• Website: https://www.hcahealthcare.co.uk/

• HCA International is based in the UK and has six hospitals and four outpatient centers in London.
• It is the largest group of world-class private hospitals with UK centers across Manchester and London.
• Their major strength include general practice, specialist clinics and services, diagnostic centers and outpatient services.

• All HCA main hospitals provide level 2 and level 3 adult Intensive Care Units (ICU) services, with a 24/7 critical unit staff to provide special care to ICU patients.
• They are equipped to take care of patients, which is enforced by their low rate of transfers of patients to other hospitals.
•  1 in 9 HCA hospital beds is for critical care patients.

• Website: https://www.nuffieldhealth.com/

• This is the largest non-profit healthcare organization in the United Kingdom.
• They focus on well-being and fitness. 
• They offer access to the largest pool of physiotherapists in the UK.

• It has a national network of 31 hospitals and over 200 medical health care clinic centers and diagnostic units across the UK.
• Besides providing hospital services, they also run over 112 wellness and fitness clubs in the UK.

• Website: https://investors.spirehealthcare.com/about/

• Spire was founded after the rebranding and acquisition of Bupa Hospitals in 2007.
• They are providers of inpatient and outpatient diagnostics services for cardiology, gynecology, orthopedics, oncology, neurology, and general surgery.
• The company also offer sports medicine, physiotherapy services, and rehabilitation programs.

• Spire has 39 hospitals and 12 medical clinics, with two specialist cancer centers (Oncology) across Wales, England, and Scotland.
• They are the largest health care provider in terms of revenue.

• Website: https://www.bmihealthcare.co.uk/

• It was formed in 1970 after AMI acquired its first hospital the Harley street clinic.
• It is the largest independent provider of private health care in the UK.
• BMI offers specialist services in general surgery, spinal care, orthopedic, cancer care, and neurocritical/neuro intensive care.

• BMI has 59 hospitals and medical clinics all over the UK.
• It offers 115 different specialist care and services.

• Website: https://www.ramsayhealth.co.uk/

• The company was established in 1964 and became one of the leading providers of private hospital services in the UK when it acquired Capio UK hospital.
• It provides a range of specialized services including orthopedics, general surgery, eye surgery, and cardiac surgery.

• Ramsay Health Care is a global hospital group with over 480 hospitals across the UK, Indonesia, Australia, Sweden, Germany, Denmark, Norway and HongKong.
• The organization employs more than 77,000 people that provide health care services.
• It treats over 8.5 million patients every year.

Research Strategy:

NHS BUDGET

• Majority of the Department of Health and Social Care's (DHSC) budget is allocated to fund the NHS. For the year 2018-2019, the NHS budget was £113.8 billion.
• According to DHSC's annual report and accounts for 2018-2019, £9.2 billion has gone to independent sector providers (ISP). This is approximately 8% of the total NHS budget.
• Spending on ISPs for 2018-2019 is around £410 million more than the spending for 2017-2018, which was £8.8 billion.
• The British Medical Association (BMA) provided a breakdown on the Clinical Commissioning Groups' (CCG) spending on ISPs by sector. The breakdown is as follows:

• Continuing Care - 40% 
• General and Acute - 27% 
• Community Health Services - 12% 
• Primary Care - 5% 
• Mental Health and Development (MH&D) - 5% 
• Accident and Emergency (A&E) - 2% 
• Social Care - 2% 
• Other Contractual - 2% 
• Maternity - 1%.

• The percentage of contracts that go out to tender is around 7% per year.
• On average, non-NHS providers or ISPs are awarded contract values totaling to £2,482,672 per year. NHS organizations, on the other hand, get a higher value of £8,716,301 per year.  
• Each CCG awards more contracts to ISPs than to NHS organizations at 2.7 and 1.5, respectively.
•  BMI and Spire are the two major ISPs that got awarded the most contracts. BMI has been awarded 52 contracts while Spire got 49 contracts.
• The total value of BMI contracts amounted to £76,900,797, while Spire's is at £69,558,517.  
• The Prime Minister set a five-year NHS funding plan in June 2018. According to the funding settlement, NHS will receive a yearly increase of 3.4% covering the period from 2019-20 to 2023-24. There is no mention, however, of how much will go to ISPs.

RESEARCH STRATEGY

Findings

Serco

• Serco began delivering clinical services in cooperation with NHS in 2006 for the out-of-hours services in Cornwall.
• Serco began withdrawing from clinical services in 2014 after a series of loss-making contracts including the Cornwall, Suffolk Community Health, and Braintree Hospital contracts.
• The Cornwall and Suffolk Community Health contracts with NHS were also filled with controversy and problems like fraud, poor management, and inadequate staffing.
• Serco continued to seek non-clinical contracts with NHS and then transferred completely to non-clinical contracts in February 2018 after it took over several contracts of Carillion.

Primecare

•  Primecare is a subsidiary of Allied Healthcare, a leading UK homecare provider.
• Primecare was awarded its first major contract in January 2017 by NHS to provide GP and out-of-hours clinical services to East Kent.
• Primecare announced in September 2017 that it would give the contract back to NHS in July 2018 after financial instability, multiple delays beginning services, and being rated as providing inadequate care by the Care Quality Commission.
• Primecare withdrew all of its remaining clinical services contracts with NHS at the end of November 2018.

Circle

• Circle began providing clinical services in cooperation with NHS in 2008 for the Nottingham Treatment Centre.
• Circle lost this last NHS contract to the Nottingham University Hospitals NHS trust in May 2019 after initially withdrawing its bid to renew the contract again in March 2018 and a series of failed legal attempts to require the NHS to increase the amount of money awarded in the contract.
• Circle was the first private clinical services hospital provider for NHS with the Hinchingbrooke hospital contract in 2012 that ended in 2015 after the Care Quality Commission rated care at this hospital as inadequate and Circle withdrew from the NHS contract after determining that it was no longer sustainable.
• Circle had a five-year NHS clinical services contract to deliver musculoskeletal services in Bedfordshire from January 2014 that ended in January 2019.
• Circle was awarded a five-year NHS clinical care contract in August 2016 to deliver musculoskeletal services in Greenwich. However, the finalization of this contract was indefinitely put on hold in November 2016 following a public outcry and concerns about the massive negative financial impact of this contract on the Lewisham and Greenwich Trust.

Research Strategy

DECREASING STAFF RETENTION RATES

• There is currently a staffing crisis in the NHS. Staff retention rates are at a record low and continue to trend downwards.
• There are insufficient staff to meet the service demands, and this trend has worsened in recent years.
• In 2018 the shortfall in staff required to meet the service demands was 108,000.
• At the same time, there was a 96% reduction in the number of EU nurses registering to work in the UK.
• This has forced the NHS trusts to become more dependent on private providers. Between April and June 2018 600 million pounds was spent on agency locums.
• It is estimated unfilled vacancies will reach 350,000 by 2030.
• A recent survey found 90% of NHS primary staff reported feeling stressed as a result of their work. Over 20% had developed serious mental health issues as a result.
• The growing crisis in the NHS, in respect of the workforce, has been recognized in the Long Term Plan.
• The Long Term Plan provides several aspirational statements on addressing this crisis but lacks the definitive action plan that is present in relation to addressing other growing trends in healthcare.
• The Long Term Plan intends to prioritize staff support and well-being and in doing so, make the NHS "a great place to work".
•  Leadership will be strengthened and supported across all areas and at all levels.
• The plan is to ensure that the right people are employed and those people have the right skills to assist patients.
• The plan talks of empowering the workforce through the introduction of new technology however, the details are scant.
• Finally, there will be retention drives to encourage healthcare professionals to continue their careers with the NHS.
• The Long Term Plan fails to address how the current shortfall in staff is to be addressed or provide any real substance as to how the current poor retention rates are to be addressed.
• The failure to properly address the staffing crisis suggests the current need for locum and agency healthcare providers to be contracted from the private sector will continue to rise.

INCREASING CANCER WAIT TIMES

• The time it takes from the time of referral, with suspected cancer, to the first definitive treatment for cancer is one of the key factors in successfully overcoming cancer.
• Since 2000 this has been one of the primary target measures for the NHS.
• In 2008 changes were made and a target that 85% of people should wait no longer than 62 days from the time of referral was established.
• Between 2008 and 2014 this target was met.
• Since January 2014 this national target has only been met on 4 occasions, and the trend is the waiting times are getting longer.
• The trend of increasing cancer wait times has seen plans to reverse this trend included in the NHS Long Term Plan.
• The Long Term Plan aims to have 75% of all cancer diagnosed at an early stage.
•  The plan has lowered the age of bowel screening and introduced new diagnostic testing for cervical cancer.
• It will also extend lung health checks as part of the fight against lung cancer.
• New Rapid Diagnostic Centers are being established nationwide to assess and diagnose a patient experiencing symptoms of cancer within a day.
• A faster diagnostic standard has been established. It aims to ensure patients are diagnosed within 28 days of referral.
• The infrastructure of the NHS and current capacity is such that private providers will have a big role to play in meeting the targets set by the Long Term Plan.
• It is predicted there will be an increase in the amount of work outsourced to private or independent providers.
• Private providers will have the ability to bid for contracts, to provide services, that will enable the targets of the Long Term Plan to be met.

DEVELOPMENT OF INTEGRATED CARE SYSTEMS

• The provision of healthcare services in the UK is unique. Traditionally all healthcare services have been provided by the NHS.
• The NHS saw the government have sole responsibility for the provision of the nation's healthcare services. The NHS could be considered "truly socialized medicine".
• A single-payer — the government — provides all healthcare services, funding the services through the taxation system.
• As a result, all healthcare services are free, as are most medications. The medications that are not funded have a maximum price to the patient of 12 pounds.
• Increasing pressure on the NHS has seen the evolution of this model of healthcare.
• In 2016 the NHS and local councils formed 44 Sustainability and Transformation Partnerships. These partnerships mean several organizations now take collective responsibility for the provision of healthcare in a certain area. They are focused on delivering the best possible care to the specific population they serve.
• These partnerships have continued on the evolution pathway and are now developing into Integrated Care Systems.
• Integrated Care Systems see a range of providers including, but not limited to, the NHS and local councils, taking collective responsibility for the allocation of resources, population or public health measures, and delivering NHS standards.
• The theory behind this move is that local service providers are better able to assess and respond to the health needs of their population.
• The NHS, as the sole provider of healthcare, was required to deal with issues on a national level whereas Integrated Care Systems can address issues at a local level based on the specific characteristics of their population.
• Private and independent providers feature strongly in Integrated Care Systems. 
• As Integrated Care Systems become more entrenched private providers will likely become the lead providers of certain healthcare services to certain populations.

INCREASING ELECTIVE SURGERY WAIT LISTS

• Between 2009 and 2013 the surgical waiting list, including those waiting an initial outpatient appointment and those that are awaiting treatment was stable at approximately 2.5 million people.
• Since 2013 the number of people waiting had grown exponentially, and by the end of 2017, approximately 3.8 million people were on the waiting list.
• This is an increase of approximately 50%.
• A key performance indicator was set in 2013 that required 92% of patients to be seen and treated within 18 weeks.
• Up until mid-2014, this target was met. Since then, the waiting times have deteriorated.
• At the end of 2017, 10% of patients were waiting longer than 18 weeks for treatment. This number continues to trend upward.
• In 2017 the number of people waiting for elective surgery by the NHS reached 4 million for the first time in 10 years.
• There have been several investigations around the increasing waiting lists and several studies around theater productivity. One study suggested a 16.8% increase in the number of surgeries performed if theater productivity was increased.
• In 2000 the UK introduced reforms that allowed independent service providers to operate on and treat NHS patients.
• By 2010 the number of operating hospitals in the UK had risen from 160 to 260 as a result.
• The introduction of independent service providers has been shown historically to decrease surgical waiting times.
• The recent upward trend in elective surgical wait lists is likely to see greater reliance being placed on independent service providers as the NHS struggles to cope with the increasing demand.

INCREASING DEMAND FOR MENTAL HEALTH SERVICES

• The demand for mental health services has been increasing in recent years.
• The NHS has now reached a breaking point in terms of its ability to meet this increasing demand.
• In 2013 there was one mental health doctor for every 186 patients. In 2018 there was one mental health doctor for every 253 patients.
• The number of patients to mental health nurses has increased from one for every 29 patients in 2013 to one for every 39 patients in 2018.
• The number of available beds in hospitals for mental health patients has decreased by 13% since 2013. This equates to 3,000 fewer hospital beds.
• This has seen an increased commitment to mental health and its inclusion in the NHS Long Term Plan.
• The aim is to rapidly expand the mental health service.
• This will result in more people receiving treatment for common disorders.
• It will also see better support being made available for children and young people.
• The budget for the provision of mental health services will be increased substantially. The mental health services budget will be increased by 2.3 billion pounds by 2023.
• The ability to access mental health care will be improved. This will enable people in crisis to get the immediate help they need.
• A specialist mental health service for postpartum mothers will be established to identify those who may require help. This will also ensure easy access to mental health services by this population group.
• Mental health services will be expanded into schools and colleges. This will assist over 345,000 young people.
• Community and hospital services will be expanded to meet the growing demand. This will include increased access to talking therapies and more mental health liaison team to reach people at need in the community.
• The inability of the NHS to provide the services required for mental health patients has seen the role private providers have to play increase.
• The shortage of available hospital beds saw the NHS pay a record of 181 million pounds to private providers in 2018. This was to meet the growing demand for residential rehabilitation. 
• The disadvantage of this approach has been that patients may need to be treated some distance from their homes and support networks.
• The current disarray in mental health services has seen an opportunity to develop for private providers. Under integrated models of service, a lead provider will be appointed to oversee the budget and the provision of mental health services for a particular area. Previously budgets and the provision of service for an area were the sole responsibility of the NHS.
• The growing prominence of private providers in the area of mental health services suggests a high probability that some appointed lead providers will be private or independent providers.

RESEARCH STRATEGY