Mending a "broken" NHS - how the independent sector can help

IHPN’s Head of Acute Care Policy, John Hopgood, looks at Lord Darzi’s current review into the NHS and how the independent sector can help support it to diagnose – and fix – the challenges facing the health service

On taking office, Health Secretary Wes Streeting announced that “From today, the policy of this department is that the NHS is broken.” With waiting lists at record levels, and patients struggling to access NHS care – whether GP appointments, community healthcare, diagnostic tests or hospital treatment – the government is under no illusions about the level of the challenge and the level of change needed to make the NHS fit for the future.  

Lord Darzi has been commissioned by the new government to diagnose the problems facing the NHS – working out why the level of service is falling below what patients should expect ahead of the expected publication of a 10 Year Plan for the NHS in the New Year.  

IHPN CEO David Hare is sitting on the Expert Advisory Group inputting into the Darzi review, along with other stakeholders from across the health system. This has been a great opportunity to make sure that the voice of the independent sector is heard loud and clear as this important piece of work takes shape alongside David’s role on the Advisory Group for Penny Dash’s work on the future of regulation. 

To help us maximise our impact we asked members for their views about the challenges facing the NHS – what the problems are but also what can be done. We think that independent healthcare providers are full of the ideas, innovation, and positivity that the NHS will need to address the problems it faces. How do we unlock that by breaking down the barriers to independent sector contribution?  

So what did we hear, and what have we fed into Lord Darzi’s important work? 

Overall, a very clear message emerged – that while the sector is an integral part of the NHS in England, all too often independent providers are regarded by NHS systems in a transactional way as contractors not partners, with huge challenges ‘getting into’ the system, whether that be because patient choice is being blocked or new service models simply aren’t being commissioned. This limits the contribution that independent providers can make to NHS recovery.  

The consequences of this are that patients don’t experience truly integrated care; are too infrequently able to choose the best healthcare provider for them; and providers with great solutions to local challenges run up against a brick wall when talking to NHS systems.  

In addition members told us that they aren’t properly engaged in system planning and even where they are that planning and contracting arrangements remain sub-optimal. 

A short-term focus leads to worse outcomes for patients 

In our evidence, we have highlighted that commissioning and care delivery still focus primarily on addressing the component parts of healthcare, rather than looking at patient pathways. Too often, NHS plans primarily concern the ability of NHS Trusts to meet existing service demand, rather than considering the overall healthcare needs of a community.  

And indeed those NHS plans are all too often short-term – relating to the NHS budget cycle rather than the long-term health needs of the population. We heard clearly from members about the frustrations caused by short-term contracting that reflects short-term thinking. 

That short-term thinking also perpetuates the focus on interventional services rather than prevention or community-based management of long-term conditions.  

We think that longer-term planning, budgeting, and contracting are all essential to break the cycle of short-termism that has dominated in recent years.  

It is too difficult for patients to access independent providers 

We know that the right to choose is an overwhelmingly popular policy. Polling from Savanta ComRes, commissioned by IHPN, found that 73% of people believe they “should have a right to choose where I receive my NHS treatment, including with an independent/private sector provider”. Similarly, some 71% of people say they would be happy to travel more than 30 mins outside of their local area to get faster treatment. 

Yet, except for ophthalmology, eRS referrals to the independent sector remain below 2019 levels despite the record high waiting lists.  

IHPN’s analysis of internal provider data indicates that more than 88,000 listed eRS slots go un-booked every month – potentially representing more than 1million additional NHS patient appointments that could be delivered in the independent sector annually if eRS was used more efficiently. 

We also know that more needs to be done to use the NHS Provider Selection Regime to ensure that providers have the opportunity to bid and deliver new types of services. We know that too often contracts are rolled over with incumbent providers and, while this is sometimes the right thing to do, there needs to be a greater emphasis on the need for the NHS to be open to new models of care and ways of working. This is particularly the case where – for instance in diagnostics – an alternative provider is able to deliver a more productive and efficient service than a persistently poorly performing incumbent. 

Financial flows don’t incentivise providers to meet patient needs 

Members were clear that the recent approach to NHS financing has been designed around the imperatives of managing tight budgets and minimising NHS Trust deficits. Money flows not as a result of patient decision-making but in relation to the needs of the system. 

The NHS financial architecture has become increasingly complex, breaking the principle where providers are paid solely on the basis of the care they deliver. The system of national tariff/unit prices has increasingly become a way of managing internal system budgets rather than a rigorous tool to encourage productivity and efficiency. 

This has led to a two-tier pricing system – with NHS Trusts treated very differently from independent, social-enterprise and charity providers – whether that comes to funding pay liabilities or ensuring that unit prices reflect the efficient cost of service delivery. 

There is an opportunity to reset NHS finances in a way that sees more rigour in ensuring that providers are adequately funded for the treatment they deliver – whether through local contracts or national prices, underpinned by a fair playing field for all providers no matter their ownership structure. 

Again, we need a long-term approach providing a predictable, stable environment on which independent providers can base planning and investment decisions.  

National leadership is needed to overcome local problems 

We heard from members that NHS systems vary considerably in how well they work with and relate to independent providers. The best embody the values of partnership working that are so important, but others take the opposite approach and independent providers are not treated as genuine partners, with some systems describing any spend going to the independent sector as “leakage”. 

Members are clear that strong national leadership is needed to set a vision for partnership working and ensure that local systems deliver on those commitments – bridging the gap between welcome national ambition and moderate local delivery. 

This means that local system autonomy shouldn’t come at the expense of key national performance indicators, including waiting times. And local systems shouldn’t have the option of taking a “public provider first” mindset into commissioning decisions – we need to focus on how the whole system (including independent providers) can deliver for patients above anything else as well as who is best placed to deliver a high quality service to patients.  

Positive for the future 

Our contribution to the Darzi review aims to identify key barriers where strong and decisive action can and will unlock the potential for independent providers to go further in supporting NHS recovery – true partners in a national effort. 

A big part of this will be clearly articulating a vision for how independent sector providers can ‘get into the system’, whether that be acute elective care, diagnostics, community and primary care services or the array of digital and technical services that are now in the market and which NHS patients need to be able to access. The reality as described to us by members is that this remains far too difficult. 

We’ll continue to keep members updated as this work continues – and we hope that, in time, the Health Secretary will feel confident to say that his policy is that the NHS is now mended!