Memorandum by the Medical Practitioners'
Union (PS 15)
THE LABOUR GOVERNMENT AND THE PRIVATE-PUBLIC
This discussion document has been prepared by
the Medical Practitioners' Union as a contribution to the current
debate that is taking place within the Trade Union and Labour
movement on the role of the private sector in the NHS. The MPU
has a proud history in support of the NHS. We were the only trade
union of medical doctors which was instrumental in campaigning
for the creation of the NHS. We also campaigned against the Tory
internal market and fundholding and have been strong defenders
of patient rights in the NHS. We remain deeply committed to the
ideals of the NHS.
This document argues the case against wholesale
private sector involvement in the health service. We accept that
there may be a limited role for the private sector in the NHS
as a short-term measure. Our objection to privatisation is based
on our deeply held conviction that privatisation offends against
the basic principle of social justice on which the NHS was foundedthat
treatment should be determined by patient clinical need, not their
ability to paywe should not be supporting private medical
practice in any way. It drains the NHS by using NHS trained staff;
concentrates on routine care; and is there primarily to make a
Our central argument is that the NHS has a proud
record of achievement in spite of decades of under-funding and
low investment. Its staff should be congratulated in having provided
a service thus far rather than blaming the staff, including NHS
managers. There is an overwhelming case for placing any new investment
in the NHS rather than the private sector, enhancing the ethos
of public service and retaining the benefits of collaborative
effort and team working.
The NHS has a proud record over the past five
decades. It has innovated; it has improved quality; it has managed
on very meagre funds. So less blaming of staff, less dreaming
"private goodpublic bad". Adequate funding of
a proven cost-effective NHS will resolve most of the issues that
have to date held the NHS back from achieving its full potential.
We recognise that the decades of under investment
in the NHS has led to outcome markers which show that the NHS
provides an inadequate service and has a huge backlog of problems.
Many hospital buildings are in a terrible state; there are unacceptable
levels of waiting for operations and visits to doctors. There
are huge variations in outcomes between different parts of the
NHS. Because of the urgent need for change, we can accept a limited
role for the private sector in the NHS for the short-term. However,
we need to be explicit about the principles under which the private
sector can be involved.
MPU believes the government needs to show clearly
why the analysis that we present in this document is incorrect
and why the solutions we suggest are invalid before embarking
on any further private sector involvement in the NHS. We believe
there is little or nothing that a well funded NHS cannot do and
will share our thoughts within MSF, with the other health trade
unions and with the wider trade union and labour movement, many
parts of which already share our view.
Why is the NHS so clearly failing to keep up with
demand and why are health indicators so bad in the UK?
Under funding is the simple answer. Tony Blair
accepted this when he pledged to raise the NHS spend to the EU
average. Unfortunately even the 6 per cent increase in NHS spend
till 2004 will not reach the EU average which itself will have
moved on by 2004. The NHS is funded to about 70 per cent of the
EU average and not surprisingly provides a below par service.
Low wages and cuts in training have resulted in shortages of nurses,
doctors and other health professionals. Unacceptable workload
pressures have led to demoralisation and recruitment and retention
crises. Our rates for heart operations and survival from cancer
are low. We do have fewer doctors, nurses and other health professionals.
For example, there are 1.8 GPs/1000 population in the UK compared
with European average of 3.4/1000.
The Government is committed to spending more
money on the NHS. 30 per cent more money will be spent on the
NHS by 2004 and the Government should be congratulated for this.
However, no account has been taken of the building maintenance
backlog, the need to modernise a large number of NHS facilities,
and the knock-on effect of running services on a shoestring for
decades. There is therefore a growing "reality gap"
between the improvements in the NHS the Government expects the
new money to supply and what can actually be achieved. A way has
to be found to fund the NHS properly beyond 2004.
Why not use the private sector to bail out the
It is perverse to identify under-funding of
the NHS as the cause of the problems and then spend money in the
private sector. Funding our health service on the cheap is clearly
failing so more money has to be found. Most people want to see
the NHS maintained, improved and remain a full public service
rather than new money being diverted into profits for the few.
There is absolutely no evidence that pouring
money into the private sector would help the NHS. There is evidence
that the privatisation of cleaning has led to filthy hospitals;
the PFI schemes are poor value for money, lead to less beds and
staff and to cramped, poorer premises.
Railtrack, BT, M&S, the Dot Coms and Marconi
are poor adverts for the abilities of the private sector. In the
era of evidence based medicine there is a total lack of evidence
based public policy in this area.
Why not use the spare capacity of the private
sector hospitals to get waiting lists down?
We do not object to using spare capacity sector
in Private hospitals where it makes sense to do so. But this should
be a temporary expedient until NHS capacity is increased. Any
short-term measures should fit the long-term strategy of properly
funding the NHS as the provider of health care in the UK.
We do not think that standards of safety in private hospitals
are as high as in the NHS, that it is sensible to encourage NHS
staff to moonlight, or that it makes sense to entice away NHS
staff trained at public expense so they can "help the NHS"
and coincidentally help profit plundering for the private companies.
Why not use the flair and imagination of the private
The NHS does not get everything right and can
learn from the private sector. That does not mean the NHS could
not also carry out these new tasks. The Hospice Movement is an
example where the NHS did learn from the voluntary sector. In
some areas, the NHS even pays significant amounts of money to
Hospices so that they can provide a service to NHS patients. The
NHS saw what was being offered in the not-for-profit sector and
changed its attitudes to and services for the terminally ill.
There is plenty of flair and innovation in the NHSthe government
Beacon practice scheme and Nye Bevan Awards for example. What
hinders the NHS is lack of cash and investment and spending hours
trying to decide which cuts to make so the budget stretches for
one more year.
Why not use the expertise of private sector management
to beef up the NHS?
Poor management in the private or public sector
needs improving. The NHS does not have a monopoly on poor management.
Disasters in the private sector such as Railtrack and the computerisation
of the Passport Office and Benefit Agency should be remembered
along with the spectacular management failures in BT, M&S
and Marconi. Private sector managers often look good because the
resources they are given match the task they are asked to address.
This has rarely been the case for the NHS. As an alternative the
Government has already suggested a University for the NHS which
we support. Both the private and public sectors have a lot to
learn from each other.
The Government says that this is not privatisation
since the bills will be paid for out of public funds and the service
will remain free at the point of use. Does it matter who provides
the service and who owns the plant and services?
Yes. If the NHS is reduced to a bill-paying
organisation it will lose the power and control that an integrated
service provides. Look at the state of the railways and what is
happening in our schools. Involving the private sector fragments
essential co-operation, introduces competition instead of team
working and leaves less money for services as profit and share
dividends are removed from the NHS budget.
PFI hospitals have done just that. In Norwich
the new PFI hospital has yet to open but already the private sector
has re-financed the PFI investment and made £70 million profit,
money which could have been used to reduce the long waits for
heart and hip surgery. Local trusts have been instructed to make
further savings by cutting beds and staff to pay for the rent
on the new hospital. Money spent in the private sector is money
leaking out of the NHS economy.
If the private sector owns the plant it will
distort clinical priorities to maximise profit. In America MRI
scans are often carried out in inappropriate conditionsso-called
over investigation. The NHS is efficient in its use of resources
because their use is based on clinical need and not for a hidden
Drugs companies are wholly privately owned and
spend millions visiting GPs to urge them, for example, to prescribe
the new (expensive) drugs to lower cholesterol in people with
heart disease. Making sure all heart patients are on aspirin is
a higher priority but aspirin is cheap and provides no profit.
It is difficult enough to get public service
bodies to co-operate with each other. Trying to get private firms
fundamentally in competition with each other to share commercial
secrets and work collaboratively is a nightmare.
The Government suggests four ways to involve the
private sectorexpanding the Concordat with the Private
sector, health factories, involving the private sector in management
and using its expertise in IT, and PFI/LIFT. What's wrong with
Concordat with the private sector
As a short term measure limited to using spare
capacity at an affordable price and without taking staff away
from their NHS duties we can accept the Concordat between the
NHS and the private sector. However it would be absurd if the
Concordat resulted in fewer NHS operations and more waiting list
cancellations because staff were at the local private hospital
"helping the NHS to cope". (Remember the Government's
contradictory commitment to prevent new consultants doing private
work, which we support).
MPU has long argued for more efficient use of
consultant's and hospital theatre time but getting the private
sector to build, staff and run stand alone factories is wrong
headed. Small, stand-alone units are not safe. Present private
hospitals are usually built away from NHS hospitals and regularly
have to transfer patients to the NHS when something goes wrong.
Private hospitals rarely have ITU facilities or a full complement
of on-call staff. The NHS picks up the pieces and the private
sector keeps its fee.
We have no objection to new ways of working.
But the NHS could run these new units for hips, hernias and cataract
services more safely and more efficiently as integrated units
within NHS hospitals. There are excellent examples of efficiently
run day surgery units in many parts of the NHS. Given the right
amount of funding, they could carry out more operations. The NHS
can be flexible if given the financial capacity and leeway instead
of the daily struggle just to cope. Current NHS inefficiency is
partly the inefficiency of under-funding.
In addition if these units were not integrated
into the NHS they could not be made available at times of emergencya
flu epidemic or major disaster for instance. The whole rationale
of a hospital is to concentrate medical resources in one place
so that they can be deployed to best advantage. Integrated NHS
units allow adequate backup for junior staff and Royal College
approval for their training.
Many private sector units are inadequately monitored
because monitoring costs money that the NHS does not have. More
private units means more monitoring and more NHS money diverted
from patient care.
Many patients needing cold surgery are elderly
and have other problems, which can be addressed while they are
in hospital. Wouldn't it be more sensible therefore to build these
units on existing hospital sites?
There are ways to improve management in the
NHS other than inviting the private sector to take the NHS over
with the associated loss of power and control. In Frenchay hospital
there is litigation pending but the patient is having difficulty
finding out whether the private sector contract or the Trust Management
is responsible for errors. It is possible the NHS will have to
pay up leaving the private sector company with its contract fee
intact. Evidently no one had foreseen such a situation of confusion
could arise. The same thing happened with Railtrack and its contractorsa
stream of disconnection and failure of accountability.
Rather than bringing private sector management
to take over NHS facilities, we suggest:
Use the NHS University and develop
management fellowships with secondment from private sector firms
with a proven record and something specific to offer the NHS.
Resource and use Beacon Management
Practices to teach colleagues about best practice.
Properly resource and upgrade estate
management within the NHS and clean up our wards so neglected
by the private sector.
The private IT sector has not served the NHS
well. There are many GP and hospital clinical systems that are
unable to "talk" to each other. IT suppliers have had
to accept specific "all NHS" standards because the market
solution brought fragmentation, poor quality and systems that
wouldn't "travel". The private sector has a poor record
on large-scale computerisation as seen in the Benefit Agency and
Passport Office for example. There are excellent examples of NHS
IT systems that are innovative and which can be extended throughout
the NHS if properly resourced.
PFI and the community variant NHS LIFT are poor
investment ideas. They are like buying a house with a huge mortgage
you can't afford. Sooner or later you have to pay up and so will
the NHS. Because rent on these schemes comes from NHS revenue
(as opposed to capital) budgets PCTs will have to find the rent
first and use what is left over to buy clinical services. Whilst
PFI schemes have maintenance charges built in it will be up to
the owners to decide when and if work is needed.
PFI to date has been poor value for money (see
IPPR Report). We can see no argument for not using money borrowed
at a low rate by the government. Investing in the private sector
is counter productiveit denudes NHS of staff and money.
The NHS is then perceived to be getting worse and so the cycle
If LIFT money is to be used, let the local community
control the facilities that come into these new premises. Instead
of retail outlets boosting investors' profit use the space for
GP surgeries, benefits advice and healthy living centres and so
on. Include in the tender documents a requirement to use local
labour and boost the local economy in deprived areas.
In response to the Governments desire to involve
the private sector, MPU suggests:
building up NHS capacity and only
using the private sector short term where there is a genuine unresolvable,
short-term capacity issue;
increasing staffing by better wages
and terms and conditions rather than take staff away from the
NHS to work in the private sector;
training "intermediate health
professionals" to work exclusively on hips, hernias and cataracts
adequately supervised by formally trained doctors and nurses,
which would also help to reduce intolerable workloads;
operating at weekends with flexible
staff policies building on success of NHS day units using new
consultants working full time for the NHS;
paying enhanced rates of pay in difficult
to recruit areas;
resourcing NHS Beacon Teams to help
other establishments to change ineffective or inefficient practice.
If the private sector is to be involved then
there are some basic questions that the Government needs to answer.
1. What evidence is there that the private
sector will improve the NHS and its delivery of services?
2. Given a cash-strapped health service where
will the profits come from?
3. If there is a way of making genuine profits
from public services, why doesn't the government invest so that
these profits can be ploughed back into the public purse?
4. How will a two-tier system be avoided
when further private involvement grows the private sector as a
In summary, we applaud the Government's new
investment in the NHS and want their support for the NHS to continue
but as a publicly funded provider of integrated, high quality
care. An adequately funded health service can learn from the non-NHS
health and commercial sectors and apply the lessons to its own
functions without losing its power to control and direct resources.
The public supports the distancing of private profit making companies
from the ideals and ethos of the NHS. So do we.