Memorandum by the Chartered Society of
Physiotherapy (PS 27)
TABLE OF CONTENTS
2. The NHS Concordat with the private and
3. Private Finance Initiative (PFI).
4. Public Private Partnerships (PPPs).
Appendix CSP Survey on PFI: members comments
on their experiences of PFI.
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.
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.
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.
1.1 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
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
and rehabilitation services, is pursued. This is important if
one of the central thrusts of the government's reformsto
place NHS staff at the centre of the reform programme, to empower
them to be part of the solution to the challenges facing the NHSis
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
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
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 goodor at least betterfacilities
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
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
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
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 buildingfresh
and clean. Dissatisfied with lots of issuestoilet for female
staff, small changing room for therapy services, staff room smaller,
flooring in both gyms unsafestill awaiting replacement!
Liftsno 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
"There are more urgent referrals to outpatients
as patients are discharged faster and with more complications".
"Patients discharged from wards in worse
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 concernsmore 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 requestedthe situation appears
to be worse for SLTs (speech and language therapists), dietetics
"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
designwasted 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 awfulfull
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/showersnot
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
problemseye problems, headaches, nose bleeds, respiratory
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
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
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."
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
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
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
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
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?
8 The government announced a planned 59 per cent increase
in physiotherapists in February 2001. Back
HSC 2001/015 Continuing Care: NHS and Local Councils' responsibilities. Back
Sussex J The Economics of the Private Finance Initiative in the
NHS. The Office of Health Economics. Back
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
Building Better Partnerships: The final Report of the Commission
on Public Private Partnerships', IPPR June 2001. Back