As a generalisation (a form of non-evidenced proposition much liked by writers of editorials), British physicians support the National Health Service (NHS) and are wary of the ethics and implications of using private, for-profit providers of hospital services. National news coverage of the top quality of care award to Hinchingbrooke Hospital provides much food for thought.1
Hinchingbrooke was the hospital that was branded ‘severely dysfunctional’ by the Royal College of Surgeons, and indeed described as a ‘clinical and financial basket case’ in the House of Lords, having run up a cumulative deficit of £39 million on an annual turnover of £79 million.2 In November 2011, the private company Circle – an employee co-owned partnership ‘with a social mission to make healthcare better for patients’ – won the contract to run the hospital for 10 years. The basis is an operating franchise, with Circle taking on the management functions of the Hinchingbrooke Health Care NHS Trust, not the creation of a private hospital. The contract projects a £31 million franchise fee for the company over a 10-year period, provided that the Trust achieves a surplus, and also projects saving of £311 million over the same period.3
Shortly after the takeover, highly critical reports of the tendering process that led to this arrangement were produced by the National Audit Office and the Public Accounts Committee.3,4 They noted that Circle's plans involved a greater rate of cost-cutting as percentage of annual turnover than had ever been achieved in the NHS. They also commented that the Department of Health, Circle, the Trust Board and the Treasury all seemed to have different views on what success would look like – including, strangely, ambiguity on whether the cumulative debt was required to be repaid. Furthermore, the Audit Office report commented that, in its first 6 months of operation under the franchise, the in-year deficit was double that projected.
And then, during its third year of operation, the accolade ‘Best Trust in England for Quality of Care’ was awarded to Hinchingbrooke Health Care NHS Trust – beating other shortlisted flagship trusts such as Guy's and St Thomas’ NHS Foundation Trust and Chelsea and Westminster Hospital NHS Foundation Trust. A cynical view, expressed by a local union leader,5 is to appreciate that this award was made by CHKS, a hospital benchmarking organisation that started within the King's Fund 25 years ago, but was acquired by Capita plc in 2009;6 the award represents ‘the private healthcare industry patting itself on the back…People must look behind the headlines to see what is really happening.’
Is that fair criticism? The NHS Choices rating, to which one might look for confirmation based on patient opinion, is indeed less glowing, with an only respectable rating of 3.5/5, but that is the consensus of a mere 63 volunteered opinions.7 The Care Quality Commission registered Hinchingbrooke's services in 2010, but states that they have not yet inspected it.8 The top quality of care award is judged from a panel of 12 medical indicators such as length of hospital stay, mortality, cancer waiting times and patient-reported outcomes,9 and that must be considered a probably more robust assessment than an accolade based on subjective opinion of an appointed panel.
So – how was this arguably unprecedented turnaround achieved? Commentators have highlighted the appointment of predominantly clinicians (11 out of 14 seats) to the Board, coupled with an immense effort to gather and act on patient feedback (a 20-fold increase numerically).10 One visiting journalist commented on Toyota-type innovations such as ‘Stop the Line’, empowering staff of all grades, and summarised the philosophy as ‘[nothing] brilliantly original – simply…free to act according to common sense. Involve staff in decisions. Make sure that doctors and nurses can run things’.11
Is it really as straightforward as that? Few stories have quite such simple morals. Yet whatever the other influences at work in this hybrid private–public management system and this employee co-owned private company, whatever the vagaries of award ceremonies, and whatever the precise cause and effect relationships, the happenings at Hinchingbrooke demonstrate a powerful correlation between empowerment of clinicians, listening to patients and enhancing quality.
- © 2014 Royal College of Physicians
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