There is a widespread consensus about the challenges which face our care system. There is a growing consensus that we need to focus more on avoidance and prevention, on behaviour and culture and on things like integrated whole person care and on community development – less on organisations and structures – no more reorganisations.
Yet there is a persistent background noise that claims that PFI, private provision, and the cost of the market are what is wrong and that full public provision is the solution.
Some PFI contracts offer very poor value for money showing the “experts” that advised the Trusts and DH were not as expert as those who advised the public sector providers. But there are PFIs that have worked well enough in health and elsewhere; and the legacy of old and decrepit NHS buildings has been reduced. The costs are hugely exaggerated usually by comparing the cost of the build with the whole life cost of leasing and maintaining the same building – but the (undiscounted) whole life cost of a house purchased by a mortgage is far greater than the build cost. So what? The issue is does the actual cost offer value for money, if you accept that there would have been no new building without the PFI?
The use of PFI does add cost as the cost of borrowing is higher, the cost of delivering the FM services is usually higher and some flexibility to control estate costs is lost. But the increased cost of this route as opposed to a publicly funded traditional route and in house FM is only a fraction of the figures often quoted.
And whilst an unwise PFI is the main cause of financial distress for 2 and maybe 3 Trusts: that is all. Arguably the same trusts (or more properly the same localities) would be in trouble if they had the same buildings but without the PFI overheads. Plenty of trusts without PFIs are also in trouble.
Most agree there are major issues around whether or not competition, commissioning and the internal market is actually worth the cost of the system. The system cost will increase as we edge to a British Rail type system with hundreds of providers and commissioners all joined through legally enforceable contracts, invoicing and huge transaction volumes.
The claim that the “market” adds 14% to the transaction cost is a figure often quoted but with no traceable source. There is a cost in having a managed system with a purchased/provider split but again this is hugely exaggerated. Unless you go back 40 years to an unmanaged system there has to be a lot of data collection about costs and outcomes; there has to be some measurement of value for money and there has to be some management of provision through some form of service level agreement of some kind – unless providers just decide what they should do and what quality to deliver. And we appear to agree we need independent regulation of some kind of quality and also organisational governance or “fitness”. So a lot of the costs that come from managing the “market” would still be there without the market, under different labels. So maybe 1% additional cost but nothing like 14%. Someone could work it out.
It is a fact that since its inception the NHS has relied on private provision – even leaving aside the heated debate which starts as soon as anyone points out GPs are private providers to the NHS. There is sadly no shortage of scandals in both public and private sector and also excellence in both.
Sadly the H&SC Act will force competition and fragmentation. However, the consensus is that we need an integrated NHS or even a Care Service with the parts joined through collaboration and cooperation not a fragmented market with connections through contracts and with competition for every service. In a managed NHS services could be planned or commissioned within the NHS without legally binding contracts (as currently between PCTs and NHS Trusts), freeing commissioners to make decisions that cannot be unpicked by competition law.
But this leaves open the possibility that for some services there could be an open tendering process and that for some services the private sector may be contracted as provider. In an integrated NHS this would happen only where the NHS itself was unable or unwilling to provide the service required to the necessary standard and offer value for money.
Anyway, a wholly publicly provided NHS (if its even possible) would require cultural and organisational change of a scale way beyond anything seen so far and would take many years to complete even with a reasonable degree of goodwill.
There may be sound ideological reasons to advocate a fully publicly provided care system but it too would face many of the same issues the managed system will have to confront – and its those issues we ought to be talking about.
Irwin Brown