Integration, not privatisation: NHS doctors speak out

A poll taken ahead of today's UK election finds strong opinions from doctors on private involvement in the NHS and the issue of integration across health and social services.

The NHS has been centre stage in the UK general election campaign, which culminates today as voters go the polls.

One of the biggest issues in the NHS currently is care integration – bringing primary and secondary care and social care together, in order to end fragmented and wasteful disconnects and to improve outcomes for patients.

Most stakeholders agree that integration is the way forward, but how it should be organised and funded remains contentious. Meanwhile, another major issue is competition and the 'privatisation' of the NHS.

A new survey of UK doctors shows that the majority reject greater private involvement in the NHS, want to see care integration and prevention initiatives, and more people treated out of hospital.

A survey of more than 600 physicians, conducted by Doctors.net.uk, found that there is a consensus among doctors that private providers do not bring more efficiency and better outcomes for patients and conditions for NHS staff.

A third of those polled were GPs and the rest hospital doctors, all working in England, Scotland, Wales and Northern Ireland. Over 40 specialities are represented and in different levels of seniority in over 100 Clinical Commissioning Groups.

Private involvement in the NHS

The research revealed that 67% of doctors do not want to see greater involvement of private sector in NHS services over the next five years, and of those, 43% strongly disagree with the proposition.

"I would like to see greater involvement of private sector in the NHS services over the next 5 years"

To what extent do you agree or disagree with each of the statements?

Strongly disagree 43%

Disagree 24%

Neither agree nor disagree 16%

Agree 12%

Strongly agree 4%

Along similar lines, 65% of doctors disagree with the statement that greater private sector involvement will improve efficiency in the NHS, within this 38% expressed a strong disagreement.

"Greater private sector involvement in providing NHS services will help to improve efficiency"

To what extent do you agree or disagree with the statement?

Strongly disagree 38%

Disagree 27%

Neither agree not disagree 17%

Agree 13%

Strongly agree 4.5%

The two main parties claim to differ on the role of private organisations in the NHS, with the Conservatives wanting to increase private contracts and Labour vowing to reduce them. The Conservative manifesto plans to promote "the entrepreneurial spirit of public servants" by introducing and encouraging a "right to mutualise" for public sector organisations. Labour has promised to reverse the current trend and repeal the Health and Social Care Act of 2012. Its ambitious 10-Year Plan for Health and Care pledges to halt competition for NHS contracts, make the NHS the preferred provider of services and to cut the proportion of income which an NHS Foundation Trust can earn from private work.

A third of NHS contracts in England have been awarded to private sector providers since the service was restructured in 2013, by the Conservative/Lib Dem coalition according to BMA figures. But the trend towards Private Finance Initiatives (PFIs) in the NHS had started under the Labour government.

GPs and hospital doctors seem to be in agreement on how the NHS should be run and there is no extensive difference of opinion, only a stronger opposition to private involvement in the NHS from GPs.

Anonymous comments of doctors on the Doctors.net.uk forum on the issue point to a general scepticism and suspicion around agendas for the NHS across the political spectrum.

"It seems a tad non-usual, that despite differing colours of political flags flying over the House of Commons over the decades, the persistence of privatisation transcends political manifesto and ethos. Which might infer a deeper strategy such as the Treasury/Civil Service, rather than politicians" said one.

Another doctor commented: "All three major parties insist on keeping the purchaser/provider split whilst insisting that they don't want to privatise the NHS...It's obvious that it's there to facilitate a shift from a universal, publically-funded system to an insurance-based model. On the supply side, the Foundation Trusts have been set up to fail: short-term they'll outsource care to corporate subcontractors (TUPEing staff), longer-term, there will be corporate buy outs and take overs."

Community-led care and increased role for primary care

The Doctors.net.uk data reveal that about 48% of doctors agree or strongly agree that more NHS services should be delivered by community-led services rather than by hospitals. But what does that mean and what are the political parties promising to do?

Community services provide care out of hospital, close to homes by a wide range of professionals. Often there is a lack of coordination between these and other NHS services resulting in fragmented, impersonal or variable patient journeys. The NHS England's "Five Year Forward View" envisions new and innovative models of care that break down the traditional barriers between primary care, community services and hospitals.

Political parties seem to think this is a positive approach and want to shift care away from hospitals and closer to people's homes but there is little detail on how this can be achieved, as the focus has been on other issues such as funding, private involvement and workforce numbers. According to Monitor, the NHS spent about £9.7 billion on these types of services in 2012/2013, and most continue to be provided under block contracts covering a wide range of services with a fixed-sum payment. The political rhetoric around a bigger role for primary care has been a feature of the election campaign but detail is sparse.

64% of doctors in the survey believe that integration of primary care out of hours and emergency care should be a NHS priority. They defend a coordinated healthcare system and would like to see a transition from some services to a primary/community setting. They believe that the most appropriate services to migrate away from hospital care are: diabetes, dementia, care of the elderly, including the frail, dermatology and pain clinics.

However, doctors fear that the "Five Year Forward View" and other plans can hide a privatisation agenda. "Innovative does indeed mean privatisation. We now know that privatisation is only innovative in that it uses the crude tool of cutting staff costs and skill levels down to the bone and hopes for the best. Which always backfires sooner or later", commented one doctor in the Doctors.net.uk forum.

To what extent do you agree or disagree that more NHS services should be delivered by community-led services than by hospital based services?

Strongly disagree 3%

Disagree 19%

Neither agree nor disagree 25%

Agree 40%

Strongly agree 8%

The challenges of integrating health and social care

Last year, the coalition government introduced the Care Act 2014, coming now into effect and seen as a major overhaul of the system. It includes standards and rights for access to services from care homes and aims at integrating and joining up this area with healthcare. This is something that doctors see as vital: 43% agree and 38% strongly agree that integrated health and social care is a top priority for the NHS.

The Conservative, Labour and Liberal Democrats promote the importance of joined-up care, particularly of the elderly or those with chronic illnesses, but manifestos are light on detail. Labour defends integrating health and social care services into a "seamless system with "integrated multidisciplinary teams working around the individual", while the Conservatives hope to build on the Better Care Fund and Greater Manchester initiative, which focus on integration and regional/local devolution. Both Labour and the Lib Dems believe health and social care integration can be achieved through pooling budgets, combining outcomes frameworks and changing paying systems. The Labour plan wishes to "bring physical, mental and social care together in a single service to treat the whole person - helping end the scandal of 15-minute care slots by incentivising providers to keep people healthy, independent and out of hospital."

Critics point to the fact that there is no commitment from any of the major parties to increase funding for social care, which will impact on the ambition to integrate services, as doctors would like to see.

"Better integration of the NHS with social care services is a top priority"

To what extent do you agree or disagree with the statement?

Strongly disagree 2%

Disagree 3.5%

Neither agree nor disagree 11.5%

Agree 43%

Strongly agree 39%

Prevention wins votes with doctors

It is an uncontentious statement from political parties that prevention is very important and the vast majority of doctors agree that investment in primary prevention improves the population's quality of life and brings savings to the NHS. 70% of doctors think NHS costs could be reduced by investing in primary prevention. However 61% recognise that healthcare prevention requires an additional investment with no guarantee of financial return.

The Conservative Party has pledged to invest more in primary care prevention although no particular funds or detailed policies have yet been announced. There is a proposal for a national, evidence-based diabetes prevention programme and actions to reduce childhood obesity, as well as a dementia strategy, which focuses on integrated care and prevention.

The Labour Party's 10-year plan prioritises prevention to reduce ill-heath and the demand on the NHS, promising to introduce new limits on the amount of sugar, fat and salt in food marketed to children, crack down on the high-strength, low-cost alcohol products, and promote exercise in schools. Labour also focuses on mental health and cancer prevention.

Conclusions

The Doctors.net.uk survey of UK doctors on political proposals regarding privatisation, care integration, community/primary care expansion and prevention found that:

• Most doctors do not want to see greater involvement of private companies and contracts in the NHS and do not believe them to make services more efficient.

• The survey and comments on the Doctors.net.uk forum, show that doctors think both the Conservative and Labour parties have veered towards privatisation of the NHS.

• Physicians agree with proposals for more integrated (healthcare and social) care, transferring some hospital services to primary care and community-led settings. 64% of doctors in the survey believe that integration of primary care out of hours and emergency care should be a NHS priority.

• Dementia, care for the elderly and diabetes are seen by doctors as services that should migrate from hospitals to primary and community care.

• Doctors support prevention of ill-heath to improve the quality of life, achieve better health outcomes and relieve financial pressure on the NHS, but its required additional investment comes without a guarantee of return, in their view.

About the author:

Catarina Feria-Walsh is a journalist and communications expert. A former BBC producer, she has worked as a media relations manager for IHS Global Insight, as a policies and market reporter at Scrip Pharmaceutical, and has been an analyst and writer for other publications. Catarina has media trained and advised executives at pharma companies such as Abbott and Ferring Pharmaceuticals. She writes about healthcare policies and markets, price and reimbursement, market access and media/digital engagement in pharma.