Striking the right balance

It was surely good news for NHS patients when the Government announced last October that it was to invest a further £40m in the Concordat process with the UK's independent health and social care sector. Under the agreement many tens of thousands of NHS patients have been treated in Britain's 211 independent hospitals at no personal financial cost to themselves.

During Labour's first term in office, over 100,000 NHS patients were treated in independent hospitals, thus helping the Government ease waiting-list pressures. At the end of 2001, just over a year since the Government and the Independent Healthcare Association (IHA) signed the Concordat, as many NHS patients again have benefited from treatment and care in the independent sector.

In line with other European countries, NHS-funded patients are no longer confined to receiving treatment and care in State-owned hospitals. Today, they can access independent hospitals and care services provided in charitable, mutual and commercially owned facilities. The Independent Healthcare Association is confident that its members can offer the NHS a further one million treatments in the full life of a parliament.

Reducing waiting lists

Let us imagine that for every working day of the year each independent hospital was asked to deliver four extra operations for the NHS. That would mean an additional 1,040 operations in each hospital every year. With over 200 hospitals in the sector, the total would be more than 200,000 operations a year, more than one million over the life of a five-year parliament. If the Government agrees to the independent sector building and operating some of the NHS's new fast-track surgery centres, then this number could be even bigger.

With over 500 operating theatres, 800 critical illness beds and 10,000 acute medical/surgical beds, the independent sector's numbers are impressive. Seeing more than one million inpatients and over four million people as outpatients each year, the sector's hospitals clearly have substantial capacity to help ease pressures on the NHS. The Mental Health Act Commission points out that independent providers now deliver more than 55 % of the NHS's medium secure provision. Offering innovative and pioneering services in high quality surroundings, independent providers have demonstrated that a partnership can work for the benefit of the NHS and its patients.

Independent providers of acute mental health and substance misuse services offer more than 70 facilities across the country. Providing more than 3,000 beds, they deliver around a quarter of the country's combined acute mental health provision. Now providing 31 specialist units for the treatment of eating disorders, the sector provides more than 80% of the country's acquired brain injury rehabilitation. Again, the sector delivers the majority of the country's substance misuse care.

Independent nursing and residential care homes provide at least 420,000 beds and more than 150 million nights of care each year. In addition, the independent sector provides most care-at-home (domiciliary care) services. Mainly used by older people who require both long or short-term care and support, they are an integral part of the nation's wider health and social care system. Sadly, for many years independent nursing and residential homes have suffered from a lack of funding by local authority social services departments. A survey by the IHA shows an annual £1.5bn shortfall on fees. Consequently, the independent sector has lost many hundreds of homes and tens of thousands of beds in the last few years.

Independent care homes

As the Government puts more emphasis on reducing delayed discharge from NHS acute hospital beds by older people, and with the promotion of forms of intermediate care as a panacea for the bed blocking problem, many believe the time has come for independent sector care homes to be better funded. To fail to do so, they argue, could jeopardise the care of older people in Britain, as well as a crucial element of the Government's NHS plan.

What is encouraging is the Labour Government's recognition of the problem facing long term care. Late in 2001, it introduced a framework agreement on partnership working between local authorities and providers of nursing and residential care in the independent sector. On the strength of this agreement, the IHA looks forward to care services being more appropriately funded in the future.

Partnerships for training

The independent sector helps to train many nurses and allied health professionals by providing clinical placements, vocational qualifications to care workers and post-graduate education for doctors. In partnership with the NHS, thousands of student nurses now spend time in independent hospitals and nursing homes where they learn about many specialities.

It also offers post-graduate training for thousands of registered nurses and allied health professionals. Training covers theatres, neuro-surgery, critical care, and cardiac, renal, infection control, risk management, care of the elderly and continence management.

It also helps to train post-graduate doctors. In the area of mental health, the sector offers courses and updates on adult psychiatry, brain injury rehabilitation, and child and adolescent care. Independent acute hospitals also run accredited post-graduate study courses for thousands of doctors.

Employing many hundreds of thousands of care workers, the sector's nursing and residential care homes offer many National Vocational Qualifications for care assistants. Finally, the sector also supports the training of statutory inspection officers.

Probably the greatest myth about the independent sector is that it somehow steals nurses away from the NHS. Over recent years, less than 4% of nurses who left the NHS moved to work in the independent sector. The majority, more than 96%, simply left nursing altogether.

Having pioneered flexible working practices for many years and now supporting return to nursing courses, staff retention levels are not only higher in the independent sector, but the sector can offer partners in the NHS proven human resource strategies.

Today, the IHA believes the independent sector is well placed to deliver the NHS Plan's target of 500 one-stop health centres and the refurbishment and replacement of up to 3,000 GP premises by 2004. In addition, as part of the NHS Plan, local NHS local improvemnt finance trusts (LIFTs) will be set up in areas of greatest need to finance and develop 'batches' of premises which they will own and lease to GPs.

There is no reason why the independent sector could not bring with it a range of management and staffing solutions. After all, it could prove beneficial in areas where GPs have little interest or experience in premises or service development, or if they are concerned with the specific delivery of medicine.

Despite the best efforts of the Blair administration and record investment in the NHS, it is apparent to many analysts that demand for healthcare will always outstrip supply. Alongside that, theories are developing for how healthcare will be funded. Although the Government is committed to an NHS funded by taxpayers' money, it has not stopped short of examining the options ' hence the commissioning of the Wanless report.

But what are the options for the future? Last year saw the first significant growth in private medical insurance (PMI) for many years, albeit mainly in the company-paid market. Businesses at least recognise the problems associated with illness.

Increasingly, individuals are venting their annoyance at NHS waiting times by purchasing PMI, cash plans or, perhaps most significantly, by paying for one-off operations in the independent sector from their own purses. Since 1997, we have seen self-funded private treatment rise from 100,000 people a year to over 250,000. There is no reason to suspect the public will not continue to support these alternatives to the NHS.

Time for change

Perhaps an NHS increasingly independent from the Treasury will offer the most radical solution. In January, Secretary of State for Health Alan Milburn announced a groundbreaking trend ' foundation status for successful NHS hospitals. Allowing them earned autonomy and granting them decision- making and budgetary freedom, Dr Milburn has opened up a whole new world of opportunity.

Taken to its extreme, we might see NHS hospitals returned to their independent pre-1948 roots, or even the re-emergence of old-school hospital funding or provident society insurance schemes to fund treatments in these foundation hospitals. Whether this would widen customer reach within the medical insurance sector or merely increase competition in a static market would be up to the insurers themselves.

Why? Because, like their counterparts in primary care trusts, managers of foundation hospitals will hold the key to the funding of healthcare in the future.

Today, with no one sector having a monopoly on quality, investment and technology, it is vital that all concerned share their ideas about UK health and social care. As rising expectations and pressures on services continue to mount, greater levels of national and community-based teamwork between all health and social care providers will be needed.

With more than one million people still on NHS waiting lists and thousands of others trying to access care and treatment, the idea of extending partnerships between the State and the independent sector ' even in terms of the funding of healthcare ' has never looked so attractive.

Peter Fermoy is communications manager at the Independent Healthcare Association