UK NHS Clinical Services

Part
01
of four
Part
01

NHS - Major Private Providers

Five of the leading independent health care providers in the UK are HCA International, Nuffield Health, Spire, BMI Health care and Ramsay Health care. The NHS UK is a major client to most of the UK private health care providers.

1. HCA INTERNATIONAL
  • Website: https://www.hcahealthcare.co.uk/
OVERVIEW
  • 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.
METRICS
  • 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.

2. NUFFIELD HEALTH
  • Website: https://www.nuffieldhealth.com/
OVERVIEW
METRICS
  • 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.

3. SPIRE
  • Website: https://investors.spirehealthcare.com/about/
OVERVIEW
METRICS

4. BMI HEALTH CARE
  • Website: https://www.bmihealthcare.co.uk/
OVERVIEW
  • 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.

METRICS

5. RAMSAY HEALTH CARE
  • Website: https://www.ramsayhealth.co.uk/
OVERVIEW
  • 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.
METRICS
  • 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:

We began our research by looking at sites that mention top independent private healthcare services in the UK especially the ones that provide services to the NHS UK. In order to identify major independent sector providers in the UK NHS who deliver clinical services, we consulted numerous news and authoritative sites such as The Guardian, HCA Healthcare UK, Private Health Advice, and Nuffield Health. Based on these resources, we identified some of the major private clinical service providers, which include: HCA International, Nuffield Health, Spire, BMI Health care and Ramsay Health care. To establish if the providers we selected were amongst the top private healthcare facilities, we went through the resources and picked those that were present in most of the resources used.

Part
02
of four
Part
02

NHS Budget for Private Clinical Care Providers

According to the latest data, 8% of the total NHS budget of £113.8 billion goes to independent sectors. Independent sector providers got a budget of £9.2 billion for the period 2018-2019.

NHS BUDGET

  • 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%.

RESEARCH STRATEGY

The research team found all the data from reports released by reliable health organizations such as the Department of Health and Social Care, British Medical Association, and Independent Healthcare Providers Network. Only the percentage of NHS budget that has gone to ISP was calculated. Based on available data, the total budget of ISP was divided by the total NHS budget. The result was multiplied by 100 to get the percentage. Hence;

0.08*100=8%
Part
03
of four
Part
03

Major Service Provider Exits - NHS

Findings

Several major independent service providers of clinical services have exited the NHS in the past two years. Some common reasons that contributed to their exit include receiving inadequate care reviews from the Care Quality Commission and disputes over the financial sustainability of these NHS contracts.

Serco

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

We researched major independent service providers of clinical services who exited NHS in the past two years from multiple credible sources like the NHS Support Federation, the Guardian, and BBC News. We continued with more in-depth research on Serco from early findings and made sure to exclude any major independent service providers who had not exited within the past two years to complete our findings.
Part
04
of four
Part
04

NHS Industry Trends - Private Clinical Care Providers

The five key industry trends within the NHS at the current time are decreasing staff retention rates, increasing cancer wait times, increasing elective surgery wait lists, the development of Integrated Care Systems and the increased pressure on mental health services. The Long Term Plan has been developed to address many of these concerns. The changing landscape of the NHS is likely to see more reliance being placed on private and independent healthcare providers in the future.

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

We extensively searched research articles and scholarly publications to determine the industry trends currently facing the NHS. To ascertain what the five key trends were we cross-referenced the list to various publications and articles that addressed solutions for various issues the NHS was facing and identified changes in the model of healthcare provided in the UK. By doing this, we were able to identify 5 distinct industry trends within the NHS.

To determine the role these trends are playing on the shape of healthcare in the UK, we researched historical data to determine how these trends had developed. One of the key findings, in respect of the provision of healthcare services and industry trends, is that often the trends have been a peripheral issue for some time but have gained momentum in recent years. By analyzing industry data and a range of historic and current metrics, we were able to identify why several of these historic trends had become key industry trends in the NHS. Finally, we considered how these trends had impacted the delivery of healthcare by the NHS. We searched a range of scholarly articles and publications and were able to determine that the emerging trends had resulted in another independent trend, the development of Integrated Care Systems.

Once we were satisfied, we had identified the 5 key industry trends within the NHS we applied the data to private and independent service providers. We searched a range of industry publications, media articles, and opinion pieces to determine how the trends faced by the NHS were impacting on private and independent health providers. The search uncovered substantial evidence regarding the increased role private and independent providers have to play in healthcare in the UK and the increased reliance being placed upon them by the NHS.
Sources
Sources

From Part 02
Quotes
  • "Of the Department’s total 2018-19 RDEL budget (£125.9 billion), £113.8 billion was allocated directly to NHS commissioners "
Quotes
  • "The Department of Health and Social Care handed a record total of £9.2bn last year to private providers such as Virgin Care and the Priory mental health group, its annual report shows."
  • "That is an increase of 14% from the £8.1bn that went to profit-driven healthcare companies in 2014-15 and £410m more than the £8.77bn they received in 2017-18."
Quotes
  • "Continuing care accounted for the highest proportion of the spending (40 per cent of the total), 27 per cent was spent on general and acute services, 12 per cent on community health services, 10 per cent spent on mental health and learning disability services and the remaining 12 per cent spent on primary care, social care, maternity care, accident and emergency services and ‘other contractual’ services combined. "
Quotes
  • "The research, featured in the Financial Times, also found that while CCGs were awarding on average 1.3 competitively tendered contracts to NHS organisations per year, compared to 3 to non-NHS providers, the value of contracts awarded to NHS organisations was almost three times greater. "
  • "Over £8.5m worth of contracts were awarded to NHS providers by each CCG every year, compared to £2.4m for non-NHS providers – calling into question NHS England’s recent claims that the legislative changes will end “NHS privatisation.”"
  • "The data from CCGs doesn’t allow us to say with the same level of confidence what the % number of contracts that go out to tender are but the information we have suggests this is in the region of 7%."
  • "On average, CCGs award competitive tender contract values totalling £8,716,301 per annum to NHS organisations, compared to £2,482,672 for non-NHS providers."
From Part 03
Quotes
  • "Beginning in 2006, the company moved into the NHS clinical services market, including out-of-hours care and hospital management. In April 2006 Serco was awarded a five year contract to provide out-of-hours service in Cornwall and the Scilly Isles valued at £6.1 million."
  • "In August 2014, Serco decided to move out of the NHS clinical market and focus on the non-clinical contracts. The clinical services market has not been an easy or profitable one for Serco; the company reported in late 2015 that on its three major clinical contracts – out-of-hours in Cornwall, Suffolk community health and Braintree Hospital – it had made a loss of about £18 million and two of the major contracts have been dogged by controversy and problems. For the NHS, these Serco clinical contracts were associated with cost-cutting, fraud, poor management and inadequate staffing levels."
  • "Serco has continued to seek non-clinical facilities management contracts with the NHS. In February 2018, as a result of the collapse of Carillion, another facilities management company, Serco took over several of Carillion's contracts with NHS hospital trusts."
Quotes
  • "Primecare is a good example of a company that was awarded large contracts, but failed to deliver and was financially unstable; the company has now abandoned contracts, often at short notice. Primecare is a subsidiary of Allied Healthcare, one of the UK’s leading homecare providers. "
  • "Primecare had contracts for out-of-hours (OOH) and urgent care throughout the midlands. CCGs and GPs had been sent letters advising them to find new providers of these services by the end of November. In November 2018, GPs at 20 Birmingham practices were told that they needed to seek replacement OOH cover after Primecare gave them just 10 days’ notice that it will stop trading at the end of the month. "
  • "Primecare has had difficulties delivering services in other areas, even before the financial situation reached a crisis. In January 2017, East Kent CCGs awarded Primecare one of the first integrated NHS 111 and GP out of hours services contracts, but after only seven months the company was placed in special measures. Primecare’s services in East Kent were rated inadequate by the Care Quality Commission. "
  • "There were issues at the start of the contract; the 111 service in East Kent was originally meant to transfer to Primecare in September 2016 together with the out-of-hours service. However, the South East Coast Ambulance Service was asked to continue to provide the 111 service first until October 2016 and then until November 2016 with a phased handover to 10 January 2017. Then in September 2017, Primecare announced that it will hand back the contract to the NHS mid-way through the three year contract in July 2018."
Quotes
  • "A private health firm has lost one of the biggest and longest-running contracts to treat NHS patients, in a significant blow to the creeping privatisation of care. Circle is losing the contract it has held for 11 years to run the Nottingham NHS Treatment Centre, which provides 240,000 operations and checkups a year, and Nottingham University Hospitals NHS trust (NUH) has been handed a £320m contract to run the centre for the next five years after a bitter legal battle between Circle and the NHS. Circle has run the centre since it opened in 2008 as one of the independent treatment centres (ISTCs) that the last Labour government set up to reduce the number of NHS patients waiting for non-urgent treatment."
Quotes
  • "In August 2013 Circle won a five year contract with Bedfordshire CCG for an integrated musculoskeletal pathway. The contract is worth about £120 million and began in January 2014."
  • "In August 2016 Circle was selected by Greenwich CCG as the successful bidder to run an integrated musculoskeletal service (MSK). The five year contract includes the possibility of two one year extensions, and will see Circle run a Prime Provider model, which will integrate all MSK services. "
  • "In November 2016, however, the finalisation of the contract was put on hold following a public outcry. The contract will not be signed until after an assessment of its impact on Lewisham & Greenwich NHS Trust. In March 2017, management consultants Price Waterhouse Coopers (PwC) published a report on the impact of the MSK contract, which found the Circle contract would have a massively negative affect on the Trust. Lewisham and Greenwich Trust stands to lose up to £6.6m of revenue over five years."
  • "The Nottingham NHS Treatment Centre contract has now come to an end. In March 2018, Circle pulled out of a bid for a renewal of this contract for another three years worth £150 million. The company withdrew because in its view the amount of money on offer was not sufficient to deliver services on a “sustainable basis” at the treatment centre."
  • "Circle threatened the CCG commissioners with legal action over the contract and as a result of the threat, in early May 2018, the commissioners of the Nottingham contract, Rushcliffe CCG, allowed Circle to continue with the contract for a further year. Following a new procurement process, Rushcliffe CCG awarded the contract to Nottingham University Hospitals NHS Trust (NUH). "
  • "In January 2019, Circle launched a second legal challenge against the CCG claiming the Trust can’t possibly treat NHS patients for less money, and that bringing the contract back in-house would be “unrealistic” and “not in patients’ interests”. In May 2019, Circle lost this legal action against Rushcliffe CCG and NUH was free to begin the five-year contract to run Nottingham Treatment Centre. "
Quotes
  • "Steve Melton, head of Circle, which ran Hinchingbrooke in Cambridgeshire, from 2012, was being questioned by the Public Accounts Committee (PAC). He said budget cuts and high demand made the deal unsustainable and denied a damning report was the cause. Last month, the Care Quality Commission branded the hospital "inadequate"."
  • "Circle became the first private firm to manage an NHS hospital three years ago."