/ Health

Do you know your options when choosing NHS care?


You need NHS treatment, but you’re not happy about where you have to go for it. You ignore the bad reviews from the neighbours because it’s your only option, right? Wrong. David Hare from NHS Partners Network explains more about your right to choose NHS care…

It’s no wonder more and more people are worried about their ability to get access to high-quality health care.

In December, statistics from the NHS showed that a record 1,750 people were having to wait over a year for routine surgery such as hip and knee replacements. While the figures may show that people are having to wait ever longer for care, there are still reasons to be optimistic.

Care options

Over the past two decades, patients have been given more power over their NHS care. NHS patients currently have the legal right to choose where they receive care if they need to see a consultant for diagnosis or treatment.

If you have to wait longer than the maximum NHS waiting times, which is 18 weeks for a non-urgent physical/mental health condition or two weeks for a cancer specialist, then you can choose to be treated by a different provider. This includes choosing independent providers, too.

An independent provider is a private sector healthcare company that is contracted by the NHS to provide healthcare. And in 2017, independent sector providers treated NHS outpatients over eight days earlier than the national NHS average. What’s more, it’s all free for patients to use, with the cost to the taxpayer the same, too.

So as an NHS patient you have the legal right to choose a health provider on the basis of what is most important to you, whether it’s the closest one to home, the one with the best Care Quality Commission rating or simply the one with the shortest waiting time.

Despite this, we know there is still very little awareness among the public of this power to choose. Indeed, the last time this was measured, only 47% were aware they had a choice about where they receive NHS care and only 40% were offered a choice by their GP.

Navigating NHS options

We want to help set out exactly what people’s rights are, to make it easier for you. We don’t want you to be worried about you or a family member getting stuck at the bottom of the waiting list of your local hospital – we want you to remember that the power to choose is in your hands.

To help us get a better idea of how people are choosing where they get NHS treatment we want to know more about your experiences, such as whether your GP has ever talked you through what your options are around choosing your care provider?

We’re also keen to know whether you’ve reviewed or used any resources, such as NHS Choices, to search for hospitals and clinics near you and compare different providers according to what matters most to you.

This is a guest contribution by David Hare, Chief Executive of the NHS Partners Network. All views expressed here are David’s own and not necessarily also shared by Which?.


I take it this “right ” is the legislation by HMG by making the public “stakeholders ” ( cover for the word shareholders as it sounds like total privatisation ) but this includes private businesses as well and their services etc. This drive to publicise variety of choice is just a propagandist cover to deflect the bad state of the NHS under Westminster dogma of privatisation . Play up choice – play down REAL government reduction in the NHS to make it look bad and cause the public to cry out —the American version is better . Of course it is — if you can pay and the biggest US public debt is medical expenses people literally dying while still paying off medical bills . As you know this is a bonanza for heath insurance companies where in many cases you need TWO US insurance policies to cover your medical costs. Think on, my wife was a US resident in a US hospital you pay for everything -each injection both by the nurse and the cost of the injection itself -each visit by a nurse- your food – your room – administration costs – each visit by a doctor – EVERY procedure carried out by the doctor in other words a whole multitude of costs beautifully laid out in a long list on your bill . Cant pay for our services when at the reception desk ? then you are sent via ambulance to a “public ” hospital with reduced services downtown . I know there are many people wanting more privatisation but they are the ones who can AFFORD it . UK medical staff are against this creeping privatisation and downgrading of services , many marches of protest but to no avail the political dogma overrules them . Dont be taken in by slick advertising practices by HMG its YOU ! that ends up hurt in the end . Wont happen ? how many times has that been said —and it happens eventually ? Look at Scotland they are fighting against it more and more Holyrood money is being spent in combatting this reduced money from Westminster they are determined not to go down the US road and they have the backing of the people there. Many people moving North are now enjoying a higher quality of service than the equivalent in England and thats a fact.

There are many complaints about the NHS, which is under massive pressure because of our ageing population, the cost of drugs and other reasons. In the circumstances, it is very encouraging that we now have choices.

One of the simplest choices we have is to change our GP, and that has existed for many years.

Changing GP isn’t always that simple when they have all amalgamated into one practice as it can mean a new GP might be out of your area and you might not be covered for home visits.

I nearly made the same point in my post, but it’s still an option for many people. Where a practice has several GPs it may be possible to choose an appointment with a GP of your choice unless you need an urgent appointment with the first available GP.

Some have specialist interests, and the best GP I ever had was very well informed about the management of asthma. If this information is not available on the website it could be worth speaking to the practice manager. I was looking at the CQC Inspection and Insight reports for the practice I’m now registered with. It’s rated ‘good’ but not outstanding in all areas examined but the reports are reassuring.

christy says:
5 April 2018

I cannot get registered at a GP practice because where i live is not in there catchement area – i am six minutes away by car and the distance from my home is 0.9 of a mile – they are taking on new patients but will not take me – the surgery is in the area i live in – so what do i do about that – i have tried the CCG- Healthwatch England-CAB and Age Uk – all to no avail. I lost a kidney because of doctors neglect and am now at stage three kidney disease – i have pernicious anemia – vitamin d as low as it can go and liver disease caused through all the medication i have been put on over the years – so please can someone tell me how to get a doctor as i do not have one and am in desperate need of one. Thank you.

This is shocking Christy , your health is in a terrible state , I take it due in some respects to the catchment area you are forced to live in and those supposedly “looking after your health ” Dont ask me to make excuses for their “failures ” its YOU thats suffering NOT them ! You do not have a doctor ?? how is that possible in this modern day + age ? has the privatization of the NHS gone so far that you are being left to die ?? disgraceful doesn’t come close . You are entitled to medical care as a UK citizen regardless ( at the moment ) of whether you have paid NI stamps or not . Not only that LEGISLATION is built in for you living in England to register with a practice OUTSIDE your catchment area since January 5th -2015 -quote ALL GP practices in England have been FREE to register patients from OUTSIDE their catchment areas –problem ? they are also free to refuse on grounds of the number of patients they have to look after . There is no way you should not be able to attend a GP surgery for treatment – call- NHS 111 for help in this matter, this state of affairs makes me very angry considering Christy,s state of health and well being , so no excuses or “it cant be done ” etc if your health was as bad as that would YOU make excuses ? I would burn the phone down in calls to get action . If I could phone on your behalf to get action I would .

Christy, pernicious anemia is an autoimmune disorder that requires frequent B12 injections. If you are unable to register with a GP go to your nearest A&E and report this. It is vital that you receive this treatment.

“There are many complaints about the NHS, which is under massive pressure because of our ageing population, the cost of drugs and other reasons.” I’m tired of older people being blamed for the ills of the NHS. The truth is GP’s surgeries and A&E departments are overwhelmed with once healthy older people made into patients complaining about aches/pains and worse caused by dangerous unneeded prescribed drugs. Seven million people take statins that cause known serious even deadly side effects. I suffered a life-threatening statin-induced adverse drug reaction in 2008 that caused irreversible cardiomyopathy and polyneuropathy when I almost died. I was abandoned by all the GPs involved and the NHS has covered up the medical disaster ever since. This is the reason why the NHS is under so much ‘pressure’. I will never support more money for the NHS until the deadly and unnecessary statin drug is banned. The pharmaceutical companies make huge profits and GPs earn a fee for every prescription. It will go down as the biggest scandal in modern medical history.

If you have to wait longer than the maximum NHS waiting times, which is 18 weeks for a non-urgent physical/mental health condition or two weeks for a cancer specialist, then you can choose to be treated by a different provider. This includes choosing independent providers, too

That explains why they always manage to find an appointment just before the 18th week.

I wish I had know about NHS Choices when my husband was in agony for 8 months.

Can anyone tell me how long NHS Choices been available to us?

Haley says:
25 August 2018

At least 10 years!! I retired as a nurse from a private hospital in 2010 and we had been treating NHS patients for a few years before that.

A relative who works for the NHS advised me to have a colonoscopy because one of my parents had suffered from colon cancer. I discussed this with my GP, who looked up a list of those who offer this procedure locally. I’ve had it done twice by the same person and the only problem was that the procedure was cancelled twice because of equipment problems. I then discovered by chance that my neighbour had successfully sued the same consultant a few years earlier because (allegedly) he had allowed a junior to carry out a procedure without adequate supervision and the bowel was damaged, resulting in subsequent need for an emergency admission and treatment. As it happens the consultant has now retired but I hope I can find information that will help me make a choice.

What is the position if you prefer to pay to see a consultant? Do you still need referral from your GP or is it possible to go directly to a private healthcare facility for treatment if you are not happy with your local NHS practice?

When we had BUPA and required treatment, we had to get a referral from our GP before we could see a consultant who then kept the NHS GP informed of treatment.

You might be able to see a private GP without a referral from your NHS GP, perhaps someone will be able to answer that question.

But I don’t think you can go directly to a consultant unless you have had previous treatment from them.

I spoke to a GP and he recommended a local consultant for private treatment. When I wanted the same procedure done a few years later I went straight to the same consultant. As Alfa has mentioned, the GP practice was kept informed about the treatment.

Now that I want to use a different consultant (and the original one has retired) I will go back to my GP, but hopefully will have done some research about my choices beforehand. I’m not sure how best to go about it.

You can shop around at all the privately run hospitals by telephoning each of them and start by asking as many questions as you think fit (obviously from a prepared list) after first searching their websites for info and hopefully take it from there if you need more than a 10 minute consultation. BUPA charge £70 for a 15 minutes with a GP and more than twice that for a consultant, (unless you are insured), paid for in advance of course!

Thanks Beryl. In my case it’s a routine procedure I know exactly what’s involved. 🙁

I have found statistics for major surgical procedures, so maybe the best bet is to look at the figures for the hospital and consultant. I’m covered by AXA PPP, albeit with a rather large excess.

I have been researching and it seems you can book an appointment with a private healthcare facility GP first who would then refer you to one of their consultants if needs be, but in any event, your NHS GP would expected to be informed, to ensure continuity of your general health records.

Check this out: telegraph.co.uk – How your GP is paid to stop you going to hospital.

when i needed a knee replacement operation I was sent a list of NHS (all local ones or not far,far away)which I could use with waiting times to be seen by a consultant The waiting times varied between a few days to a few months I chose the one with shortest waiting time (also it was the nearest) and it turned out to be one of the best hospitals in the area and still is

Nice to hear the NHS is still working Bishbut and I hope your operation was a complete success it can be a tricky operation at times.

Knee replacement is complex but it’s amazing how many people have been treated successfully by the NHS.

I’m sure everyone else knows what the NHS Partners Network is, but just in case :
The NHS Partners Network (NHSPN) is the trade association representing independent sector providers of NHS clinical services. It was established in 2005 and incorporated into the broader NHS Confederation in June 2007. The independent sector has supported NHS patients since the NHS was created in 1948 and now delivers half a million elective operations, 15% of MRI scans and one third of community services, along with general practice, pharmacy and NHS dentistry.

I think it would have been useful if Which? had included this in the introduction.

Am I against a mix of private and state health care? No, I think that would be unrealistic. We have much healthcare provided under private health insurance which partly enables much quicker access to treatment for non-urgent conditions for those prepared to pay. This then provides a parallel set of facilities and staff that, if underused, give the NHS an extra resource. As any procedure costs the NHS money, paying an independent provider seems reasonable to meet demand.

However, I contend that the money should only be used to satisfy unusual demand and that the NHS should be funded to deal with normal demand. I don’t want the state to get lazy about meeting this demand by taking soft, but maybe expensive, options.

I also wonder how carefully the NHS purchases outside treatment and whether they are good at getting value for money. We’ve heard occasional stories about them being apparently taken for a ride on drugs and supplies costs; I’d like to know just how good their purchasing expertise is. The intro says: “ What’s more, it’s ( independent healthcare) all free for patients to use, with the cost to the taxpayer the same, too.” This is a bit surprising, since private healthcare providers are expected to make a profit and the NHS is not. So is it true, or is the NHS less efficient than the private sector?

Not that good in my limited experience.

My finger was going to get looked at by a specialist who flew over from Germany every fortnight. If that isn’t a waste of money, I don’t know what is. I had to wait about 8 weeks for an appointment but as I was going on holiday and had BUPA, went that route and had a choice of appointment times within the next week. NHS money would have been better spent on that specialist instead of paying for flights.

We also hear of out-of-hours doctors who fly over from Europe for their shifts. Must cost the NHS a fortune.

A couple of years ago I posted about meeting a GP who was travelling weekly to act as a locum many miles away. It was a long distance, something like Bristol to Scarborough. Obviously it is essential to provide adequate cover, but it seems unlikely that more local cover could not have been arranged.

There have been reports of “excessive premium overtime payments” made to consultants; one, in 2016, earned £375 000 extra to normal salary. It is perfectly reasonable to pay extra for overtime when a resource is short, as a very temporary measure, but I wonder how 3-4 times normal pay is justified and, for the long hours this consultant must have worked, whether it can possibly be safe and efficient.

However, these are probably isolated instances and not typical of the whole NHS. My concern is the financial discipline (or lack of) that allows these aberrations to happen.

When you have a complex and longstanding health issue,10 minutes is not nearly enough time to establish the root cause of a problem when symptoms presented can also relate to a number of causes. It puts both the practitioner and the patient under duress if the practitioner (a) does not have enough time to listen to what the patient is trying to say and (b) the patient under duress when attempting to relate their symptoms and is constantly interrupted by the practitioner who has been allocated 10 minutes per patient.

A private patient will most likely be given more time, more attention conveyed in a more convivial manner and advised accordingly before being handed a prescription for more pills to relieve symptoms that only provide temporary relief from a more serious underlying problem. The practitioners approach can go a long way to alleviate some of the anxiety experienced by a patient and also goes a long way in assisting the recovery process.

I had the unenviable task last week of finally advising my GP who constantly interrupted what I tried to tell him that the problem was most likely medication related and that more tests were in fact necessary. I thanked him very much for seeing me so quickly and beat a hasty retreat.

Have you tried asking for a longer appointment, Beryl? I’ve not done this but the website for the previous practice I used invited patients to ask for a longer appointment when booking.

I would like to see more attention paid to establishment of the cause of medical conditions rather than just handing out treatment. That could cost more to start with but might save money in the long run and would be better for the patients.

Our surgery gives double appointments (at least) for consultations that might be expected to require more time. I don’t know if this is general, but it should be.

Medical research into genetics has revealed a myriad of diseases that can be passed down through generations, but interestingly, these diseases can lie dormant until triggered by environmental processes. For example, most whites with type 1 diabetes have genes HLA-DR3 or HLA-DR4 and it is autoimmune but the disease is still not considered heriditary and is dependent upon environmental factors to trigger it. This phenomenon apparently also applies to a host of other diseases.
See: diabetes.org – American Diabetes Association – Genetics of Diabetes.

Unfortunately establishment of the cause is still very much a scientific research project and not all GPs are up to date with it, but I wholeheartedly agree with your suggestion Wavechange.

We expect GPs to be experts in all things and to keep up to date, but that’s a major challenge. Some GPs declare particular specialities and the only specific commendation in the CQC report was the focus on dermatology, presumably due to the one GP who has this down as one of his specialisms. Patients are often referred to consultants who do have good expertise in their field but might not understand other conditions and medications relevant to their patient.

The involvement of both genetic and environmental factors in certain diseases is well established but not something I know much about.

I am due a follow up appointment after blood tests so I may request more time, although I am not aware whether this is available at my surgery. The doctor I saw was not my usual and it was an emergency appointment he made following the telephone call the day before but failed to lodge it on the practice computer, as I have already posted.
Thanks Wavechange and Malcolm, I appreciate the helpful advice

Ann Swindale says:
23 February 2018

Am I correct in thinking that this only applies in England? The NHS operates very differently in Wales, Scotland and NI. There is no reference to these differences in this article.

Correct Ann Scotland has its own NHS rules which are to stop privatisation and its more socially aware . Holyrood spends more on keeping it a public concern . As a result many people from England gravitate to Scotland for a whole load of social benefits that have been removed in England , Scotland has control over the Scottish NHS but Westminster is trying to remove that in its Brexit exit legislation. Be aware that Scotland has a socialist point of view not far left but somewhat like Germany its not full of Tory voters so if you dont like that maybe moving to Scotland might not suite . Having said that it is pro small businesses (grants available ) and even big ones that benefit Scotland in the long run. Many English people live in Scotland and -shock-horror actually vote SNP and they are among the most active in many community councils.

After referral by my GP, I was given a number to ring, to choose a hospital and make an appointment. The service I rang then told me that I would receive a call back so that I could do so. When I asked when I might expect a call, thinking it might be this afternoon, they told me it would be in 6 – 8 weeks time. That’s just for the call-back to make the appointment! A friend who works for the NHS tells me this is a deliberate means of kicking the ball down the road, as the waiting time to see a consultant is measured from the choosing of the hospital and the making of the appointment, not the attempt to do so. So they are fiddling the figures, and in fact I’ll be lucky to be seen in 26 weeks, never mind 18.

Jane, Holyrood in Scotland has clamped down on long waiting lists and have given short waiting times for hospital appointments but I am staggered that you have to wait 8 WEEKS just to MAKE an appointment . Privatisation and restriction of money into the English NHS in action.

Dave Lummis says:
25 August 2018

I am now 70 years old and my wife is coming up 73. She has severe mobility problems. For 39 years I paid into my retirement plan to be taken care of – when I am sick or unable to cope on my (our) own. It was called National Insurance Contributions.

Count the number of years I have been commenting on the Privatisation of the NHS in England to critical. patronising replies of – wont happen here – impossible – scare mongering -stop saying it. I also brought in the USA/UK “secret ” trade talks involving the same to cries of -not true- not going to happen – maked down continually . Well how about the “darling newspaper ” of Which ? NOW coming out with the same warnings –“all of a sudden ” there must be something in it then? . I knew about this from American government websites –at least THEY are honest enough to put on the web and newspapers in the USA what they want out of the so called “even-handed ” trade negotiations –America FIRST and dont think the Guardian is giving all the facts ,if I said the “American version ” it would certainly upset NHS patients . So keep on “nay-saying ” but remember its not me you have to answer to its the British Public ( god help them ) https://www.theguardian.com/politics/2018/sep/18/rightwing-thinktanks-unveil-radical-plan-for-us-uk-brexit-trade-deal-nhs I will not post the US version as I would be accused of panicking people. I have much more if needed.

These are “think tanks” making proposals, not policies. Policy will be down to the government of the day and I doubt either one will see the NHS “privatised” other than the kind of services they already have. Providing the care we need remains “free at the point of delivery” and selected outsourced services are properly tendered, evaluated and resourced on a results basis then it is not necessarily a bad thing. Saying “public good” “private bad” is a sweeping generalisation (if it were made). There is stuff that is wrong with the NHS that might be improved by using a different model. Eye tests, dentistry, private hospitals and consultants, some diagnostics, work very well. The key is to set up the right contracts with the right safeguards and monitor them. That really applies to “public” as well.

Thats not how Donald looks at it malcolm , its a big issue with HMG as he insists on American “intervention ” in the NHS . You know how Donald operates- my way or –sanctions . Talking of “think tanks” there is a call for complete privatisation of all government services by several far right Ministers.

It will be a government/parliamentary decision, not “Donalds”. As has been said by others, privatising the NHS would be political suicide for any party. More bits may be, and that could be a good thing.

The term “America First” goes right back to the aftermath of the First World War, but during the middle years of the 20th century it had overtones of isolationism and, at times, anti-Semitism. It is interesting that Trump has resurrected it. But then, day by day, he seems to be behaving more and more like a dictator. He has now got himself into a trade war with potentially the biggest market in the world; smart move.

Trump’s pronouncements are so inconsistent and changeable that it is foolish to place any reliance on his comments as forecasts of future policy. The notion that he is going to bust open the NHS and force the UK population to pay for their treatment, operations, and medications is ludicrous. The financial implications would not be the most important aspect; if people had to pay for all the NHS now does at no upfront cost, taxes and NI could be dramatically reduced but the price of healthcare would be very high and a large proportion of the population would be excluded from essential treatment. I don’t think the citizens of the UK would accept that now or in the future. The two main parties spar with each other to see who can be credited with being the best protector of the NHS.

Patrick Taylor says:
20 September 2018

There seems to be a blindness to the fact that the NHS is being cherry-picked to death by private enterprise which has been occurring for some years. From a reputable journal …

And of course PFI for hospitals is a terrible cost of commercial answers versus state provision.

Exactly Patrick , I am afraid I am not convinced by your argument John and it sounds like a pat government line to cover up the sliding privatization which –in England is now over 30 % . You have most of those at the sharp end of the NHS -IE- surgeons-doctors- nurses etc opposing your line , of course you have the NHS “administration ” on your side —and “shareholders ” and its a big reason a lot of people from England have moved to Scotland , and yes John I speak to many including a “Professional ” with letters after his name with a big St.Andrews cross flag in his main road facing house half a mile from me and guess who he not only votes for but is very active in the local area in this regard ? You seem to forget we lost an old regular over the same issue a good while back.

DerekP says:
20 September 2018

I hear what Patrick and Duncan are saying but I still doubt that Trump has his sights fixed on our NHS.

But wouldn’t it be nice to be able blame anyone other than ourselves for any shortcomings of the NHS?

PFI was an inept way to get debt off the books and in this case to finance more public hospitals. It was not directed only at the NHS – schools, road maintenance just two other examples. And similarly the MoD sold off many of its properties and rents them back; that does not mean the armed forces are privatised.

What do most of us use regularly in the NHS – probably our GP. As far as I know, always private operations that the NHS pays to use.

Patrick is right in my view. Having spoken informally to senior staff in the NHS, both current and recently retired, I’m convinced that privatisation is responsible for at least part of the financial problems and in some case poor standards – poor cleaning of wards and toilets is an example we can all see.

Most GPs work in practices funded by the NHS rather than on individual contracts, or that certainly was the case when I had friends and family working as GPs.

And, of course, the armed forces were always privatised in the past.

as far as I know, GPs are self employed (and have been since 1948) and many (most) own their own surgeries. They naturally get funded by the NHS for the work they do for NHS patients, but they also do private work.

An example of the blurred line between public and private.

I’m no expert on how GP practices are funded but there is no doubt that we are seeing changes and some of them are outlined in this document: https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/commissioning-and-funding-general-practice-kingsfund-feb14.pdf

And how its done in Scotland https://www.bma.org.uk/news/2017/march/funding-pledge-for-gps-in-scotland but remember the Scots pay more income tax. Its already been implemented.

Duncan – I am not arguing anything. I am merely commenting that the NHS – as a state-organised health treatment system – is popular with the public as it is and the major political parties appear to have no intention of managing it as a private enterprise. It is a mixed organisation with many of the senior medics and specialists self-employed and contracted to the NHS. So long as they are commissioned well and managed competently by the NHS management I think the employment distinction is irrelevant. Nurses, junior doctors and other medical personnel tend to be employed directly by the NHS – probably because that is the most practical and efficient arrangement given the round-the-clock work patterns. A large number of those people are agency workers, of course.

Cleaners, catering staff, maintenance workers and so on tend to be employed by contractors. So long as the supervision and management is competent I can see no reason for any difference in the performance quality between directly employed labour and outsourced contract workers.

The important aspect of the NHS is the way it works as a system – interconnected with a range of highly-specialised units and capabilities. As I have said, the results depend on the managerial competence of the directing organisation and I am concerned with outputs rather than inputs. I get the impression from the numerous complimentary letters published in the media that the overwhelming majority of patients feel that they have been well-treated by the NHS and were possibly unaware of the particular status of each person who dealt with them.

If there is poor cleaning or maintenance that is entirely due to the failure of the NHS management to allocate sufficient resources to the activity,draw up good specifications, and supervise the delivery of the services properly.

This will always be a major issue with me John, its those at the lower financial end of the scale who are hardest hit by bad health . To me this really is a “Life & Death” issue , its fundamental to this country and if you did not know it has been widely acclaimed worldwide in the past . The problem is it is being heavily condemned in the USA by Big Business who stand to gain from full privatization and that includes the US Government & Congress who have “vested interest ” financially in this happening . Its not so easy nowadays to say no to the USA so its creeping privatisation over the years so that the British public will wake up one day and find a $10,000 bill for a few days visit to their local hospital which has just happened in the States to a UK tourist without insurance ( USA ) to cover it. Americans now have to decide whether to live with heart trouble / kidney/liver disease etc so that they can survive or get the operations and join other US citizens in paying long term for the biggest US public debt– Medical bills.

US healthcare funding is totally different from ours, and as far as I know in the main requires personal insurance. We are urged to take out adequate insurance when travelling abroad to cover any health issues. If the tourist did not have insurance they were very remiss.

In the UK we, fortunately, all have more or less equal access to necessary health care. Those at the lower end of the financial scale have exactly the same access to the NHS as the wealthy, so in this context life and death is not dependent upon wealth. Those with wealth can choose elective procedures privately, funded by their optional health insurance or assets. But if things go wrong they’ll end up in an NHS hospital.

I believe that there is ample evidence that outsourcing hospital cleaning has been a bad move. Here is a short article: http://www.ox.ac.uk/news/2016-12-21-nhs-hospitals-outsource-cleaning-‘linked-higher-rates-mrsa’

The article says “They calculate that, on average, the incidence of MRSA infection between 2005 and 2009 was 2.28 in every 100,000 bed days in trusts that outsourced their cleaning, compared with 1.46 bed days in trusts that used in-house cleaners –.a difference of almost 50 per cent.“. however, unless I’ve missed something, this is for data between 9 and 13 years old. Was their more recent data in the report? If data is that old perhaps there is a newer and more relevant study.

The standard of cleaning should be determined by those who construct and let the contracts, and monitoring the performance of the providers. The latter would apply to both outsourced and in-house cleaners. It may be the NHS people who put the contracts together were more concerned with cost than performance? A culture, if so, the NHS should address; the remedy would lie in their hands.

Yes the NHS has a responsibility to monitor the effectiveness of cleaning but the companies should be doing a decent job in the first place, don’t you think?

I expect that more recent reports are available but I have not looked.

It is certainly the case that the outsourcing of hospital cleaning has introduced additional risks by creating an intermediate position – the contractor’s on-site manager or supervisor – between the operatives and the hospital matron or facilities management. This means that any complaints or concerns have to be raised formally through an administrative process and the hospital staff cannot perhaps address the operatives or their supervisor directly since they are employed by the contractor. This is predictable with an outsourcing arrangement and it is possible that some of the hospitals that have outsourced the cleaning function did not pay sufficient attention to this contingency when setting up the contractual arrangements. It is also possible that when the cleaners were employed directly by the hospital they knew their role well, did not work to a prescriptive specification, and had a practical and more responsive working arrangement. Again the breakdown in such relationships following outsourcing is predictable and should have been anticipated before the work was put out to contract.

It could also be that the specifications drawn up for the tendering process were done in a hurry and were incomplete or deficient in certain details. It is well known that contractors will only do what the specification says, no more and no less, and seek to take advantage of such inadequacies at the tendering stage in order that they can, after the contract has been awarded, negotiate lucrative contract variations. It would not surprise me if, in the haste to save money on non-medical functions, hospital managements neglected to perfect their specifications or did not have the competencies required for managing external contracts. Running an in-house cleaning function with people who have been around for a long time involves an entirely different skill-set to the demands of organising the contract award and managing an outside contractor whose employees might also be deployed across several other contracts and have no particular attachment to the specific hospital or facility..

I agree that, ideally, it would have been better if hospital cleaning had been retained in-house, but there is no question that it was an expensive and and poorly managed function with over-staffing, poor productivity, high levels of sickness absence, and slack discipline, albeit the performance outputs were generally good. And there is no doubt that the pressure was on from the new management-qualified breed of Chief Executives and the Chief Financial Officers to cut the costs without ensuring that the private sector had the capabilities to deliver the same level of performance from a depleted operation, or to ensure that the senior hospital staff left behind after the transfer of the operational personnel were capable of managing complex contracts where the private companies had superior commercial knowledge and experience.

I believe that fine-tuning the internal performance regime and management controls, and a focus on productivity under more competent management, could have achieved the right outcome for a lower cost, although still not competitive with the private sector where the management style is more forthright and where, over the long term, the pay and conditions will diverge from the NHS scales and national conditions in order to increase the profits on the contracts.

I think the hospitals were put in an impossible position and not equipped properly for the transition [much of which was indeed bound up with the PFI contracts where the use of the PFI-partner’s allied contractual operations was mandatory]. However, we are where we are, and I question whether this can now be unpicked except at prohibitive expense by buying-out the remainders of the PFI contracts and taking the service functions back in-house. Given that many hospital trusts are carrying very large deficits the likelihood reducing the outsourcing seems remote.

There are two other aspects of hospital cleaning and hygiene that have not received adequate attention in my view: (1) the prevalence of allowing numerous visitors [including babies] into hospital wards for extended periods [with the consequent need to consume food and drink and use the lavatories] has introduced additional and unnecessary risks into what should be a semi-sterile environment; and (2) with more foreign travel these days, the tendency of people to go into hospital [whether as patients or visitors] after contracting infections abroad, or picking up viruses [for example, from self-service open food provision or through confinement in contaminated accommodation – both notably associated with cruise ships] has compromised traditional hygiene routines.

As John says, when you let any contract the contractor, who is in competition with others, should price up exactly what it asks for. No less, and no more. It may also allow for means of agreeing variation costs for unspecified items (an emergency deep clean perhaps). The onus is directly on those who put the contracts together to make sure they have done the job properly. The contract should specify penalties if the requirement are deviated from, and that is the incentive for a provider to give the level of service they have signed up to. The same monitoring should, of course, apply to in-house cleaning, so I see no excuse for the “customer” not to understand what to ask for, specifically. It starts with competence at the customer’s end.

I agree to some extent Duncan.

I have had personal experience in working with a Mental Health Trust in setting up rehabilitation units in the community via the private sector, whose responsibility it is to provide a new and NHS approved building and qualified medical staff, but the actual care is funded by the NHS via the taxpayer. It is just one aspect of the ever increasing interconnection of continuing private care provided under the auspices of the NHS, without which it would most probably cease to exist.

While this is happening in England Beryl its the other way around in Scotland one very large hospital in Clydebank- 7 miles from Glasgow called the (NHS ) Golden Jubilee Foundation . It was privately owned and run and is now NHS run ( Scotland ) https://www.nhsgoldenjubilee.co.uk and don’t think -“Golden Jubilee ” must have private funding–wrong ! read https://www.goldenjubileefoundation.org and the word Jubilee goes back many 1000,s of years as I posted elsewhere Sumer/Babylonia when a new king came on the throne all debtors were released from their debt . So its giving it back to the people rather than shareholders making a profit out of your health —-yes I know HMG calls them Stakeholders -in my view they have the public “tied to a stake ” . Again I say Scottish tax codes have a S in front of them as the Scots pay more for social/welfare/medical services . As regards Metal health, as I posted personally my wife is being attended by several mental health nurses because she has agoraphobia as this is covered in a blanket coverage . She is getting help FOR FREE that many would envy in England and they are eager to help as Holyrood,s policy by the First Minister is very strong in all things social , again to the envy of England causing many in England to move to Scotland as they don’t mind paying more for better service .

There was a chance just over a year ago for the country to elect a different government which might have made the situation in England more like that in Scotland, but . . .

By the way, stakeholders and shareholders are completely different things and, so far as the NHS is concerned, the shareholders in the private companies that provide certain services are not “stakeholders”. The stakeholders – in no particular order of significance – are the patients, the patients’ relatives, the staff, the consultants, hospital welfare volunteers, the members and directors of the trusts and the commissioning groups, the GP’s and their staff, and the other service providers such as optometrists and dental surgeons. If I had shares in a drug company, or a manufacturer of sheets and medical gowns, I would just be an investor and would not have a stake in the Service because my company’s products would not be associated with a particular establishment or provision; shares can be bought and sold on a whim whereas a stake has a degree of placement and endurance and should involve some personal commitment beyond a financial return. When the government or other commentators refer to “stakeholders” in the NHS that is not a euphemism for profiteers and to suggest otherwise is somewhat insulting.

Insulting John ? it was a well thought out way of involving private enterprise in increasing its hold over then NHS (England ) sounds nice and “cuddly ” -bizfuent.com-Creditors/Bondholders under the heading of “stakeholders ” == creditors providing finance to a company (NHS ) by issuing loans and BUYING corporate Bonds –their objective is to receive repayment on loan amounts and INTEREST earned . If that isn’t a devious way of getting profit from the NHS I don’t know what is. But if everybody in England is happy with that then I have no problem —–but John everybody in England ISN’T happy with this arrangement and if you take offense at my position on it you have not heard /been in contact with /exchanged emails with NHS staff like I have. They are a lot more forthright than me , I am a “pussycat ” compared to their comments and considering they do the actual work on British citizens instead of “working ” by investment to gain profit that should be ploughed back into the NHS but is “ploughed ” into their bank accounts. Bond is a debt security sold to investors and the physical assets can be used as collateral / bonds only earn interest but are safer than stockholders in that they are paid first in any default/crisis in the company along with creditors remember the banking system ? creditors first debtors last.

Yes, I understand that, Duncan, but perhaps I did not make myself clear. I regard it as insulting to the real stakeholders in the NHS – as I listed above – to describe the profiteers in creative financial schemes, or the shareholders in companies that do business with the NHS, as “stakeholders” when at best they are mercenary investors or just commercial traders.

I believe there is a role for the profit motive in public services as it incentivises better performance and efficiency, both financial and managerial, but it needs managing. Decades of under-performance and bloated establishments led to the pressure to de-nationalise other industries and utilities. The NHS is totally different from those but does suffer from some of the same outmoded cultures. Like any organisation the NHS needs to manage its contractors effectively to prevent abuse of the system and to protect the benefits to patients or other service recipients.

Apart from PFI contracts, I am not aware of any investment schemes of the kind that you have described but there is always the possibility that some NHS Trust somewhere has entered into such an arrangement in an attempt to cover a hole in its finances.

If the NHS borrows money on the open market (I’m not sure whether it does) then it will enter into contract with the lender. Interest will be payable. That does not mean the lender has a “stake” in the NHS. as far as I can see. There has also been talk of the NHS realising money from property, and issuing NHS Bonds as an interim measure, but I don’t believe these goive anyone a stake in the NHS that buys influence. No more than PFIs do for hospital finance. Simply a financial means to an end (and I hope PFIs do end). Interest on money lent is the norm in any walk of life or business.

However, government can normally borrow money at cheaper rates than is achievable on the commercial markets. That is where public services – national and local – should go to for loans, rather than saddling the current accounts with more outgoings. We seem scared stiff of disclosing government debt and go to considerable lengths to conceal it.

Yes its funny malcolm that the USA has no problem disclosing its debt –even “proud of the fact –$20Trillion –and rising , hence the balloon busting soon and my constant comments to buy high carat gold as we are tied very tightly to the $ . John how many members of the British public have “shares ” in the NHS ? I am talking of Joe Bloggs down the street who has a service industry job can hardly afford the high rent , runs a 10 year old car, if he is lucky , has beans on toast for dinner and wears old clothes because he cant afford anything else due to “austerity ” -aka- depression to pay the IMF/WB back at high interest. When is THEIR Jubilee year coming up—I will tell you when they die. No that was “cute ” wording by HMG . You want an honest answer malcolm well you only get it in America where they put on websites that the USA owes $20 Trillion , as that is confirmed to me by various sources I believe it , so if a US website says that then the UK figures on the same website must be real (or near it ) –nearly THREE $Trillion in a 66.7 million population , even Italy with near the same population has less debt by one $Trillion .

This might keep us up to date (and amused perhaps). usdebtclock.org/?#

Nobody can buy shares in the NHS, Duncan. It is not a company.

Very few individuals hold shares in companies directly and their aggregate holdings are very low as well [as a percentage of the share capital], but every pension fund and insurance fund and many other investment vehicles have shares in the leading stock market-listed companies.

Did the government say that commercial speculators and investors were “stakeholders” in the NHS? If so it, was wrong, not “cute”. It was also misleading, and insulting to the actual stakeholders. There are no “shareholders” in the NHS unless you count the government itself.

The term “stakeholder” has been much misused in recent times, often by politicians, to imply a closer connection or obligation to a body than is represented by the mere holding of a loan note or similar instrument. I expect that PFI contracts [or slices of them] are bought and sold within the financial services industry but, as Malcolm has said, that does not include a “stake” in the NHS; a financial interest is just that – it is not a “stake”.

Notice the apostrophes John , I was only approximating to a lesser degree , you said a “stake ” is not is not a financial interest but the same word is used in business websites (USA ) in conjunction with bond holders so trying to separate it into sections of -good guy-bad guy doesn’t work . HMG knew exactly what it was doing using that language as I read all the arguments of why the British public would find it unacceptable to use the word shareholders as it implied private input and control –bit at a time was the answer . I have had adamant replies that – HMG advert- the NHS is “safe in our hands ” –really ? Do you know how many Tory ministers /MP,s want it fully privatised and owned by the USA ? Liz Truss told a right-wing US think tank that a thicket of regulation and control is holding back business and called for a new Anglo- American dream while the group published details of a proposed deregulatory US-UK trade deal.

Her speech given at the Cato Institute during a taxpayer-funded trip to Washington came as Cato and other right-wing think tanks launched a major report at joint events in London and US outlining an ideal free-trade agreement after Brexit.

The proposed deal would threaten environmental regulations, remove current rules on imports of chlorine chicken and hormone-fed beef and open up the NHS to competition from the American healthcare industry. At the Washington DC launch of the report yesterday, Truss delivered a speech entitled Market Millennials in which she described Brexit as a huge opportunity to shape a new relationship with America and turbo charge freedom.

The DC launch was also attended by former UK environment secretary Owen Paterson, Utah Republican Senator Mike Lee, and MEP Daniel Hannan, who edited the report.

Speaking at the London launch of the report in Westminster, the Cato Institute,s
Daniel Ikenson said workplace and environmental rules do not belong in trade agreements, insisting that companies can be self-regulating when it comes to environmental standards.

Ikenson also suggested local farmers had been scaring people about chlorinated chicken and suggested that incumbent providers such as the NHS should be opened up to competition as part of a de-regulatory trade deal.
The report calls for an extensive free trade deal between the US and the UK, with no tariffs on any goods, reductions in regulation, and equivalence between the UK and USA rules, which could open up the UK to the sale of chlorinated chicken, hormone beef, and other products.

In remarks at the report London launch, its primary author Daniel Ikenson, the director of Herbert A. Stiefel Center for Trade Policy Studies at the Cato Institute was blunt about its effects and his view on regulation.

Healthcare is a service, we call for opening services to competition. he said. And I know some people are worried about what happens to the NHS, for example. We think competition is a good thing and it would lead to better quality healthcare. Is the your point of view too John ? If they tried to implement that in Scotland there would be a riot and the need to send the “Redcoats ” back to “quell ” the population as well as gifting the SNP with a big majority to hold Referendum mk 2 and a separation from England.

I don’t share all of your opinions, Duncan. Also I am never quite sure of what quotation marks mean sometimes. There are plenty in your comment and also a missing set.

No wonder some people are worried about the future of the NHS given the number of unsubstantiated scare stories being spread around.

As I suggested previously, the word “stakeholder” in the context of the NHS is completely different to its common meaning in a business context of a financial stake. If the government did actually refer to investors in hospital contracts or other financial activity as “stakeholders in the NHS” then, as I said before, it was wrong to do so. I wonder which Minister said it and in what context.

From the other things you said above I did not infer that Liz Truss was advocating American business taking over the NHS. All she appears to have done is tell “a right-wing US think tank that a thicket of regulation and control is holding back business and called for a new Anglo- American dream“. She is well known for such meaningless waffle.

I don’t thinkI’d pay much regard to what Liz Truss says. It a bit get a bit tired of politicians taking their own party lines. A pity government members don’t work as a team.

I could live with imports of chlorinated chicken and US beef providing it is clearly labelled so I have the choice in what I buy. Has it, out of interest, harmed the Americans?

But you are, I think, barking up the wrong tree with the NHS. I’ll bet you a £1 to a penny it won’t happen. Particular bits, as now, will be and that is not necessarily a bad thing.

Last sentence malcolm –I hope you are right.

So do I duncan 🙂

And I do too, Malcolm – you’re playing for high stakes.