NHS
Evidence suggests that privatising healthcare services does not produce better health outcomes. So why is Labour so keen on doing this?
The medical journal, The Lancet has published a paper this month with the following heading:
The Summary of the piece is as follows:
Over the past 40 years, many health-care systems that were once publicly owned or financed have moved towards privatising their services, primarily through outsourcing to the private sector. But what has the impact been of privatisation on the quality of care?
A key aim of this transition is to improve quality of care through increased market competition along with the benefits of a more flexible and patient-centred private sector. However, concerns have been raised that these reforms could result in worse care, in part because it is easier to reduce costs than increase quality of health care. Many of these reforms took place decades ago and there have been numerous studies that have examined their effects on the quality of care received by patients.
We reviewed this literature, focusing on the effects of outsourcing health-care services in high-income countries. We found that hospitals converting from public to private ownership status tended to make higher profits than public hospitals that do not convert, primarily through the selective intake of patients and reductions to staff numbers. We also found that aggregate increases in privatisation frequently corresponded with worse health outcomes for patients.
Very few studies evaluated this important reform and there are many gaps in the literature. However, based on the evidence available, our Review provides evidence that challenges the justifications for health-care privatisation and concludes that the scientific support for further privatisation of health-care services is weak.
I added the paragraph breaks: there were none in the original.
Let me be clear about what this paper does not say. It does not suggest what form of state-supplied medical care might be best for a population. This is not, therefore, an article that by itself justifies the existence of the NHS in its current form.
That said, what the paper does suggest is that over a wide range of surveys, privatisation of whatever form of state-delivered healthcare there might have been has not improved health outcomes.
What the paper does, however, suggest is that the privatisation of previously state-provided services did deliver an improvement in the profitability of private healthcare companies. In other words, a clear winner from privatisation can be identified, but it is not the patient or the state that then funds the provision of privately supplied health services. Only health companies gain.
Is there, in that case, any reason for labour or anyone else to think that the answer to healthcare supply in the UK might rest with the private sector? The straightforward answer would appear to be, 'No, there is not.'
In that case, why are Labour so keen on using private medicine and privatising the NHS? Is it simply that the private healthcare lobby has got to them? Or is there more to it than that, about which we should know?
Is Stealth NHS Privatisation Happening in Plain Sight?
Is the NHS really being privatised on the quiet, before enough of us realise it?
It remains a taxation-funded, largely publicly-provided, universal, free at the point of use service, notionally based on need not the ability to pay, in line with its founding principles. And you can’t buy shares in the NHS – a million miles away from the situation in our privatised utilities and public transport providers.
International health system comparisons and league tables have consistently shown that the NHS is a leader in terms of efficiency, cost, equity of access, not financially charging patients, and not damaging them financially by the cost of care or avoiding care due to fear of cost.
That said, the World Health Organisation defines privatisation as occurring “where non-government bodies become increasingly involved in the financing or provision of health care services”. Use that yardstick and the situation warrants further scrutiny.
Services such as dentistry, community pharmacy, and eye testing have been provided by the private sector for many years without considerable pushback (although the recent crisis in the provision of NHS dentistry and a contract that makes it unviable for dentists to deliver at any kind of scale has raised doubts about this).
Support services such as catering, car parking, cleaning, security and maintenance, and records storage have been outsourced for years – although not without concerns regarding their value for money, quality, competence, or comparison with traditional in-house provision (not to mention NHS frontline staff being fined for parking at their own workplace and companies profiting from patients or their families visiting hospital).
Legislation in recent decades has created an internal market with a 'purchaser-provider split’: the “any qualified provider” clause in Andrew Lansley’s 2012 Health and Care Act made it compulsory for the Government to put NHS contracts out to competitive tender. This has since been repealed with the creation of 42 "integrated care systems" and the Alternative Provider Medical Services Contract, enabling primary and community services to be bid for by non-NHS providers.
NHS trusts are also saddled with debts from the private finance initiative (PFI) for building and maintenance of facilities. In 2022, the Guardian found that 101 trusts owe £50 billion between them and several are spending more than 10% of their revenue on servicing PFI contracts. There are numerous ongoing disputes between NHS trusts and providers about the quality of the contractors’ work and plans when the contracts come to an end.
Despite all of this, respected health policy think tanks such as the King’s Fund have pointed out that notwithstanding the growth in clinical contracts being awarded to the private sector after the 2012 Act, they have often been of low value (with a total spend of only about 7 % of NHS expenditure).
Meanwhile, adult social care – including personal care at home or long-term care in residential and nursing homes – unlike the NHS, has long been rationed by highly restrictive eligibility assessment. It is far from universal and is also subject to means testing and personal payments. Cuts to local government funding, competing pressures on councils, repeated failures of government to provide social care funding solutions, and the crisis in the poorly paid social care workforce, have seen a growing gap between requests for support and provision.
Earlier this month, it was reported by the director of the Centre for Healthcare in the Public Interest that private equity funds and US health corporations were taking more than £1 billion in profit annually from their stakes in care homes for older people and homes for looked-after children. These facilities are currently essential to service provision and represent a stable opportunity for return on investment.
It was also reported that half of the UK's sexual assault referral centres were backed by private equity and that companies had made several millions in dividends during the past two years, not only from these centres but also from healthcare provision for people in custody and secure units.
Around one in three inpatient mental health beds, and the majority of addiction, drug and alcohol rehabilitation facilities, are now private sector provided. Local government cuts have also impacted capacity in such services.
This is despite a major evidence review this year in the Lancet, which found that research in the past 40 years had shown that an increasing aggregate of private sector provision has been linked with worse outcomes for patients. It concluded that the evidence for the benefits of privatisation was weak.
A review by the British Medical Journal last year of the literature on private equity investment had shown that a growing involvement of private equity in all healthcare settings was associated with higher and harmful costs to patients and “mixed to harmful” impacts on care quality.
The Guardian also reported this month that private hospitals are now carrying out 10% of all elective NHS operations (a record high). The biggest areas among the 1.67 million NHS-funded operations carried out in the private sector were in routine orthopaedic surgery, eye surgery and dermatology – a 29% increase in the numbers reported in 2019.
The Independent Health Provider Network praised the increasing access and choice for patients as helping to reduce waiting lists (as part of the NHS referral to treatment scheme).
The Centre for Healthcare in the Public Interest has also reported that cataract operations being conducted in the private sector are also being clinically coded as of higher complexity than those in the NHS – with more complex codes attracting a higher price.
Meanwhile, between 2019 and 2022, the proportion of British citizens taking out private medical insurance nearly doubled from 12% to 22%, bringing the UK more in line with other industrialised nations from a historic low uptake.
Again, the insurance industry is pleased with this progress. Last year, both Aviva and Axa celebrated the opportunities this provided and the growth in their market share.
We know that more than one third of patients having private sector surgery are now paying out of their own pocket, even without any personal insurance policy, and that this too has seen a steep rise in recent years.
The pandemic caused a sharp rise in privatisation tendencies.
The National Audit Office published a series of reports on pandemic procurement, showing tens of billions of pounds squandered on personal protective equipment – much of it unusable, on test and trace, apps, ventilators, and consultancy contracts often from unqualified and unsuitable commercial organisations with insufficient scrutiny and transparency and poor value for money.
As Byline Times has reported on extensively, some of the individuals and organisations who won contracts had links to the Conservative Party or were known donors, with a 'VIP lane’ created to facilitate this.
The private hospital sector was also given an additional £2 billion of government money between 2020 and 2023 to help with pandemic elective care, but its activity continued to be dominated by private work.
There is also the issue reported by Byline Times of several MPs or peers holding shares in private healthcare providers, or private equity firms who fund them and lobbying on their behalf.
The private healthcare sector employs and poaches staff trained by the NHS and bears none of the training costs itself; selectively cherry-picking low-risk elective procedures it can monetise and avoiding acute, urgent or complex care – including the provision of emergency departments, intensive care, or inpatient care for sick older people.
It evades the degree of regulatory scrutiny the NHS must rightly meet. And it ships thousands of patients each year back to NHS hospitals when they develop acute complications that private hospitals are not staffed or equipped to deal with.
Analyses by the King’s Fund, the Nuffield Trust, Health Foundation, and even global consulting giants McKinsey, have shown that there is no inherent advantage in an insurance-based system with greater marketisation and profit motive compared to predominantly tax-based and publicly-provided systems.
Nor is it true that those systems do not exist outside of the NHS. Versions can be seen in Italy, Spain, Portugal, New Zealand, Canadian Provinces, Malta and Scandinavia – albeit often with less centralised political leadership and control.
Data from the British Social Attitudes Survey, the Health Foundation and Ipsos Mori has shown no public appetite, and no political mandate, for a change in the current tax-funded and notionally publicly-provided NHS model or its founding principles.
The same goes for support for an European-style insurance-based models (repeatedly touted by small state lobbyists from the Institute of Economic Affairs, the Adam Smith Institute, or columnists in right-wing publications who ignore the presence of perfectly decent, publicly-funded, models in their selected examples).
Sadly, a major reason why so many more people are now feeling they must take out private insurance or use their savings to pay for treatment or consultations – and why the NHS itself is placing ever-growing volumes of business with the private sector – is the years of declining performance since 2010.
I believe the majority of the public wants the existing NHS model to work like it used to, in terms of access, waiting times, staffing, patient, and staff satisfaction – rather than a complex market involving multiple payers and competitive providers.
With a Labour government likely after the next general election, it would be good to see it openly defending the NHS’ founding principles – and to stop and reverse the expansion of the profit motive and markets in the service. I have seen no such commitments yet.
‘A Rollercoaster Of Awful Emotions’: Family Speaks Out for NHS Overhaul to Prevent Deaths of Severely Ill ME Patients
"I feel like I’m going to die". These were the haunting words of 18-year-old Millie McAinsh, wrongly sectioned and left without care in an NHS hospital.
Before autumn 2019, Millie was a healthy teenager. She loved the performing arts and was excited to attend sixth form and go to university. Then, what started out as a simple virus, became Myalgic Encephalomyletis (ME), and everything changed.
ME – sometimes erroneously referred to as Chronic Fatigue Syndrome – is a multi-system post-viral illness that leaves 25% of its sufferers housebound or bedbound, and 75% unable to work. Its primary symptom is post-exertional malaise – a dramatic increase in neurological and immune symptoms following exertion.
Over the next four years, Millie went from being the “spontaneous and adventurous” person her family knew to being almost entirely bedridden and relying on them for her basic needs.
By last December, Millie was too unwell to feed herself.
In January, she was subsisting on a mainly liquid diet taken through a straw. When this became too difficult, she was admitted to the Royal Lancaster Infirmary.
Millie's family hoped it would be a brief stay, simply to have a feeding tube fitted that would allow her adequate nutrition, but she was instead placed under a deprivation of liberty safeguarding (DOLS) order. She was subsequently sectioned under the Mental Health Act. That decision was overturned by an emergency tribunal 12 days later.
Her mother and primary carer, Lucy Montgomery, has been banned from visiting – leaving Millie at the mercy of tests that she says are causing her daughter to rapidly deteriorate.
“Being banned from the hospital after caring 24/7 at home for Millie was extremely distressing and difficult,” Montgomery told Byline Times. “She trusted and relied on me to help advocate for her needs, and the new environment in hospital was challenging enough without having her main carer and support taken away.”
Due to the severity of her condition, Millie is mostly non-verbal. But during a traumatic procedure in which a tube was wrongly inserted into her lung, she was heard to beg: “Take it [the tube] out. I don’t consent to being touched… I want the tummy [feeding] tube… I want my mummy to decide my medical decisions… I want to go home.”
At the time of writing, no such tube has been fitted, although there are tentative plans for a procedure next week.
Millie in hospital, where her family says her condition has rapidly declined. Photo: Millie’s family
“Millie has declined massively in hospital,” a member of her family who wished to remain anonymous said. “She is now unable to leave her bed at all and has recently said many times that she thinks she is dying and will not live another week.”
This is not an unreasonable fear.
Despite an estimated 1.2 million people in the UK living with post-viral disease, there is a lack of knowledge within the medical profession regarding how to treat these patients.
In particular, a gap in the care pathway for severe ME patients means that many risk death or the worsening of their condition if they seek hospital care.
In 2021, 27-year-old Maeve Boothby O’Neill died after she became too unwell to take in food and water due to the severity of her ME. She was discharged three times when an NHS hospital allegedly mishandled her care and she died at home in Exeter.
An inquest into her death is ongoing, but the pre-inquest hearing last November heard written evidence from the medical director of her local hospital trust that there was a dire lack of NHS services for patients with severe ME.
“The trust was not commissioned, and therefore not resourced, to provide inpatient treatment for severe ME,” Dr Anthony Hemsely wrote. “[And there was] no opportunity to refer Maeve to a specialist inpatient centre.
“There is a lack of commissioned specialist services for severe ME, both locally, regionally, and nationally. In order to rectify this situation, action is required at the highest level.”
The history of ME is long and fraught.
For many years, it was thought to be a psychological phenomenon, but a growing body of biomedical research studies have suggested that this is incorrect. While the National Institute for Health and Care Excellence (NICE) guidelines for ME were updated to reflect this in 2021, the change has been slow to reach general medical practice.
Many doctors and medical professionals still believe that ME is predominantly a psychological or behavioural problem, rather than an illness that can cause death – like those of 21-year-old Merryn Crofts in 2017, and 32-year-old Kara Jane last year.
Millie’s family are now facing the same struggle to access appropriate care and say they are “emotionally and mentally exhausted".
“The whole experience is a roller-coaster of awful emotions," they said. "This has permanently changed us all as people."
While the inquest into Maeve’s death is scheduled for July, campaigners have written an open letter to the Health and Social Care Secretary, asking for the urgent creation of an NHS protocol for patients with severe ME.
Millie’s family have launched a petition urging the medical team at Royal Lancaster Infirmary to abide by the NICE guidelines, fit Millie with an appropriate feeding tube, and allow her to come home.
Jane McNicholas, chief medical officer at University Hospitals Morecambe Bay NHS Trust, told Byline Times: “Due to the complexities of the case, it would be inappropriate for us to comment except to say that our teams are working hard with relevant specialists to provide the best possible care.”
‘Extraordinary’ Claims of Evidence Spoliation in NHS Whistleblower Case
Questions have been raised around court claims of evidence spoliation and recoverability in a high-profile NHS whistleblowing case during which tens of thousands of emails were deleted.
NHS doctor Chris Day has won the right to challenge a tribunal decision about information governance in NHS hospital trusts and the scrutiny applied to attempted evidence destruction at employment tribunals.
Day exposed acute understaffing at a south London intensive care unit linked to two patient deaths in 2013. His decade-long legal campaign has since revealed a lack of statutory whistleblowing protections for nearly 50,000 doctors below consultant level in England.
An appeal tribunal in February refused Day the right to challenge key aspects of an earlier ruling that cleared Lewisham and Greenwich NHS Trust (LGT) of concealing evidence and perverting the course of justice when one of the trust’s directors deleted up to 90,000 emails during a tribunal hearing in July 2022.
That hearing heard that LGT communications director, David Cocke, had attempted to destroy tens of thousands of emails and other electronic archives that were potentially critical to the case.
An unsigned witness statement submitted to the tribunal on behalf of Cocke claimed that the information had been “permanently” deleted. LGT has since claimed that the cache was recovered and submitted to the tribunal, something Day disputes.
Appeal tribunal judge Andrew Burns described Cocke’s conduct during the 2022 hearing as “extraordinary”.
Cocke’s actions followed LGT’s late disclosure of more than 200 pages of documents and, the tribunal heard, suggested that the trust’s CEO, Ben Travis, had given “inaccurate” and potentially misleading evidence to the tribunal days earlier.
Day’s barrister, Andrew Allen, told an employment appeal tribunal in February that Cocke went "in the middle of the night and destroyed them... because he was in a panic".
According to Allen, Cocke "had been observing the case and realised that key evidence had not been disclosed".
That Cocke "destroyed documentation potentially relevant to the litigation,” Allen argued, “is intimately tied up with" Day's concealment and detriment claims.
He added that there was a “failure to make findings” at the 2022 tribunal on the attempted destruction of electronic evidence.
Burns noted in his judgment that “although the employment tribunal has mentioned that it can draw adverse inferences… from the respondent’s deletion of documents, it doesn’t seem to have turned its mind to doing so.” He described Day’s patient safety disclosures as been of “the utmost importance”.
Allen also raised questions about LGT’s destruction of electronic records prior to the 2022 hearing.
"Documents had not been sought from key personnel,” he said, including from Janet Lynch – an ex-workforce and education director at the trust who, as its instructing client, had been responsible for advising the trust’s solicitors up until late 2018. “And key documents [including Lynch’s emails] were destroyed after she left the trust.”
Five trust directors’ emails – Travis, Cocke, Lynch, and two doctors involved with Day’s whistleblowing case – were either said to have been deleted or unavailable during the key dates being examined by the 2022 tribunal.
The hearing considered whether the trust had caused Day detriment linked to his whistleblowing. His appeal will examine whether public statements the trust issued about the settlement of a previous hearing did so.
The directors whose emails were unavailable at the 2022 tribunal are understood to have been involved in producing the statements, which drew criticism from the Care Quality Commission regulator.
The appeal hearing will not consider Day’s allegations of concealment. He has asked the tribunal to review its decision and applied for a further ground to be added.
Martin Nikel, an expert in e-discovery who heads Thomas Murray's cyber risk advisory e-discovery and litigation support practice, told Byline Times that a number of key questions regarding the emails’ status had not been answered by the tribunal or LGT.
"It's very irregular for a director of communications to have the ability to permanently delete emails without administrative privileges,” he said.
“When it's said that he deleted 90,000 emails, that's potentially a big task to undertake. In these scenarios, an end user without significant knowledge and access rights, would leave three potential sources of email, which could be explored to see if the email can be recovered.”
The NHSMail system, which LGT has confirmed was in use in 2022, usually retains emails for a minimum of 30 days and up to two years, Nikel said. A forensic discovery request or search of the Microsoft 365 environment could also establish the presence of the emails.
Nikel added that the way LGT board members were asked to provide evidence for the 2022 hearing was “unreliable” and explained that “it appears that board members were instructed to simply search their own emails".
“This is an obviously unreliable way to perform any collection of evidence in a neutral way," he said. "The NHS has processes in place for such situations – and organisations like the Counter Fraud Authority – that I am sure could provide better evidence-handling processes in such high-profile matters.
“Legal advisors could appoint external forensic experts, which if nothing else, would help with perception in future situations such as these.”
Robert Maddox, an employment lawyer with Doyle Clayton, told Byline Times that employment tribunals apply the same evidence to disclosure and preservation rules as the civil courts, but don't have “the same level of rigorous procedure that goes with a High Court matter”.
“For example, in the civil courts, a party can be obliged to complete a disclosure certificate of compliance confirming where they’ve searched, what they’ve searched for, confirming they’ve disclosed all relevant documents," he said.
“That’s not necessarily done in the tribunal. There is an obligation on parties to perform a reasonable search and to disclose any documents that are relevant, irrespective of whether they are favourable or adverse for a party’s case.
“But there certainly is an obligation to preserve documents and tribunals will look unfavourably on documents having been lost or destroyed.”
Maddox added that, although it is possible to enlist an IT expert to assess lost or deleted evidence, tribunals can take a party’s statements at face value.
It is more common for a party to make submissions on adverse inferences that can be drawn from missing, lost or deleted evidence, he said, rather than incur costs or risk further delays.
A LGT spokesperson acknowledged the outcome of the appeal hearing but declined to comment further "as legal proceedings are ongoing”.
LGT declined to say if Cocke still works at the trust and whether it paid his legal costs after he enlisted the services of a separate firm during the 2022 hearing. Travis remains the trust CEO.
Video: EGM leak reveals RCP ‘refusing to answer patient safety questions’ and more
Clips from 2-hour leaked extraordinary general meeting appear to show Royal College of Physicians avoiding scrutiny – but making damning admission of financial conflict of interests in government’s expansion of ‘non-doctor-doctor’ roles
A leaked video of the entire ‘extraordinary general meeting’ (EGM) of the Royal College of Physicians (RCP), called by doctors to try to force a slow-down in the roll-out of the government’s expansion of the use of non-medically-trained staff in ‘doctor’ roles, has revealed comments and obfuscation that have led medical professionals to call for the resignation of senior RCP officers. One has already resigned.
A number of patients have already died avoidably because of errors by ‘physician associates’ (PA), who have only two years’ training compared the seven-plus years completed by doctors. A Doctors’ Association UK survey has found ‘deeply disturbing’ abuse of the PA role in NHS trusts.
Keele University cardiology Professor Mamas A Mamas wrote of the leaked video:
The ‘PlatinumPizza’ Twitter/X account has posted a number of excerpts from the EGM video highlighting what it feels are the most noteworthy evasions and obfuscations. The first two reveal that, while the RCP claims that PAs must complete national exams, a freedom of information request revealed that this can be bypassed – and that the RCP, which criticised a far more comprehensive survey by the British Medical Association (BMA) as biased, in fact skews the results of its own small survey to present a falsely positive outlook:
Next, Dr Read tries to present the results of the survey. It's important to remember that Dr Read has since resigned from his post following the EGM.
Somehow, they've managed to mess-up even a basic Likert scale survey and clustered the neutrals with the positives! pic.twitter.com/G2DRpdegBx— platinumpizza
(@Xeon4f145d96s1) March 17, 2024
Doctors participating in the EGM also raised the issue of the fact that PAs are paid more than the junior doctors who often have to supervise them (and can be held to blame if a PA screws up) – but the RCP said it was ‘not a union’ and not interested in getting involved in pay issues:
Next, slightly sped-up, @DrOKaneAgain eviscerates the survey and its results. An insinuation about the BMA survey being "biased" and "leading" is raised. This comes after the RCP tries to pawn off its results by aggregating positive with neutral, as @doctor_oxford shared with us. pic.twitter.com/MefdfOmxT4
— platinumpizza
Next, the first of two posts about the RCP’s prioritisation of its finances above what nine out of ten doctors feels is a grave threat to patient safety:
Back to it, this clip talks about the fiscal and fiduciary responsibilities the RCP have. Although not shown in this particular clip (I'll include it in the thread later), mentions of millions in reparations/ law-suits/ class actions is made. pic.twitter.com/OYLBQtN5VO
— platinumpizza
And then the second, which shows the RCP’s treasurer admitting/warning that the RCP could stand to lose millions if the PA expansion is halted or even slowed down – and the RCP apparently disagreeing with the RCP of a short while below about being a ‘union’, at least when it comes to ensuring PAs have jobs:
I know you are all waiting to hear the millions the RCP might be forced to pay up…so this clip is just that!
Will someone think about the pensions?! pic.twitter.com/s8JD70ooXs— platinumpizza
And, adding farce to the ‘contempt’ of which doctors accused the RCP after the meeting, the panel refuses to say what additional benefit a PA brings to a ‘multi-disciplinary team’ that is not already present in the mix – rounded off by a clip of a doctor warning of the dangers of pressing ahead with the whole damaging system:
And lastly, in what can only be described as an epic season finale, @DrAsifQasim drops an absolute banger.
"i am deeply concerned we will take a patient safety hit if we do not act" pic.twitter.com/LaqIozrAEV— platinumpizza
And in a clip not included in the thread but created by Skwawkbox, one of the movers of the motion for the expansion to be slowed down until it can be shown to be safe for patients explains why it is so important for voting members of the RCP to support it, despite the RCP management’s recommendation to reject it and plough on:
Other discussions during the meeting included the panel failing to explain how it was going to ‘hold the government to account’ for the safe functioning of the system, as it had claimed it would – and treating the mere inclusion of any extra doctors in the government’s ‘long-term workforce plan’ as an achievement by the RCP.
The use of PAs, which is considered by nine out of ten doctors to be dangerous to patients and confuses many patients, who do not realise that they have not been seen and treated by a fully-qualified medic, is being pushed by the government as a way of ‘downskilling’ the NHS, reducing costs and allowing increased profits for private providers, under the guise of the so-called ‘NHS Workforce Plan’ as part of the ‘Integrated Care Systems’ (ICS) project.
ICS, formerly called ‘Accountable Care Organisations’ (ACOs) after the US system it copied, were renamed after awareness began to spread that ACOs were a system for withholding care from patients and that care providers were incentivised to cut care because they receive a share of the ‘savings’. The system remained the same, but the rebranding disguised the reality.
The government used a ‘statutory instrument’ (SI) to pass these changes, avoiding proper parliamentary scrutiny, but both the Tories and Keir Starmer’s Labour support these and other measures to cheapen the NHS for private involvement and only independent MP Claudia Webbe spoke against them during the brief SI debate. Green peer Natalie Bennett’s motion in the House of Lords to attempt to kill the instrument was defeated by the Tories with the help of Labour peers.
Watch the full RCP meeting here.
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Doctors’ Association survey finds ‘deeply disturbing’ misuse of govt’s non-doctor roles
Danger to patients and conflicts of interest as government continues to push for expanded use of ‘associate’ roles – with help from the Royal College of Physicians
A survey by the Doctors’ Association UK (DAUK) has revealed ‘deeply disturbing’ ‘scope creep’ in which – as warned by the British Medical Association (BMA) and others – ‘physician associates’ (PAs), who are not qualified as physicians, are being used and acting as doctors.
A statement by the group warns that PA are not only overstepping the boundaries in which they are meant to operate, but also being used by NHS trusts and health companies to fill positions that require fully-qualified doctors:
PAs are overstepping boundaries, putting patient safety at risk, and impacting doctors’ training. This is shocking in itself, but made far worse by recent events at the Royal College of Physicians… Doctors at Torbay report PAs being used as “middle grades” – clear scope creep.
According to a doctor recruitment agency:
Doctors in speciality training programmes are known as Middle Grade doctors. Junior Middle Grade doctors are trainees who have completed their foundation training and are now in the early years of their speciality training. They are: ST1/ST2: ST stands for Specialty Training.
According to survey responses from doctors at Torbay and South Devon NHS Trust, as well as being used as ‘middle grade’ doctors and putting patients at risk by acting outside their competencies, PAs:
- work without adequate supervision
- consent inappropriately
- participate in unsafe clinical activity
- treated severe infective colitis with antibiotics and steroids simultaneously
According to NHS Scotland, steroids “shouldn’t be used if you have an ongoing widespread infection. This is because they could make it more severe.”
The DAUK also linked the survey results to this week’s fiasco at the Royal College of Physicians (RCP), where attendees of an extraordinary general meeting (EGM) regarding concerns about PAs linked the behaviour of the RCP’s panel, which was accused of ‘contempt’, shutting down discussion and even filibustering, to the RCP’s financial conflict of interest in the millions of pounds it reportedly makes from administering PA examinations.
The RCP is hiding their full survey data from FRCP and Council until after the EGM vote. This lack of transparency is unacceptable…
The RCP Registrar, who sets RCP professional standards, works at this Trust. (Important note: there is no indication she was involved in this case [of steroid/antibiotic administration].)
Doctors at Torbay report PAs being used as “middle grades” – clear scope creep. Yet the Registrar, whose job is to “create consensus” & uphold standards, has been involved in withholding critical data that potentially sways the EGM vote. This is not leadership.
The Registrar’s own job description emphasises “accountability for clinical and professional affairs” and “…setting and maintaining professional standards.” How can the Registrar fulfil these duties, ensuring patient safety and upholding standards, when those very standards are being violated in their own Trust? This is an untenable conflict of interest.
In our view, the Registrar has failed in their core responsibility for transparency and integrity of RCP decision-making. We call for their resignation to restore trust in the RCP. The RCP’s position on PAs is currently compromised.
The statement concludes with a call on all voting members of the RCP to vote to support all the motions tabled at the EGM calling for a rethink on the issue of PAs:
Lastly, we are asking that Fellows vote in favour of all five motions as presented, to ensure that a safe revaluation of the PA role can be conducted to ensure patient safety and to ensure continued viable training of the medical profession moving forward.
The use of PAs, which is considered by nine out of ten doctors to be dangerous to patients and confuses many patients, who do not realise that they have not been seen and treated by a fully-qualified medic, is being pushed by the government as a way of ‘downskilling’ the NHS, reducing costs and allowing increased profits for private providers, under the guise of the so-called ‘NHS Workforce Plan’ as part of the ‘Integrated Care Systems’ (ICS) project.
ICS, formerly called ‘Accountable Care Organisations’ (ACOs) after the US system it copied, were renamed after awareness began to spread that ACOs were a system for withholding care from patients and that care providers were incentivised to cut care because they receive a share of the ‘savings’. The system remained the same, but the rebranding disguised the reality.
The government used a ‘statutory instrument’ (SI) to pass these changes, avoiding proper parliamentary scrutiny, but both the Tories and Keir Starmer’s Labour support these and other measures to cheapen the NHS for private involvement and only independent MP Claudia Webbe spoke against them during the brief SI debate. Green peer Natalie Bennett’s motion in the House of Lords to attempt to kill the instrument was defeated by the Tories with the help of Labour peers.
At least two people have already died avoidably because of misdiagnosis by PAs. Emily Chesterton, 30, who didn’t realise she wasn’t seeing a doctor, was treated for a calf strain when she had a deep vein thrombosis that led to a lethal embolism. Ben Peters, 25, was sent home from A&E with a ‘panic attack’ that was really a serious heart condition. A doctor’s Twitter/X thread includes details of others said to have died because of issues around PAs.
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Doctors’ fury at RCP ‘contempt’ and financial conflict of interest in non-doctor ‘associates’
Royal College of Physicians’ extraordinary general meeting turns to farce as doctors accuse panel of filibustering and lecturing them after concerns raised about dangers of untrained ‘physician associates’ carrying out doctor roles
The Royal College of Physicians (RCP) has provoked fury among doctors for its handling of an extraordinary general meeting (EGM) called by members to discuss motions against the College’s support for the government’s moves to both expand the use and roles of ‘physician associates’ (PAs) and to have them regulated by the General Medical Council (GMC).
PAs, who do not have medical degrees and receive only two years’ training compared to the seven years and more required to be a doctor, are increasingly being presented in healthcare settings as medical professionals and are even performing unsupervised heart surgery in some hospitals, as well as diagnosing, prescribing and seeing more patients in many general practices than GPs. Privately-owned GP companies are even making GPs redundant in order to replace them with cheaper PAs. Several patients have died, including at least two confirmed by coroner’s inquests, after misdiagnosis and inappropriate treatment by PAs.
The meeting, called to debate several motions around patient safety by enough members to trigger an EGM under the RCP’s rules, quickly descended into anger and farce. Doctor and professor Trisha Greenhalgh summed up in a series of her own and reposted Twitter/X posts indicating that the RCP panel was attacking those who raised concerns as irresponsible and damaging and were shutting down debate, even to the extent of ‘filibustering’, or talking at length to run out time:
More “headlines” without any actual RESULTS from the six questions. pic.twitter.com/SB5H6uAnW2
— Trisha Greenhalgh (@trishgreenhalgh) March 14, 2024
Here’s more. The category “neutral or positive” allows them to over-egg what they are spinning as a positive finding. Assumes that lack of experience with PAs *causes* a negative view. This would be a FAIL in any undergraduate essay on survey analysis. Correlation ≠ causation. pic.twitter.com/ZNPniLRLNM
— Trisha Greenhalgh (@trishgreenhalgh) March 14, 2024
Members attending online reported being unable to connect or losing their connection partway through:
This is fun pic.twitter.com/B4DKbbXgw7
— Trisha Greenhalgh (@trishgreenhalgh) March 13, 2024
Although opportunity to ask about financial conflicts of interest were not addressed, according to attendees, information emerging subsequently seems to indicate that the RCP does indeed have a financial interest extending to ‘millions of pounds’ in at least one aspect of the continuation and expanded use of PAs, as one disgusted doctor and NHS campaigner, Dr Rachel Clarke, pointed out:
Greenhalgh commented on the financial conflict of interest – and pointed out that the RCP’s president had just written an article about there being a role for PAs in healthcare for the British Medical Journal (BMJ) in which she did not point out the conflict, despite each BMJ article ending with a statement of potential conflicts of interest:
Even as of the time of writing, the end of the BMJ article still states that RCP president Sarah Clarke has not declared any competing interests:
So disgusted was Dr Rachel Clarke with the ‘lack of respect’ she witnessed at the meeting that, having originally been thrilled to be scheduled to appear as a keynote speaker at the RCP’s annual conference later this year, she has now withdrawn and has published an open letter about her reasons:
The use of PAs, which is considered by nine out of ten doctors to be dangerous to patients and confuses many patients, who do not realise that they have not been seen and treated by a fully-qualified medic, is being pushed by the government as a way of ‘downskilling’ the NHS, reducing costs and allowing increased profits for private providers, under the guise of the so-called ‘NHS Workforce Plan’ as part of the ‘Integrated Care Systems’ (ICS) project.
ICS, formerly called ‘Accountable Care Organisations’ (ACOs) after the US system it copied, were renamed after awareness began to spread that ACOs were a system for withholding care from patients and that care providers were incentivised to cut care because they receive a share of the ‘savings’. The system remained the same, but the rebranding disguised the reality.
Labour and Tories combine in Lords to defeat attempt to protect your right to see a doctor
The government used a ‘statutory instrument’ (SI) to pass these changes, avoiding proper parliamentary scrutiny, but both the Tories and Keir Starmer’s Labour support these and other measures to cheapen the NHS for private involvement and only independent MP Claudia Webbe spoke against them during the brief SI debate. Green peer Natalie Bennett’s motion in the House of Lords to attempt to kill the instrument was defeated by the Tories with the help of Labour peers.
At least two people have already died avoidably because of misdiagnosis by PAs. Emily Chesterton, 30, who didn’t realise she wasn’t seeing a doctor, was treated for a calf strain when she had a deep vein thrombosis that led to a lethal embolism. Ben Peters, 25, was sent home from A&E with a ‘panic attack’ that was really a serious heart condition. A doctor’s Twitter/X thread includes details of others said to have died because of issues around PAs.
The RCP was contacted for comment.
Update: the RCP has now said:
In organising the EGM, we wanted to ensure that a broad spectrum of views could be heard and addressed. There was a high volume of questions and we made clear it would be unlikely that all could be answered. However, every effort was made to facilitate an inclusive and constructive discussion where fellows, whether they were in the room, watching remotely, or contributing through randomly selected pre-submitted questions and comments, had the opportunity to express their view.
While as host to the Faculty of PAs (FPA) there will be a range of issues for the RCP to consider once the EGM ballot results are known, our core mission is excellent patient care. We agreed to host the FPA exactly because we wanted doctors to have oversight of the development of the profession. There is a workforce crisis in the NHS and when employed appropriately we believe PAs can be useful supplementary members of the multidisciplinary team. As a valued member of the RCP community we are saddened that Dr Clarke has made the decision to withdraw from the upcoming conference. However, we understand and recognise her strength of feeling on this issue and will be writing to her directly to respond to the concerns raised in her open letter.
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Gina Miller and wellbeing
Gina Miller has issued a manifesto for the parliamentary seat that she aims to fight, which is Epsom and Ewell: That ‘all policy decisions might be approached through the lens of health, happiness and wellbeing’ is pretty basic – but these days must be regarded as decidedly radical and right! Wellbeing community hubs and preventative... Read more
‘Please Close My Hospital’
The fundamental problem surrounding the current political debate about the future of the NHS is that it is ignoring the fundamental issue: the current pattern of provision.
On the one hand, the Government is proposing building more hospitals and a 15-year plan for more staff – without any suggestion of how it will cough up the money to pay for it all or enact the immigration policies that would welcome new and needed foreign health workers.
On the other, Labour promises new targets for ambulances and diagnoses times, cutting deaths from heart disease and suicide – targets that presumably can be used to manage NHS managers, who too often carry the can for political failure. While it has gone quiet on “salaried GPs”, more helpfully the Opposition proposes repayment of health professionals university debts and bans on junk food.
However, the missing narrative remains the need for radical change to the NHS’ patterns of care. Neither party’s proposals have the courage to address that.
There is handwringing on both sides about the comparatively low provision of hospital beds. Yes, Germany and France both have more beds per 1,000 population than the UK, assuming they count beds in the same way as we do. But as a percentage of healthcare spend, according to the Office for National Statistics, the proportion of UK expenditure on hospital care (41.8%) exceeds Germany (28.9%), France (38.3%), and even European countries with similar numbers of hospital beds per 1,000 population, like the Netherlands (33.7%) and Sweden (38%).
Simply put, we over-hospitalise, partly because we don’t invest in more appropriate – and cheaper – types of care and partly because the one-stop-hospital-shop is pretty convenient for some of our most powerful clinical workers.
What the health of the nation needs most is a radical reconfiguration of services to less acute, more appropriate, and less expensive care.
The current provision of services does not match current patterns of need, especially among the elderly chronically ill. The political debates give lip service to the need for 'integrated care’ but ignore the elephant in the room – the all-consuming ever-dominant hospital. This lack of acknowledgement undermines the possibility of service transformation by continuing to entrench both money and power in big acute hospitals.
Of course we need hospitals, but not nearly as many as we have currently. I say that as someone who spent two nights in my own local NHS hospital following hip replacement surgery recently. That could not have been done in my home nor (easily) in a community health centre. Some conditions, some services, do need acute hospital facilities.
However, health policy experts estimate that as much as 60% of the NHS’ clinical budget is being spent on the chronic conditions of elderly people and ageing baby boomers which can be cared for in facilities other than hospitals – smart homes, care homes, hostels.
In my own case, my local hospital is located less than a mile from my home, which is great. Within two further miles, however, are two other large acute teaching hospitals that could have provided the same care.
Now, I know friends in rural Scotland, for example, will point out that they have to travel tens of miles to their local hospital. But in our urban areas, we have plenty of hospitals, many of them sited and built before the motor car. Indeed, a former director of healthcare in the London region opined that we could close at least a half dozen acute facilities in the metropolis without any significant impact on the population’s health.
Currently, we do not have enough low-level chronic facilities or home care professionals – neither in cities nor in the shires – because the current configuration of the NHS is so dominated by acute hospitals and by the medical professionals who work in them.
Many of the relatively new Integrated Care Boards are trying to come to grips with this, exercising analytically informed commissioning decisions (of considerable volume and money) in a manner that seeks to change patterns of care. But they are being undermined in their efforts, often being forced by their regional supervisors to first meet the expenditures – frequently in excess of prescribed budgets – of local hospitals, led by hospital managers and clinicians who know that whatever they spend will be covered before any shift of funds to non-acute care. It’s that perverse.
Only large-scale commissioning decisions to close hospitals as part of a programme that simultaneously opens and staffs home care, urgent care centres, smart homes and chronic care facilities is capable of providing the fundamental change we – as potential patients – and the NHS require. Of course, standing in the way are not only the acute elephants but also the political dinosaurs who wish to retain a hospital within site of every ballot box.
The current political talk of reform – on all sides of the political spectrum – only protects the status quo. That’s not good enough.
Greg Parston is a Visiting Professor at the Faculty of Medicine, Institute of Global Health Innovation
Revealed: Five Politically-Connected Healthcare Giants Rake in NHS Contracts Worth Billions
five politically-connected healthcare giants have profited from a share of public contracts worth at least £70 billion – despite a murky history of scandals and regulatory violations, a new report reveals.
Corporate Watch, a corporate-critical grassroots research organisation, spent several months delving into government procurement data on Bridgepoint, Bupa, Centene, Spire, UnitedHealth Group (UHG) and their myriad of subsidiaries.
In partnership with Good Jobs First, researchers targeted these companies because all five are members of the Independent Healthcare Providers Network – a lobbying group with close links to Rishi Sunak’s post-pandemic Elective Recovery Taskforce, which has effectively ‘turbo-charged’ private healthcare capacity.
During the past 10 years, these firms won a share of public health and social care contracts with a combined value of £70.59 billion, with serious questions also emerging about the opacity of reported contracts, as well as the integrity and reliability of the data made publicly available.
Between 2013 and mid-2023, £61.87 billion of this overall total was awarded without a breakdown of how much money each of the winning bidders were paid. More than one-fifth of contract award notifications did not even report a total value, meaning that the true figures could be far higher.
Other significant obstacles to reporting included missing details related to the extension of existing contracts, inconsistent figures across datasets, and a lack of uniformity in the way data was presented.
Even so, the length of awarded contracts appears to have been increasing over time, as the Conservative administration has sought to ‘lock in’ privatisation, with some tenders set to run for up to 15 years.
Corporate Watch and Good Jobs First uncovered a plethora of financial scandals and violations of patient and worker safety.
In particular, corporate giants Centene and UHG have faced hefty penalties for defrauding patients and public healthcare systems in the United States, where both are based, including to settle allegations of overcharging for Medicare, a US Government health insurance programme, through duplicated or inflated claims.
Perhaps the most egregious scandal to have engulfed any of the UK-based companies targeted in the report was the case of Ian Paterson – a former breast surgeon currently serving a 20-year prison sentence for performing unnecessary or unapproved procedures on more than 1,000 cancer patients at Bupa and Spire hospitals in the West Midlands, with a further 1,500 victims discovered on an old IT database in February 2023.
After his conviction in April 2017, Spire released a statement saying that “what Mr Paterson did in our hospitals... absolutely should not have happened” and expressing “how truly sorry we are” – only to then sue the NHS four months later for allegedly failing to warn it of his conduct. That action came just weeks after the firm was sued by hundreds of Paterson’s patients, who claimed Spire had allowed the surgeon to continue work well after his 2012 suspension by the General Medical Council.
Meanwhile, Bridgepoint subsidiary Care UK has been repeatedly slammed for cost-cutting at the expense of both staff and patient welfare. In 2022, it was fined more than £1.5 million after a resident choked to death.
Similar criticism has been levelled at Bupa, with its UK care facilities variously described over the years as “disgraceful”, riddled with “systemic failings”, and sources of “serious concern”.
In Australia, the 2019 death of an elderly cancer patient, admitted to hospital with maggots crawling in an open and fungated ear wound, saw the firm's CEO forced to “unreservedly” apologise for “totally unacceptable” shortcomings in its aged care network.
The list of top executives and shareholders at each of these firms are politically-connected figures.
When the Government announced the launch of its Elective Recovery Taskforce in December 2022, it was little surprise that David Hare and Jim Easton had seats at the table. As chief executive of the Independent Healthcare Providers Network, it is Hare’s job to represent the interests of firms including Bupa, Centene, Bridgepoint and UHG at Westminster; while Easton previously held several senior NHS positions before becoming CEO of Practice Plus (a Bridgepoint subsidiary) in 2012.
Care UK co-founder John Nash, and UHG’s former head Simon Stevens, who was chief executive of NHS England between 2014 and 2021, join the ranks of at least 16 members of the House of Lords who have at various times declared interests in the companies featured in the recent report.
The wife of Conservative Health Minister Neil O’Brien also currently acts as GP engagement lead for Centene subsidiary Circle Health, while former Tory MP Mark Simmonds has previously worked as a strategic advisor at the firm.
COVID-19 appeared to provide the context for the Government to accelerate a policy of privatisation stretching back over decades. As demand for private treatments slumped, private healthcare providers were given publicly-funded bail-outs – which available evidence suggests actually did little to benefit the NHS or its patients. Significant financial commitments have now been made, either through the issuance of new awards or the inflation and extension of existing arrangements.
The paucity of publicly-available data on these commitments, alongside the list of scandals and regulatory violations, compiled by Corporate Watch and catalogued on Violation Tracker UK and Violation Tracker, raises serious questions about the Government’s decision to entrust the provision of public healthcare to these five companies – themselves just a small handful among hundreds of other firms being awarded contracts, with little competition.
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