29 March 2007

Private contractors are bidding for dermatology services in central Liverpool, threatening to undermine the existing Liverpool-wide NHS service based at Broadgreen Hospital.

The scheme, expected to start in April or May, is being rushed through with no public consultation. Liverpool Primary Care Trust and a consortium of 19 South Central GP practices invited bids for an “Integrated Treatment and Clinical Assessment Service”. An advert appeared in the Health Service Journal on 11 March announcing a 2 week bidding window. The contract is due to be awarded tomorrow (Friday 30 March), after bidders make powerpoint presentations today (Thurs 29 March).

Assura Medical Ltd is one of the private bidders. Assura Group operate the Health and Wellness Centre at Ropewalks in Liverpool City Centre, visited by Health Secretary Patricia Hewitt MP on 19 January. Brownlow Group Practice is housed in the Assura building, and is part of the consortium inviting bids. Keep Our NHS Public is concerned at a possible conflict of interest with Assura’s double involvement.

Liverpool GP Colin McKean, recently retired, believes the latest hasty move will undermine the quality of care. “We have an excellent dermatology service, based at Broadgreen Hospital and serving the whole of Liverpool. Breaking it up for profit is not in the best interests of patients. There’s been no public consultation on the proposed changes, but the implications deserve wider debate. ”

The British Medical Association has criticised the surge in private Treatment Centres throughout the North-West, with controversial schemes in Preston, Manchester, and Runcorn.

Liverpool GP Margaret Reid highlights the hidden long term costs of the dermatology scheme:

• fragmenting a high quality service
• implications for training future dermatologists, hardly a priority for private companies
• downplaying the needs of patients with chronic skin conditions who require the back up of beds for admission, monitoring of cytotoxic treatments, and the full range of hospital services along with continuity of specialist care
• A successful private bid could mean job losses in our local hospital department with consequences for other Liverpool patients not represented by the South Central consortium.

Dermatologist Andrea Franks, from the Countess of Chester hospital, is also sceptical. “The Government is using every opportunity to privatise the NHS one piece at a time, hoping no-one will notice. We are in real danger of losing the National Health Service as an integrated publicly owned provider of health care for all. ”

Notes to Editors

1. The Health Service Journal (www.hsj.co.uk) carried the advert on 11 March:

Dermatology - Integrated Treatment and Clinical Assessment Service

LIVERPOOL PRIMARY CARE TRUST

SOUTH CENTRAL PRACTICE BASED COMMISSIONING CONSORTIUM

South Central PBC Consortium wishes to appoint a number of ‘willing providers’ to provide the following primary care based service:

Dermatology - Integrated Treatment and Clinical Assessment Service

The Consortium encompasses 19 practices covering a population of c96 000 within inner city Liverpool.

This arrangement will be through the ‘any willing provider’ model, and approval to provide the service will be awarded to providers who meet national minimum quality criteria. For an information pack, including service specifications, terms of the agreement and required quality standards, please contact email carol.taylor@liverpoolpct.nhs.uk

Deadline for submission of proposals is 23rd March 2007.

Anticipated start date is April / May 2007.

2. Patricia Hewitt’s visit to the Assura centre was reported at

www.assuraproperty.co.uk/index.asp?PageID=258

3. Keep Our NHS Public is a national campaign launched in Sept. 2005. For details see

http://www.keepournhspublic.com/index.php

for the Executive Summary of the KONP pamphlet “Patchwork Privatisation” see:

www.keepournhspublic.com/pdf/Patchworkprivatisationexecutivesummary.pdf

4. BMA - Summary of concerns regarding proposed CATS schemes in North West England, February 2007

The growth of Clinical Assessment Treatment and Support (CATS) services in the NHS has developed in recognition of the need to improve the interface between primary and secondary care and thus provide an environment in which patients can undergo assessment, diagnosis and treatment in an alternative setting to that of existing hospital outpatient services. Naturally, the BMA strongly supports closer collaboration between clinicians in primary and secondary care and welcomes initiatives to provide patients with rapid access to high quality, appropriate care in a community setting.

However, current proposals regarding the development of CATS schemes in Cumbria and Lancashire and in Greater Manchester are the cause of a number of concerns. These focus on the proposed role of the independent sector; the manner of the consultation with the public, patients and local medical professionals in respect of the proposals; and the potential impact the schemes may have on the continuity of patient care, patient and professional choice, and the stability of local NHS organisations.

They can be summarised as follows:

Lack of adequate consultation and impact assessment

• impetus for schemes driven by central policy direction, not locally determined.
• shortfall in presenting robust evidence to stakeholders of definitive need for, and consequences of, change.
• failure to provide stakeholders with alternatives to the proposed CATS service redesign.
• failure to adequately consult with stakeholders including public, patients and local medical professionals.
• failure to employ pilots and develop a reliable evidence-base sensitive to local context.
• lack of clarity on knowledge and experience of healthcare professionals expected to staff the CATS schemes.

Involvement of independent sector

• lack of a ‘level playing field’ with existing local NHS organisations prevented from bidding for CATS schemes.
• concern that an open and transparent bidding process has not taken place.
• concern that independent sector provision will encourage competitive, not collaborative, behaviour in the NHS.
• concern that independent sector provision will lead to fragmentation, not integration, in local health economy.
• concern that public money will be taken out of the NHS as profit for independent sector shareholders.

Adherence to referral management best practice

• failure to adequately discuss and seek agreement from representative primary and secondary care clinicians.
• lack of transparency of principles that will underpin referral management process in proposed CATS schemes.

Potential to destabilise local NHS hospitals

• concern that local NHS trusts are already, or are close to, meeting the 18-week waiting time target.
• concern therefore that the additional capacity requirements informing the CATS development are misguided.
• subsequent mistrust of the stated intention of CATS schemes being the provision of additional activity.
• concern that activity to be carried out in CATS schemes will be transferred from local NHS hospitals.
• concern therefore that core NHS activity is simply transformed into independent sector CATS-activity.
• with a significant volume of activity transferred to the proposed CATS schemes, local NHS hospitals will be forced to cut services, both those duplicated in the CATS schemes as well as emergency and support services.
• concern that the loss of income resulting from the loss of activity will further compound financial pressures in local NHS organisations thus threatening the employment of doctors, nurses and ancillary staff.

Curtailment of clinical/professional judgement

• significant concerns that proposed CATS schemes will weaken professional relationships between local doctors.
• potential for the loss of clinical autonomy, with managerial, not clinical, grounds for referral taking precedence.
• concern that the proposed CATS schemes may undermine the development of Practice Based Commissioning.
• concern that GPs’ ability to refer through established and proven local care pathways will be diminished.
• concern that GPs’ capacity to act as patients’ advocate throughout the system as a whole will be diminished.

Subversion of patient choice and access principles

• concern that PCTs are advising that GPs will be required to send referrals in relevant specialties to CATS centres.
• concern that any such management of referrals reduces choice for both the patient and the referring clinician.
• concern that in many cases the CATS centres offer no greater prospect of delivering ‘care closer to home’.
• concern that traditional GP to named consultant referrals are threatened, further reducing patient choice and clinical acceptability.

Impact on medical training

• concern that medical training in the local NHS will suffer due to the loss of clinical activity to CATS schemes.
• concern at lack of details as to whether training opportunities will be available in CATS schemes.
• concern that appropriately trained medical trainers will not be available in proposed CATS schemes.

Quality of care and value for money

• with the absence of piloting and an awareness of the significant shortcomings in the quality of data in respect of independent sector procurement programme schemes to-date, there is a lack of confidence that reliable quality of care and value-for-money assessments of CATS schemes will be forthcoming at an early stage.
• at the earliest stage activity, audit and benchmarking datasets for collection by CATS staff should be agreed.
• concern at the lack of available details on the proposed clinical governance structures for the CATS schemes.
• concern that guaranteed levels of income provided to the independent sector over the duration of the contracts, not dependent on activity level, make the potential value for money of the schemes questionable.
• belief that relatively smaller levels of investment in existing services would lead to a better integrated, higher-quality and cost-effective local health economy.

What next?

The BMA is currently taking the concerns of its members to central Government, local MPs, local councillors and NHS organisations. The BMA will continue to lobby for further consultation of all key stakeholders on the development of the proposed CATS schemes and will continue to challenge the manner of their introduction. A BMA campaign is targeting the relevant localities and BMA Regional Services staff will be coordinating activity through local representative structures. At the same time, BMA members have the opportunity to contribute to the debate through a number of means.

As regards the proposed CATS scheme in Cumbria and Lancashire we would encourage local medical staff (and patients) to respond to the PCT consultation at www. cumbriaandlancashirecats. nhs. uk. Furthermore, participation at planned public meetings (where BMA representation will be present) is also recommended.

What follows is a series of questions that can usefully be posed by medical staff (as well as the public and patients) during any consultation process or for lobbying purposes.

Questions regarding proposed CATS schemes in North West England Some of the questions which need to be asked of CATS and ICATS are:

• When was the need for the scheme identified and how was this tested and assessed?
• Who has been consulted, and at what stages, on the development of the scheme? Where and when?
• What assessments of the impact of CATS on the local health economy have been, or are being, undertaken?
• Who is conducting the impact assessments, when will they conclude and will the results be made public?
• How do PCTs plan to deliver on their intention that CATS work will be entirely additional to core NHS activity?
• What evidence is there that planned CATS activity cannot be carried out by existing NHS staff (with or without extra investment)?
• What assessment has been made of the impact of the diversion of clinical activity on the future training of NHS staff?
• Where will staff working in the CATS schemes be recruited from?
• How many staff will be required and at what grades?
• Who will train, monitor and assess the staff in the CATS schemes?
• Who will draft and agree the protocols under which they will work?
• Will GPs and/or patients have a choice not to go via the CATS service?
• What interaction will GPs have with healthcare professionals staffing CATS schemes?
• What reliable evidence is there that the CATS scheme will improve accessibility?
• How will clinicians and local patients know that the service has improved?
• How will the quality of the treatment received in CATS be recorded and assessed?
• How will quality be compared with that previously received in the local NHS hospitals?
• How will the guaranteed levels of income provided to the independent sector over the duration of the contracts, not dependent on activity level, drive value for money?
• How will they ensure that the quality of work is maintained when existing audit in independent sector treatment centres has been severely criticised by the Healthcare Commission?
• What plans are being made for the end or completion of the five year contracts?

1 In this paper the acronym CATS (Clinical Assessment, Treatment and Support) services shall be employed to cover all schemes of similar scope and designation including ICATS (Integrated Clinical Assessment, Treatment and Support) services.

2 Preferred bidder status for the Cumbria and Lancashire CATS scheme has been awarded to Netcare UK, a subsidiary of Network Healthcare Holdings Limited (Netcare South Africa). Procedures planned include ENT, General Surgery, Orthopaedics and Rheumatology, Gynaecology, Urology, and Minor Treatment Room Procedures. Preferred bidders for the Greater Manchester ICATS contracts are Netcare UK and Care UK, who currently operate 90 community-based care homes and independent hospitals. Specialties expected to be included in the contracts are Orthopaedics and Rheumatology; General Surgery; Ear, Nose and Throat (ENT); Gynaecology; and Urology.

(c) British Medical Association 2006