Select Committee on Health Appendices to the Minutes of Evidence


APPENDIX 14

Memorandum by the Chartered Society of Physiotherapy (PS 27)

TABLE OF CONTENTS

EXECUTIVE SUMMARY

  1.  Introduction.

  2.  The NHS Concordat with the private and voluntary sectors.

  3.  Private Finance Initiative (PFI).

  4.  Public Private Partnerships (PPPs).

  Appendix  CSP Survey on PFI: members comments on their experiences of PFI.

EXECUTIVE SUMMARY

The Concordat

  The CSP believes the concordat to be a sensible option to help alleviate NHS pressures. We believe, however, that it should be time-limited, used only as a stop-gap measure whilst the government's larger scale expansion of the NHS, including the aim of expanding physiotherapy and rehabilitation services, is pursued. This is important if one of the central thrusts of the government's reforms — to place NHS staff at the centre of the reform programme, to empower them to be part of the solution to the challenges faced by the NHS — is to be achieved. Problems of access to treatment and funding for services, however, need to be addressed.

PFI

  The CSP has a number of reservations about PFI, which are grounded in immediate practical considerations as well as long term strategic concerns. Although at an early stage, PFI is already having an impact on physiotherapy and physiotherapists, their working environment and their delivery of patient care (a selection of CSP members' comments on their experiences of PFI is included as an appendix). The CSP supports an evidence based approach to policy but remains unconvinced of the case for further expansion of PFI. We would like to see a full review and reassessment of PFI before seeing further commitment to PFI from the government. We would not wish to see clinical services included in any future PFI deals. We are concerned over the appropriateness of PFI as the major vehicle for capital investment in the NHS and the claims that PFI demonstrates value for money or contributes additional investment to existing public spending. The CSP believes the key to government reform lies within the NHS itself and in the expertise of its staff. We propose a reform and boost to the public services and call for greater flexibility for the NHS to be innovative and for the discount rate used in PFI deals to determine value for money to be revised.

PPPs

  Although PFI is the predominant form of public private partnership in the UK there is no reason why this should be the case. A more methodologically robust approach to the development of PPPs would be to pilot a variety of PPP models with a view to establishing a clear evidence based approach to policy. Any model of PPP developed should be subject to a "Public Services Charter" that sets clear public interest criteria that must be met prior to the rolling out of a public private partnership.

1.  INTRODUCTION

  1.1  The Chartered Society of Physiotherapy (CSP) welcomes the opportunity to respond to the House of Commons Health Committee's Inquiry into the role of the private sector in the NHS. The CSP is an independent and TUC-affiliated trade union as well as a professional and educational body. The CSP represents approximately 38,000 qualified physiotherapists, physiotherapy assistants and students. The majority of our members work in the NHS, but a significant proportion are employed in independent hospitals and higher education. Our members also work for charities, in residential homes, sports clubs and in private practice. Around 98 per cent of qualified practising physiotherapists are in membership of the CSP. Physiotherapy is the third largest health care profession after medicine and nursing.

  1.2  The CSP supports the broad thrust of the government's ambitions for reform of the NHS, and see ourselves as a willing partner in this process of change. The CSP has, and always has had, members working in the private and voluntary sectors and we have good relationships with many of the independent sector organisations for which our members work.

  1.3  As a signatory to the TUC's statement on public services, we believe that the key to government reform lies within the NHS itself and in the expertise of the NHS' greatest asset: its staff. There are a considerable number of government initiatives underway designed to place NHS staff at the centre of the NHS reform programme. This, however, is a long-term process and whilst we recognise the political imperative for change and reform it is important to get this reform right by engaging NHS staff and their representatives fully and thoroughly in the process and programme of change. Building up the culture of confidence in NHS staff that is necessary for effective reform will be more difficult if there is real anxiety over the government's proposals for extending the involvement of the private sector at the expense of the NHS. It is in this context that we submit our evidence to the Committee.

2.  THE NHS CONCORDAT WITH THE PRIVATE AND VOLUNTARY SECTORS

  2.1  The announcement of the concordat was welcomed by the CSP as a sensible measure. Providing any arrangements made with the voluntary or private sector are closely monitored to ensure that patients are receiving the highest standards of care, free at the point of delivery irrespective of where they are treated, then from a clinical perspective the use of spare capacity in the private or voluntary sector can be a positive development in alleviating NHS pressures.

  2.2  However, the CSP believes that the concordat should be time-limited, used only as a stop-gap measure in the short term whilst the government's larger scale expansion of the NHS, including the aim of expanding physiotherapy[8] and rehabilitation services, is pursued. This is important if one of the central thrusts of the government's reforms—to place NHS staff at the centre of the reform programme, to empower them to be part of the solution to the challenges facing the NHS—is to be achieved. It is also important to safeguard against the development of health inequalities in terms of access to services, social exclusion and to ensure NHS services are not, in the long term, undermined.

  2.3  The CSP has identified access to services as being a problem, and we are particularly concerned about the development of a two-tiered system of access to physiotherapy, where the principle of treatment free at the point of delivery is compromised. Whilst government guidance[9] clearly states that physiotherapy is a service which Health Authorities and Primary Care Trusts (PCTs) are responsible for arranging and which should not be charged for, there is, it appears, a reality gap between what the guidance says and what happens in practice. For example, a growing number of services are providing rehabilitation within a nursing home setting. In one example of which we are aware, two parallel rehabilitation packages were developed: one provided in an NHS facility (free at the point of delivery), the other in a residential home setting, which was means tested. Perhaps not too surprisingly, the service based in the NHS facility was over-subscribed (patients/clients voting with their feet) which created a waiting list for rehabilitation which, ironically, was one of the issues the new service was seeking to address.

  2.4  The CSP is aware that private health care providers are lobbying hard for the NHS concordat to be used to strike more long-term deals. We would caution against this. The provision of healthcare in Britain is inversely related to the need for it (ie poor facilities in depressed areas characterised by high morbidity, and good—or at least better—facilities in affluent areas characterised by low morbidity). This is related to the market economy: the more prosperous areas attract the most resources, including skilled health workers in both primary and secondary care. A short term arrangement under the concordat while NHS capacity is being built up, or to use the concordat during periods of occasional overload, is sensible but more long term arrangements, where funds flow into non-NHS organisations on a regular basis and where access may be compromised, is something else. The merits of long term concordat arrangements need to be investigated. The key to their development should lie in an evidence based approach as to who would prove the most appropriate provider of a service and under what terms.

  2.5  Scope may exist, however, for the concordat to be used effectively in the voluntary sector, where specialisms such as neurology, paediatrics, palliative care and learning disabilities/mental health services are provided, albeit patchily. Extending partnerships at local level to promote the accessibility of these services could also improve the regulation of health care in the independent sector and, in terms of pay and conditions of non-NHS staff in this sector, could help to harmonise up pay rates to NHS levels.

  2.6  Any arrangements made with the private and voluntary sectors should ensure that NHS staff who find themselves working in the independent sector are guaranteed protection from any erosion of pay and/or terms and conditions. The CSP supports the TUC's call for a fair wages resolution which would, effectively, put a floor under the private/voluntary sector so that public sector pay and conditions should at least be matched.

  2.7  The CSP also supports the need for clinical staff to remain NHS employees under any concordat arrangement, including any models which include private sector management of stand-alone specialist surgery centres, as the government has proposed. This is important to ensure pay, terms and conditions, health and safety standards, access to Continuing Professional Development (CPD), peer support, professional mentoring, clinical governance and other NHS standards are not eroded or compromised.

Questions to be addressed

    —  Is the plan to use private sector spare capacity a long-term one, or just an interim measure while NHS capacity is being built up?

    —  Is there any hard evidence that can be made available to public scrutiny to show that the private sector can deliver health care more cost effectively than the NHS, taking into account the need to generate profits and dividends for shareholders?

    —  Can standards of care/clinical governance in the independent sector be monitored as rigorously as in the NHS (even allowing for some of the lapses that have occurred in the NHS in recent years)? Could the Concordat be used as a framework to improve regulation in the independent sector?

    —  In recognition of the value of partnership working in the area of rehabilitation within the context of intermediate care, will the government guarantee that monies will be ring-fenced for the funding of rehabilitation?

3.  THE PRIVATE FINANCE INITIATIVE

  3.1  When PFI was first launched in 1992, PFI projects were meant to offer value for money; to transfer the risk of liability to the private sector and be additional to existing public expenditure. Before we offer comment on these elements we give consideration to the direct impact of PFI on physiotherapy.

  3.2  Physiotherapy as a clinical service and physiotherapists as clinicians have been exempt, to date, from transfer to the private sector under PFI deals. Partly because of this, and partly because PFI schemes are just beginning to come on-stream, it is in many ways too early to properly assess the impact of PFI on physiotherapy, physiotherapists and their delivery of patient care. However, in August the CSP sent out a questionnaire to CSP stewards, safety representatives and physiotherapy managers in PFI project areas currently operational or due to come on-stream shortly, and asked them to distribute the survey to members within their workplaces. We received 135 returned questionnaires spanning 25 different Trusts. A broad range of issues were raised as being of concern and we illustrate some of the problems experienced by our members by quoting directly from the respondents themselves, although we have opted to preserve their anonymity to respect members' concerns about confidentiality (we include a representative selection of comments received in the appendix). We received comments from right across the spectrum of the profession, from newly qualified through to Superintendents, District grades and heads of service.

  3.3  Many of the respondents to our survey reserved judgement on the impact of PFI. The majority of comments received were negative in nature and many were mixed: most respondents who did have positive comments to make about their new PFI-built workplace counter-weighted these with an equivalent negative. For example, one member (by no means untypical) commented:

    "Satisfied (with the) new building—fresh and clean. Dissatisfied with lots of issues—toilet for female staff, small changing room for therapy services, staff room smaller, flooring in both gyms unsafe—still awaiting replacement! Lifts—no hard rail to steady patients. Too hot in summer. Ramps unsafe to garden from ward . . . Parking and not enough signs front and rear of building. Not disabled-friendly."—Technical Instructor III, Rehabilitation

  3.4  One of the most common arguments that has been deployed against PFI has been the reduction in bed numbers in PFI hospitals. This has an impact on physiotherapy as fewer beds leads to pressure for a faster throughput, which increases workload (in terms of more patients and paperwork) and affects patient care as patients face "curtailed physiotherapy treatments". Two separate comments from members specifically highlight these concerns:

    "There are more urgent referrals to outpatients as patients are discharged faster and with more complications".

    "Patients discharged from wards in worse functional state".

  3.5  The adverse impact of PFI on patients, however, is not only due to loss of beds. Physiotherapy departments and facilities appear to have "lost out" under PFI, leading to frustration amongst staff and a deterioration in the quality of the working environment within which physiotherapists deliver patient care. A fairly senior manager (Supt II), for example, whilst welcoming her new PFI building felt "frustration at not being able to influence plans for building at my grade".

  3.6  Poor planning and consultation under PFI, where the views of staff have either been ignored or where staff and patient requirements have been compromised on the grounds of cost, have had an adverse impact on staff and patients. Poor design is indivisible from the impact on patient care. For example:

    "Quality of patient care is poorer. Increased health and safety concerns—more risk as laid a floor which isn't suitable for rehab. In gyms there is little or no ventilation (too hot for clients in summer who can't auto-regulate). Fire doors not magnetised therefore limiting wheelchair access, disabled toilets too small."

    "The design/facilities for patient delivery are a huge compromise on that requested—the situation appears to be worse for SLTs (speech and language therapists), dietetics and chiropody."

    "Physiotherapy department is generally felt to be better, though it could have been improved further with a little forethought. There has been much criticism of the hospital design—wasted space in atrium, cramped ward conditions, no shop, nowhere to purchase newspapers, poor parking. More people seem dissatisfied than satisfied."

  3.7  The frustrations felt by poor design are cemented by the fact that, once in place, it is difficult to affect changes to unsatisfactory elements of the design.

  3.8  PFI has also led to smaller and fewer treatment bays (in one case a reduction of a third, from 18 to 12 bays) and work spaces around beds. Inadequate space in which to administer treatment potentially compromises patient care. Safety is also compromised for both the patient and physiotherapist. For example, a lack of space around a bed may preclude the use of a hoist, for example, which would necessitate the use of a manual handling procedure which carries with it a risk of injury to both the patient and the physiotherapist (musculoskeletal injuries gained from manual handling are a significant problem for physiotherapists).

  3.9  Other patient care issues of concern to our members include patient privacy and access for disabled patients. For example:

    "Access for disabled in all areas awful—full report written by ourselves to management and largely ignored due to cost."—Senior I physiotherapist, Rehabilitation.

  3.10  The issue of inadequate space in new PFI hospitals is not confined to treatment bays or space around beds. New gyms have been reported as being either too small or, although the same size as before, as having less available space due to the positioning of equipment. This has caused some frustration amongst physiotherapists working in rehabilitation, for example. Problems with storage and changing/showering facilities featured in over 60 comments on returned survey forms, indicating severe frustration, for example:

    "No staff room or lockers, no cupboard spaces allocated for frames etc. Huge reduction in neurological outpatient treatment space. Smaller library. Am satisfied with building but dissatisfied with lack of physiotherapy space."

    "No staff room initially, now a small room with no windows. Offices very full and hot, poor changing facilities/showers—not enough space."

  3.11  The disappearance of staff rooms or physiotherapy departments under some PFI schemes deprives staff of the chance to liaise with colleagues to discuss treatments and obtain professional peer support.

  3.12  Poor ventilation and temperature control has been described as a "major problem". One respondent commented that the poor ventilation and "little natural light" meant it was "like working underground". Another respondent commented that the "ventilation system is causing lots of problems—eye problems, headaches, nose bleeds, respiratory problems."

  3.13  Significant problems were also reported in cleaning, portering and general maintenance facilities. Poor cleaning standards feature heavily in PFI projects according to our members. Comments that under PFI wards were "visibly dirtier" or "filthy" were common, along with "unreliability" of cleaning and the lack of monitoring of cleanliness. Some cleaning problems were described as "teething troubles" evident only at the outset of the PFI project and now resolved, whilst others are described as ongoing. Support services such as cleaning are transferred to the private sector consortia under PFI deals. The experience as suggested from our members is that this has led to worse service. Hospital cleanliness is vital in preventing against risk of infection.

  3.14  Portering is reported to be a problem in terms of delays and in terms of availability. Having to request portering services via computer was cited as a problem when the computer system crashes (IT is an area where the government proposes extending private sector involvement), and arguments between PFI employed staff and Trust staff over who has the responsibility for moving patients was also cited as an issue. The lack of support staff training in dealing with the public was also mentioned, along with the increased cost of support services under PFI and problems getting the PFI company to pay for and conduct repairs. It is worth registering our concern over the artificial distinction made between clinical and non-clinical staff in PFI deals. This causes tension and erodes the sense of working in a team.

  3.15  Staffing problems also feature in concerns over PFI. One respondent, commenting on the problems experienced replacing staff who have left or retired, said:

    "The cost of the Trust merger, relocation and PFI repayments have led to a freeze of staff recruitment leading to a number of unfilled senior posts. Both the acute and community services suffer from a distinct lack of senior therapists, causing some major clinical supervision issues."

  3.16  The provision of hydrotherapy also appears to be an issue in some PFI deals, although not in others. Pool closures or problems acquiring or keeping hydrotherapy pools, the location of the physiotherapy department in relation to the hydrotherapy pool or the sharing of the hydrotherapy pool with other disciplines and poor design were all raised as issues. Cost seems to be a major factor in problems experienced keeping hydrotherapy pools open. Comments received include:

    "We did plan for a hydrotherapy service but PFI said no because of allocation of space."

    "Inappropriate positioning of physiotherapy department on plans: lack of knowledge of what hydrotherapy is leading to pool being two floors away (from the physiotherapy department) on plans."

    "We have had to put forward a strong case to preserve a paediatric hydrotherapy facility already available (but) we are expected to share the pool with the adult side at the new central site."

  3.17  Reception areas being located away from the physiotherapy department, leading to more travel time to retrieve outpatients, was also mentioned as a problem. The impact of this being that the physiotherapist has less treatment time with the patient.

  3.18  The lack of car parking facilities and high car parking charges, for both staff and patients, featured strongly in responses to our PFI survey. Car parks is one area potentially ripe for greater private sector involvement, but experience to date suggest that this will contribute to greater frustration for staff and patients alike. Members have commented on the difficulties faced by staff who can only park on-site if issued with a permit (hard to secure) and patients who are "excessively charged" for parking whilst attending two 20 minute physiotherapy appointments per week. Car parking has been cited as a factor in staff "looking for more convenient places to work".

  3.19  The physical location of PFI hospitals also causes concern. For example:

    "The PFI involves a new hospital build approximately four miles away from the existing sites. It will involve major change to everyone's working life and is viewed with suspicion and apprehension."

  3.20  It is clear from our members experiences that PFI is a cause for concern. There are concerns over its impact on clinical care because of bed losses and inadequate treatment facilities, and there are staff-specific concerns such as the availability of parking, changing facilities and staff rooms where contact can be readily made with colleagues. The failures of PFI in these areas, as cited by some of our members, affect government commitments such as staff involvement and "Improving Working Lives" (IWL), for example. The IWL Standard is a commitment "from NHS employers to create well managed, flexible working environments that support staff, promote their welfare and development", but inadequate facilities would suggest the IWL commitment has been compromised in some areas. Similarly, where staff views have been ignored in the PFI planning stage this does not demonstrate a commitment to staff involvement. Where PFI has had a detrimental effect on the working environment it has also had an impact on the morale of those directly affected. There are many concerns over the future expansion of PFI and what this might mean both for members' working conditions and terms of employment and for the NHS itself.

  3.21  In July, the Prime Minister announced an extension of PFI from hospital building to primary care, social services and the provision of imaging and laboratory equipment and the use of private sector management expertise to run NHS buildings and IT systems and the proposed stand alone specialist surgery centres. While we recognise the need for the public sector to improve, and support initiatives to help achieve these improvements, we have significant concerns over this expansion and what it may mean for staff. We are concerned, for example, about the possible inclusion of clinical staff in future PFI deals and the impact this may have on terms and conditions, access to professional support and CPD. We question too the policy of bringing in private sector managers without evidence that the private sector might be able to run clinical centres better than the public sector.

  3.22  One of the government's justifications for PFI has been that PFI offers better value for money. However, it is far from obvious why this should be the case. The State can always borrow more cheaply than companies because there is no risk that the state will go bankrupt and there are no shareholders to pay. How "value for money" is calculated and how "risk" evaluated under PFI is also very contentious. Proof of "value for money" in PFI schemes is supposed to be demonstrated by comparing the PFI scheme to a Public Sector Comparator (PSC), which must include a measure of the risks that will be transferred to the private sector under the PFI but which would remain in the public sector if the PFI scheme was not to go ahead. However, the methodology for working out the comparison with the PSC appears to be, at best, an inexact science. According to the Office for Health Economics:

    "The net benefits of NHS PFI schemes relative to their public sector comparators appear small. For NHS PFI schemes so far signed-off, the estimated net benefit would disappear if the real annual discount rate used to calculate the new present value costs of the different options were reduced from 6 per cent to a more appropriate, risk-free, level of 4 per cent. The current discount rate is too high given that the costs of risks transferred are estimated separately and added onto the publicly financed project's costs."[10]

  3.23  If, as appears to be the case, that the methodology of calculating the benefits and costs of PFI projects is flawed, then we would support a review of this process which could also encompass investigating alternative methods of calculating value for money and risk transfer in PFI deals.

  3.24  A further element to the value for money consideration of PFI is the steady payment stream to the private sector. The National Audit Office, for example, stated:

    " . . . value for money will be compromised if the public sector's requirements take second place to providing an attractive opportunity for the private sector."[11]

  3.25  This factor causes considerable concern in terms of public interest and the best use of public funds. Is the public interest best served by locking the Department of Health in to very long term payments, ie in excess of 20-30 years, to private consortia who's priority is the payment of dividends to shareholders, not the provision of health care on the basis of need? This element of PFI strikes us as incompatible with the aims of the NHS, and potentially compromises future health planning as the NHS is contractually bound to PFI regardless of whether PFI hospitals built now are best placed to serve health needs in 30 years time. There is also a "democratic deficit", where local input into planning health needs and public accountability issues appear at risk.

  3.26  A possible alternative to the current "PFI or nothing" choice could rest on liberating the public sector from the restrictions imposed on its ability to innovate. The public sector's ability to be innovative is hampered in comparison with the private sector as it does not have the same freedoms to invest (public authorities are prevented, for example, from taking advantage of a range of cheap loans available from the European Investment Bank). Changing the framework within which public sector procurement is undertaken could enable any perceived benefits of the PFI method of procurement to be transferred to conventional schemes. It strikes us as odd that a government so keen on much needed modernisation of public services concentrates disproportionately on encouraging private sector involvement without first freeing up the opportunity for the public sector to innovate. It is our view that PFI is, potentially, an expensive mistake to make and that, bearing in mind the considerable weight of concern over PFI, a halt should be called on further PFI expansion pending a proper and thorough independent review, evaluation and assessment of PFI. As the Office of Health Economics has observed,

    "The benefits of PFI could be achievable without the extra costs, by dropping the requirement to borrow capital from the private sector. Design, build and operate (DBO) deals combined with public financing of the initial investment should be tested as another option."

  3.27  Another factor to be considered in evaluating PFI is the assertion that PFI contributes to extra investment in health. There is considerable doubt over whether this is indeed the case. The IPPR, for one, asserted that PFI had not contributed significantly to increasing public investment (it called the argument that PFI allows for more capital investment "spurious"). This is a serious cause for concern. The CSP would like to see more attention given to this issue and calls for a reform and boost approach to the public services. We would particularly like to see the government bringing forward and building on its promise of increased public spending on health to the European Union average by 2006.

Questions to be addressed

    —  What is the evidence base supporting the scale of use of PFI?

    —  Should the "discount rate" used in PFI value for money calculations be revised?

    —  Will PFI, with the long contracts involved, compromise future health care planning?

    —  In terms of public interest, should the payments made from the public purse to the private sector under PFI not be reinvested into the NHS?

    —  Is there scope to enhance the public sector's opportunity to innovate before proceeding with a PFI project?

    —  Can lessons learnt from PFI projects be applied to aid development in the public sector?

    —  Can PFI planning rules and consultation procedures be amended to require consortia to take greater account of the views of clinicians?

4.  PUBLIC PRIVATE PARTNERSHIPS (PPPS)

  4.1  Although the Private Finance Initiative (PFI) is the predominant form of public private partnership (PPP) in the UK it is but one form of PPP and there is no reason why PFI should continue to be the dominant model of PPP.

  4.2  The Institute for Public Policy Research (IPPR), in its report[12] published in June, called for an evidence-based approach to policy—"Depending on the evidence that emerges PPPs could be rolled out or rolled back"—and this is an approach the CSP supports. In its current form, and without a proper evidence base to suggest that this is the right way forward, the CSP would not like to see an expansion of PFI. Rather, it strikes us that a more sensible, prudent and methodologically robust approach would be to pilot a variety of PPP models, each strictly controlled so that comparisons for value for money, effectiveness and other public interest considerations can be openly and transparently made, verified by an independent assessor.

  4.3  We have already stated our belief in an evidence-based approach to policy. Consequently, any form of PPP that is introduced into the health sector should only be done on a pilot basis, strictly controlled and properly evaluated.

  4.4  We believe that, in terms of PPPs, a greater diversity in public service provision which offers alternative models to PFI should be looked at, but that any model of PPP should be subject to strict constraints. Consequently, we recommend that a "Public Services Charter" could be established that sets clear public interest criteria against which any PPP or public service provider must comply before being approved for pilot. Such criteria may include, for example, value for money, public accountability, the suitability of private sector organisations looking to secure a profit from health services, ownership and management control, industrial relations policies (ie adherence to NHS terms and conditions, quality standards and HR and equal opportunities standards), the financial and legal structure of the partnership, funding and financing.

Questions to be addressed

    —  Is there scope for a Public Services Charter to be developed to set clear benchmarks of public interest criteria that must be matched before any PPP (not necessarily PFI) is developed?

September 2001



8   The government announced a planned 59 per cent increase in physiotherapists in February 2001. Back

9   HSC 2001/015 Continuing Care: NHS and Local Councils' responsibilities. Back

10   Sussex J The Economics of the Private Finance Initiative in the NHS. The Office of Health Economics. Back

11   Examining the value for money of deals under the Private Finance Initiative, Report by the Comptroller and Auditor General National Audit Office, HC 739 Session 1998-99 13 August 1999. Back

12   Building Better Partnerships: The final Report of the Commission on Public Private Partnerships', IPPR June 2001. Back


 
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