schemes are concerned with a specific client group, and have been integrated into countywide strategies and appropriate national service frameworks where those exist. There is more evidence of the involvement of clinical staff in the PFI planning process, and problems associated with the new building are generally referred to as minor. Staff and patients both report that the environment of care has improved with new and additional facilities, all of which contribute to enhanced care and recovery.

    —  The larger schemes are concerned with the centralisation, rationalisation or development of district general hospital services and facilities. Significant problems were reported in relation to design and construction, reductions in bed numbers, increases in workload and patient dependency, changes to skill mix and concerns over early discharge, readmissions and impact on the capacity in the community. The effects these factors have, both directly and indirectly, on the ability to deliver quality patient care was highlighted by all respondents.

    —  Other national health policy initiatives, local planning decisions and the absence of a traditionally procured NHS comparator mean that it is difficult to attribute improvements or deterioration in NHS services solely to PFI.

Concordat

    —  The vast majority of respondents reported that it was still too early to fully evaluate these arrangements, but there was clear support for the principle of closer working with the private and independent sectors to utilise spare capacity.

    —  Improvements in speed and access to care were reported, and intermediate care was identified as an area where there was significant potential to develop these arrangements. There was a clear view that, particularly for elderly patients, improved services and facilities could be provided promoting both independence and rehabilitation.

    —  To realise this potential it is important that all sectors develop a better understanding of the capacity, capabilities and systems of their prospective partners.

Public Private Partnerships

    —  What PPPs are or can be is unclear and confusing.

    —  How value for money decisions are made is unknown and clinical, staffing and accountability boundaries between the sectors are ambiguous.

    —  It is not clear whether the redevelopment of NHS cottage hospital facilities in Herefordshire, which proposes transferring NHS clinical services and staff, is a PPP or concordat arrangement.

CONCLUSIONS

Cost

  To date the economic case for PFI has not been made. There is concern that the method of costing a traditionally procured NHS hospital is over-inflated; that the argument that PFI passes financial risk from the NHS to the private sector has been exaggerated; and that the total costs to the NHS over the term of a PFI contract are excessive.

  In Concordat and PPP arrangements it is not known how value for money decisions are reached.

QUALITY OF PATIENT CARE

  The design and construction of PFI hospitals impact directly and indirectly on the delivery of patient care and the ways in which clinical staff work. It is misleading to suggest that there is a clear distinction between core and ancillary services and staff. There is no mechanism for assessing quality of care implications alongside economic considerations.

  Within Concordat and PPP arrangements it is unclear where clinical, staffing and accountability boundaries lie. All partners can influence and have some degree of responsibility for the quality of care. Greater clarity is required in respect of how the NHS exercises control over the quality of services for which it is ultimately responsible.

CONTROL

  Risk sharing is at the heart of partnership arrangements. Therefore if the NHS decides to provide a service in partnership, where previously it was solely responsible for providing that service; it will be sharing both the risks associated with the provision of the service and control over them.

  The RCN is firmly committed to the principles of the NHS and remains a strong advocate of partnership working. However, the provision of health services involves both direct and indirect relationships between the design, construction and delivery of services and the work of clinical and non-clinical staff. If the nature of these relationships and key boundaries are not clearly defined the level of control one partner is able to exert may, over time, significantly alter the nature of the intended partnership or undermine the viability of another partner.

  In response to calls for the Government to spell out its endgame in relation to the role of the private sector in the NHS, it is not enough just to say that clinical staff and services will not be transferred. In order to address the growing and genuine staff and public concerns about how this policy could develop over time, the Government needs now to clearly set out the proposed nature and extent of each of these initiatives and the boundaries between them.

RECOMMENDATIONS

  Whilst this evidence is based on the experience of PFI, PPP and the Concordat in England, not all these initiatives have been implemented across the UK, eg there is no Concordat in Scotland. However, the RCN proposes that the following recommendations and principles be adopted on a UK-wide basis:

    —  all non-operational large-scale PFI schemes concerned with the centralisation, rationalisation and redevelopment of NHS services should be suspended;

    —  a robust independent evaluation of PFI schemes should be undertaken giving at least as much consideration to quality of care as to economic factors;

    —  the RCN recognises there will be a small number of PFI schemes that are close to completion for which suspension will affect planned delivery of services. In these situations the feasibility of suspending the scheme will need to be assessed. These schemes must also be included within the evaluation;

    —  a framework document should set out the relationship between the scope and nature of PFI, PPP and Concordat arrangements;

    —  detailed guidance should be produced to inform the development of PPP and Concordat arrangements. This should include how value for money decisions are reached and where key boundaries and responsibilities lie between the partners; and

    —  guidance for private sector involvement in the NHS should include the following principles:

      1.  there should be extensive involvement of nurses and other clinical staff in the planning of all partnership arrangements;

      2.  at least as much consideration should be given to quality of care as to cost implications;

      3.  the NHS must be able to assert ultimate control over clinical staff and the delivery of clinical services;

      4.  planning decisions in respect of partnership arrangements must include both patients and the public, must form part of an assessment of community needs, and must, where appropriate, be integrated into national NHS service strategies and frameworks;

      5.  partnership arrangements should not include the introduction or extension of charges to patients for NHS services; and

      6.  there should be no compulsory transfer of NHS clinical staff as a result of a partnership agreement.

1.  INTRODUCTION

  With a membership of over a third of a million, the RCN is the largest professional association and union of nursing staff and students in the UK. As such, it is an influential voice for nursing at home and abroad. The RCN promotes nursing interests on a wide range of issues by working closely with the Government, politicians, unions, professional bodies and voluntary organisations.

  1.1  The RCN campaigns on behalf of its members and the people they care for, and is a leading player in the development of nursing policy and practice, and standards of care. It provides a comprehensive range of services and benefits for its members, including advice and support on a range of clinical and employment issues, the foremost nursing library in Europe, and RCN Direct, the 24-hour telephone information and advice service for members. The RCN also provides continuing professional development opportunities through its distance learning and short course programme, and promotes research, quality and practice development through the RCN Institute. Approximately three-quarters of RCN members work in the NHS, and a quarter outside the NHS in a variety of settings including residential homes, independent hospitals, clinics and hospices, nursing and care agencies, and in companies outside the health care sector (eg as occupational health nurses).

  1.2  The RCN is firmly committed to the NHS and its founding principles of universal healthcare, free at the point of delivery and based on need not ability to pay, whilst recognising the role which the independent sector provides for those who choose to use it. The experience of public private partnerships in the NHS in the past has in the main been in the form of the Private Finance Initiative. The RCN has thus far taken a pragmatic approach to PFI and has assessed the merits of each individual scheme with a view to the impact of each on patient care and quality of services. However, as the role of the private sector in the NHS looks set to expand, concern has been growing amongst our members as to the medium to long-term effect this will have on the principles of the NHS and the impact on the quality of nursing care and patient outcomes.

  1.3  The RCN is aware of the considerable research that has been published challenging the economic basis of PFT[1]. A robust assessment of value for money in respect of these arrangements is essential. The RCN has also been concerned for some time, and argued publicly, that equal weight and attention should be applied to the quality of care implications of these schemes. Some of these issues are explored here; however on the basis of our findings the RCN believes that further urgent evaluation of the implications for patient care is required.

  1.4  This issue may be even more critical in respect of PPP and Concordat arrangements that, unlike PFI schemes, currently operate outside of a prescribed and comprehensive framework. It is therefore not known how value for money assessments are made for these type of arrangements or where clinical, staffing and accountability boundaries fall between the NHS, private and voluntary sectors. The lack of clarity in respect of these arrangements, coupled with the experiences of nursing staff in some PFI sites to date, has served to foster concerns about the medium to long term implications of all these arrangements on the NHS.

2.  THE NHS CONCORDAT WITH THE PRIVATE AND VOLUNTARY SECTORS

  The Secretary of State for Health announced the new Concordat arrangements in October 2000. The RCN does not oppose the use of spare capacity in the private sector for NHS patients in the short term. It is too soon to have concrete evidence as to whether these arrangements are working, however some initial feedback from RCN members has been positive in terms of speed of access to care.

  2.1  Intermediate care for older people might be one area where this type of arrangement could help to alleviate pressure on NHS acute settings. Early feedback is positive, with previously inappropriately placed patients gaining access to good quality care in a more suitable environment, with increased independence and improvement in daily living activities. However an understanding of systems and a level of trust still needs to be established between two mutually suspicious sectors, with both reporting unrealistic expectations of the other in terms of formulating contracts and care plans. Clear systems need to be agreed that work effectively for both sectors, and for patients.

  2.2  Feedback in the acute services is less positive, with nurses concerned that patients might be being transferred in order to achieve the political targets of reducing waiting lists, rather than on the basis of clinical urgency or to improve standards of care.

  2.3  If Concordat agreements are to work, the following must be taken into consideration:

    —  contract negotiation must include clinical staff with a real understanding of the patient group;

    —  there must be agreement on the qualitative patient outcomes to ensure consistency;

    —  agreements must be agreed, open and explicit;

    —  clinical governance must be shared between both sectors;

    —  discharge planning, taking into consideration the on-going care needs of the patient, must be negotiated and the impact on community care and social care agencies should be made explicit and form part of the contract; and

    —  to assist the planning process it would be helpful to know the nature and extent of spare capacity in the private and independent sectors.

  2.4  The RCN also has concerns over the impact of Concordat agreements on the workload and morale of NHS staff. It seems likely that the independent sector will take the less clinically demanding patients, leaving more acutely sick patients in the NHS. This may impact on workload and morale of NHS staff and increase patient dependency within the NHS.

  2.5  Concerns have been raised over the poor track record of some private health care providers in dealing promptly with payments due to the NHS. Financial arrangements between sectors should be closely monitored.

3.  THE PRIVATE FINANCE INITIATIVE

  The RCN is able to offer much more evidence in relation to the experiences of nursing staff and patients in PFI hospitals. As of June 2001 there were 16 operational PFI sites in England with a capital value of in excess of £5 million. Whilst the operational date of each site varies, the opportunity exists to consider the experience of PFI in practice.

  3.1  During August of this year the RCN surveyed each of these sites. A questionnaire was sent to the RCN member of staff responsible for supporting and advising nurses in each PFI site and they were asked to complete this in conjunction with local RCN activists (lay officials) and nurses working in the trust. Twelve completed questionnaires were returned, which represent the views of a wide group of nurses.

  3.2  The capital value of six of the respondents was less than £25 million. Three were concerned with the delivery of mental health services, two with elderly care and one with ENT and ophthalmology services. The capital value of the other six respondents was in excess of £45 million and all concerned the centralisation, rationalisation or redevelopment of district general hospital services and facilities.

  3.3  Over half of all respondents reported that they had none or only minimal input into the PFI planning process. Where discussion had taken place this was predominantly through established joint staff and management committees and involved management updating staff on progress. Those sites that did report a greater degree of staff involvement were predominantly the smaller sites (less than £25 million). At one of these sites prior to the move a "day in the life" exercise was undertaken to identify changes in working practices. Only one of the larger sites (in excess of £45 million) reported that staff were able to visit the new facility to comment on the clinical environment before it was opened. The opportunity for frontline clinical staff in these sites to have direct input into decisions about the design and layout of clinical areas seems to have been extremely limited.

  3.4  In all of the larger PFI sites staff reported a decrease in bed numbers. The six smaller schemes revealed a more mixed picture. Some of these sites reported that bed reductions were based on an assessment of bed and staffing needs on a countywide basis in relation to a national service framework and was not therefore directly related to PFI.

  3.5  Nurses at the six largest schemes also reported an increase in workload, higher patient dependency and faster patient throughput. As a consequence staff expressed concern regarding increases in early discharges, which is placing added pressure on community staff and facilities. Clinically inappropriate early discharges, increasing re-admission rates and Accident and Emergency waits were all reported. There was also concern that patients were placed on inappropriate wards, without the staff properly trained for their condition (eg a 90 year-old female patient being nursed on a gynaecological ward, rather than by older people's nurses).

  3.6  Only one of the six largest schemes reported an increase in the number of registered nursing staff employed by the Trust. However, increases in non-registered staff (health care assistants) and in agency staff was reported. One site noted that this has resulted in a shift in the staff skill mix to the extent that non-registered nursing staff now exceed the number of registered nurses on some wards and outpatient departments. As a consequence registered nurses reported having less one to one contact with patients, and patients expressed frustration that the nurses always seemed extremely busy. Again there was a mixed response from the smaller sites in relation to changes in staff numbers and skill mix; although reference was again made to countywide planning and strategies.

  3.7  There was also distinction between the smaller and larger sites in relation to the impact of building design and the delivery of services. All of the smaller sites reported anecdotally that patients considered the clinical environment to have improved. Purpose built facilities, with patients having private rooms or sharing smaller bays compared favourably with old Victorian buildings. Environments were considered light and airy, and new facilities such as gym, shops and gardens were all welcomed. Problems such as temperature control and plumbing were reported but these were considered to be teething problems which might be associated with any new build. Nursing staff commented that building design enabled improved observation of patients and easier compliance with single sex guidance. The environment was considered to be conducive to car and recovery. Some staff reported an improvement in environmental working conditions and that a sense of pride was developing in the new facilities.

  3.8  By contrast patient reactions to the six larger schemes were overwhelmingly critical. A lack of space and cramped conditions, lack of natural lighting, leaking pipes and sewage, smaller meals of poorer quality, fewer parking spaces with increased charges, lack of telephones, poor signage and confusing layouts were all cited as problems. These environmental factors were linked by patients to the quality of their care experience. For example, large windows and lack of air conditioning not only contributed to uncomfortable temperatures (to the extent that one site had had incidents of both nurses and patients fainting) but also led to concerns over lack of privacy. Positive patient reactions were limited to the appearance of the building—"it looks nice from the bus to the front door", and "you think its posh until you're nursed here".

  3.9  Two of the sites have introduced Patientline, a service where patients can watch television and make telephone calls from the bedside for a charge. Many patients liked the convenience of the service, but some had expressed concern at the cost. Although communal televisions and phones are still being provided, nurses report that some patients felt embarrassed to use them as this singles them out as not being able to afford the bedside service.

  3.10  Nursing staff confirm that while the outside appearance of some buildings has improved, design faults have led to operational difficulties and concerns that patient care is being compromised as a result. Poor design and layout can mean it is difficult to see patients clearly. For example in one site nurses stations are further away from patients, in another nurse call lights are not clearly visible and in another the distance from Accident and Emergency to theatres has doubled, dangerously increasing waiting time for treatment. Further reported design faults include being unable to take an x-ray in an orthopaedic ward due to inappropriate wall construction, recovery bays in day surgery being too small for beds, and the absence of magnetic locks for main corridors door so that access becomes difficult and the doors suffer from being constantly barged.

  3.11  Standards of cleaning in larger sites was reported to be variable; in one site nurses have to remove all objects from the shelves before cleaning staff will wipe down surfaces, and replace them afterwards. Staff reported that the length of time for repairs to be completed has increased. Water and sewage leaks have caused health hazards; in one site staff were forced to use the toilets as a sluice. Some nurses reported that the environmental and design difficulties associated with many of these new builds, coupled with increased workload, has led to declining staff morale and, in some cases, nurses leaving.

  3.12  As clinical staff and clinical services are not included within current PFI schemes there should be no changes to nurses pay or terms and conditions of employment. However, one negotiated change was reported, from one of the larger sites, whereby an allowance was introduced for nursing staff working in clinical areas with a bed occupancy rate of over 95 per cent. The vast majority of staff working in acute wards were eligible; however issues around equity arose, particularly with those staff working in areas where beds have to be kept vacant, such as emergency gynaecology, or for an MRSA outbreak. Staff relationships became strained. This year the Trust have decided instead to give staff an extra day's leave and to increase the rate for working additional hours so it is closer to the rates paid by agencies.

  3.13  Staff facilities were also reported to have deteriorated. Concerns in respect of reductions in car parking space and increases in charges for both parking and food were frequently reported from the larger sites. In one case car parking charges have increased by 60 per cent and staff meals cost on average an additional 50 pence. Accommodation for staff has become a significant issue in one trust which sold off existing accommodation as part of the PFI scheme, and did not replace it in the new build. Pressure from staff side organisations has since led to some replacement accommodation but this is considerably more expensive compared to the previous, subsidised rents. In some parts of the UK average property prices are more than seven times the salary of a registered nurse with over five years experience. When nurses find they cannot afford to live near their workplaces, they move away or leave the profession.

  3.14  Overall, there is a clear difference between the experiences of staff and patients in small and large-scale PFI projects. Those schemes with a capital value below £25 million, focused on the provision of services for a specific client group, planned on a countywide basis and integrated into a national strategy, are reporting some positive feedback. Those schemes in excess of £45 million, concerned with the centralisation, rationalisation or reprovision of traditional district general hospital services are not working well. The larger schemes have seen a reduction in bed numbers coupled with increased patient throughout, early discharge and increased staff workloads. Many nurses feel that their ability to deliver high quality care has been compromised. Reports of early and inappropriate discharges, increased readmission and increased infection rates are worrying signs. The implications for capacity in community services must also be examined.

  3.15  The link between building design, construction and support services and clinical care is evident. Within the smaller schemes the new facilities have contributed positively to patient care. In comparison the design and construction of larger facilities have led to operational difficulties and a negative impact on patient care. It also appears that the greater the involvement of clinicians in the planning and design process, the fewer operational difficulties these sites have once operational.

  3.16  These findings show:

    —  there is a clear difference between the experiences of staff and patients in the larger (in excess of £45 million) and smaller (below £25 million) operational PFI sites;

    —  within the larger schemes a reduction in bed numbers has been coupled with increased patient throughput and dependency and staff workloads. In some sites this has resulted in changes to skill mix and/or working practices and is also identified as a cause of increased staff sickness and lower moral;

    —  both nursing staff and patients report having less one to one contact;

    —  the extent to which these factors impact on the quality of patient care is difficult to judge; however reports of inappropriate early discharges, increased readmission rates and increased demands on community staff require further urgent investigation;

    —  there has been noticeably greater involvement of nursing staff in the smaller sites in the PFI planning process and considerably more positive comments from both patients and staff about the improved facilities and environment of care in these sites; and

    —  in the larger schemes there has been minimal involvement from clinical nursing staff in the PFI planning process. In addition there have been significant "teething" problems associated with design, construction and facilities which have had a negative impact on both the patients experience of care and the nurses ability to deliver high quality care.

  3.17  The RCN has concerns over the implications of the risk sharing relationship between private sector consortia and the NHS. Those lending money will always seek assurances that the borrowers are able to exert maximum control over the services they are providing and any other factors which might influence this service. Pressure from those lending money, coupled with the knowledge and experience of NHS services which the private sector will develop, could result in arguments being made for the transfer of clinical staff and services to the private sector. It could also be argued that since the private sector must bear the consequences of political health policy decisions it also has a legitimate right to much greater involvement in these processes. The RCN would strongly oppose this.

4.  CLINICAL STAFF AND CLINICAL SERVICES

  The Government has said that clinical services and staff will not be included within PFI schemes and the RCN strongly supports this position. However, the RCN is aware of one attempted transfer of clinical staff as part of a PFI deal and another where it is proposed to transfer both clinical services and staff under what has been described as both a Concordat and PPP arrangement. The latter case is set out below.

4.1  Kington and Ledbury hospitals—Herefordshire

  Ledbury and Kington are small cottage hospitals currently managed by Herefordshire Primary Care NHS Trust. The Health Authority and PCT reached a view that both hospitals were no longer suitable for modern healthcare and an arrangement was reached with Shaw Homes, a voluntary sector provider, to replace facilities at Ledbury and with Blanchworth Care, a private sector provider, to replace facilities at Kington. Nursing staff at Ledbury will be transferred to the employ of Shaw Homes. Nursing staff at Kington were given the choice of transferring to Blanchworth Care or moving in other NHS facilities which could be some distance away.

  4.2  As the transfer of clinical staff and services would constitute a considerable reversal in stated Government policy, the RCN sought clarification from the Department of Health about these arrangements. In a statement, the Department of Health commented[2]:

    "The schemes at Ledbury and Kington are examples of the NHS and the independent sector working together to produce innovative developments. The catalyst was local health commissioning decisions to modernise local services.

    Both sites involve the construction of modern integrated health care facilities in which GPs can provide services at the same time as the NHS can use the capacity of independent sector providers for the treatment of NHS patients, in line with the new Concordat initiative signed last year.

    Both schemes were required to demonstrate value for money but they do not predominantly involve capital expenditure on facilities or equipment to the NHS, as would be the case under the Private Finance Initiative (PFI). Similarly, in these cases the GPs and independent sector are responsible and accountable for the delivery of clinical services and not wholly the NHS, as would be the case in a PFI project.

    These new service developments resulted in an option arising for some NHS nurses to transfer to the private sector providers at both sites if they so wished under a TUPE transfer. Some have taken this up and we will not stand in the way of any future arrangements like this. We fully realise that many ex-NHS nurses now work for private sector healthcare providers.

    However, the commitment remains that the Government will not approve the transfer of NHS clinical services and the staff who provide them—like nurses—to an independent provider as part of a PFI scheme for the provision of NHS facilities and equipment to the NHS.

  4.3  The RCN is deeply concerned about these arrangements and is seeking clarification from the Department of Health on several points. The statement from the Department of Health asserts that these developments are in line with the Concordat initiative. However, the extent of capital expenditure on NHS facilities and equipment, the level of NHS accountability for clinical services, and a rationale to determine whether the schemes offer value for money are all unclear. It would appear that the arrangement is taking place outside any robust mechanism to ensure value for money or set out the exact nature of the powers and responsibilities of the partners to the arrangement.

  4.4  The RCN believes the exact nature of the scope and type of arrangements that can be entered into under the Concordat needs to be spelt out clearly. This should include where financial, clinical, staffing and accountability boundaries lie within Concordat arrangements, PFI arrangements and throughout public private partnership.

  4.5  Current Government policy prevents the transfer of NHS clinical staff or services under a PFI scheme (for which a clear national process exists), but would appear to allow the transfer of NHS clinical staff and services under Concordat or PPP arrangements for which there is no agreed comprehensive process. Urgent clarification is required as to both the boundaries between and limits of PFI, PPP and Concordat arrangements and schemes. The RCN opposes the compulsory transfer of clinical staff to the private sector under any scheme.

5.  THE WIDER PUBLIC PRIVATE PARTNERSHIP DEBATE

  There have always been good examples of clinical services being provided by the independent sector to the NHS for particular specialisms, contracted for on a case by case basis. Such arrangements can succeed where there is a demonstrable track record of the private provider being able to deliver high-quality patient services and integrate these with community care. There may be scope for innovative and creative partnership models, but these must be within a robust evalutory framework.

  5.1  Practical issues around the limits of capacity in the independent sector will need to be considered. There is currently a global nursing shortage, and modernisation of health services will depend on expanding the nursing workforce in all sectors.

  5.2  Health service modernisation must primarily be concerned with improving services for patients. Issues of quality and accountability are paramount. The RCN has concerns that existing systems for ensuring quality and investigating complaints will not be robust enough to work with services contracted by the NHS but delivered by the private sector. The blurring of boundaries of responsibility which seems to be occurring at Ledbury and Kington is an example of this.

  5.3  The Government continues to state that clinical staff will not be transferred from the NHS to the independent sector under partnership agreements. However, it seems that this may be happening in practice. Boundaries between clinical and managerial staff are not always clear. False distinctions between support and clinical staff ignore the very real effects that cleaning, catering and porting services have on quality of care and clinical outcomes.

  5.4  It is difficult to say whether some of the problems at the larger PFI hospitals are a direct result of the involvement of private finance, or problems which might be associated with any new build. This issue will need to form part of a thorough evaluation of value for money and quality of services in all public private partnerships.

  5.5  There is real concern among front line staff about the long-term direction that developing partnerships with the independent sector are taking. There is a perception that no clear vision has been set out by the Government for the future of health services. This uncertainty is leading to decreased morale amongst NHS professionals. Until the Government is clear about what it sees as the end point for the role of the private sector in the NHS, many staff will resist change out of a fear of "privatisation by stealth" of the health services. Above all, the underlining principles of the NHS must not be undermined.

6.  CONCLUSIONS

Cost

  To date the economic case for PFI has not been made. There is concern that the method of costing a traditionally procured NHS hospital is over-inflated: that the argument that PFI passes financial risk from the NHS to the private sector has been exaggerated: and that the total costs to the NHS over the term of a PFI contract are excessive.

  6.1  In concordat and PPP arrangements, it is not known how value for money decisions are reached.

6.2  Quality of Patient Care

  The design and construction of PFI hospitals impact directly and indirectly on the delivery of patient care and the ways in which clinical staff work. It is misleading to suggest that there is a clear distinction between core and ancillary services and staff. There is no mechanism for assessing quality of care implications alongside economic considerations.

  6.3  Within Concordat and PPP arrangements it is unclear where clinical, staffing and accountability boundaries lie. All partners can influence and have some degree of responsibility for the quality of care. Greater clarity is required in respect of how the NHS exercises control over the quality of services for which it is ultimately responsible.

6.4  Control

  Risk sharing is at the heart of partnership arrangements. Therefore if the NHS decides to provide a service in partnership, where previously it was solely responsible for providing that service, it will be sharing both the risks associated with the provision of the service and control over them.

  6.5  The RCN is firmly committed to the principles of the NHS and remains a strong advocate of partnership working. However, the provision of health services involves both direct and indirect relationships between the design, construction and delivery of service and the work of clinical and non-clinical staff. If the nature of these relationships and key boundaries are not clearly defined the level of control one partner is able to exert may, over time, significantly alter the nature of the intended partnership or undermine the viability of another partner.

  6.6  In response to calls for the Government to spell out its endgame in relation to the role of the private sector in the NHS, it is not enough just to say that clinical staff and services will not be transferred. In order to address the growing and genuine staff and public concerns about how this policy could develop over time, the Government needs now to clearly set out the proposed nature and extent of each of these initiatives and the boundaries between them.

6.7  Recommendations

  Whilst this evidence is based on the experience of PFI, PPP and the Concordat in England, not all these initiatives have been implemented across the UK, eg there is no Concordat in Scotland. However, the RCN that the following recommendations and principles be adopted on a UK basis:

    —  all non-operational large-scale PFI schemes concerned with the centralisation, rationalisation and redevelopment of NHS services should be suspended;

    —  the RCN recognises there will be a small number of PFI schemes that are close to completion for which suspension will affect planned delivery of services. In these situations the feasibility of suspending the scheme will need to be addressed. These schemes must also be included within the evaluation;

    —  a robust independent evaluation of PFI schemes should be undertaken giving at least as much consideration to quality of care as to economic factors;

    —  a framework document should set out the relationship between the scope and nature of PFI, PPP and Concordat arrangements;

    —  detailed guidance should be produced to inform the development of PPP and Concordat arrangements. This should include how value for money decisions are reached and where key boundaries and responsibilities lie between the partners; and

    —  guidance for private sector involvement in the NHS should include the following principles:

      1.  there should be extensive involvement of nurses and other clinical staff in the planning of all partnership arrangements;

      2.  at least as much consideration should be given to quality of care as to cost implications;

      3.  the NHS must be able to assert ultimate control over clinical staff and the delivery of clinical services;

      4.  planning decisions in respect of partnership arrangements must include both patients and the public, must form part of an assessment of community needs, and must, where appropriate, be integrated into national NHS service strategies and frameworks;

      5.  partnership arrangements should not include the introduction or extension of charges to patients for NHS services; and

      6.  there should be no compulsory transfer of NHS clinical staff as a result of a partnership agreement.

September 2001


1   PFI in the NHS-is there an economic case? Gaffney, Pollack, Price, Shaoul BMJ 319 July 1999: The economics of PFI in the NHS Jon Sussex Office of Health Economics April 2001. Back

2   Department of Health statement 30 August 2001. Back


 
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