After announcing his departure from AXA PPP healthcare, Dr Adrian Bull looks back on the challenges he has faced working in the sector with Kirstie Redford
Dr Adrian Bull has just handed his notice in as medical director of AXA PPP healthcare to embark on a new career.
In his seven years at PPP, Bull has not so much worked for the company as led it into previously unchartered ground. He spearheaded a funding strategy that helped to cap runaway consultancy costs and tip the balance of choice in private healthcare provision back into the favour of paying patients.
Indeed, following a well-trodden career in clinical practice never suited Bull ' he has always had his sights set on wider issues.
'I knew clinical practice was not going to hold my interest for my whole career. I was interested in the broader aspects of health service provision and health service design,' he says.
Before joining PPP, Bull had an avid interest in the health politics of the day ' namely the purchaser-provider split at the time of Margaret Thatcher and Kenneth Clarke's NHS reforms. From an early stage in his career, Bull spoke out about the Government's developing policies on healthcare purchasing. Although his views were at the time unpopular with many of his contemporaries, it was his determination to improve healthcare provision that kept him true to his cause.
'I was interested in the concept of purchasing healthcare for the population ' deciding what the population needed and wanted and buying in the services to meet those needs. I was fully supportive of that as a principle for the NHS right from the start ' at a time when it was extremely unpopular with most doctors. In fact I wrote an article in the British Medical Journal, which created a bit of hate mail at the time. Doctors were adamantly against it.'
Bull was, however, fairly critical of the way in which the NHS was going about developing purchasing, believing it was slow and limited. After working in a couple of different roles in the NHS, PPP asked for his help in developing a strategy for actively buying healthcare for its customers.
'It was a case of put up or shut up. I had said purchasing was the right thing to do, I felt the NHS was not doing it properly and here was a company saying 'come and lead our purchasing strategy.''
So Bull joined PPP in 1995. The first major strategy he embarked on was to establish a network of selected hospitals across the country.
'That was a huge step for the industry at the time because the common practice was for insurers to do business with any hospital that had opened its doors and got its certificates. BUPA and PPP salesmen used to go around saying 'my list of hospitals is longer than your list,'' says Bull, 'there was no link between price and the choice that patients and their GPs were making about where they received care.'
This meant there were no market forces properly operating and, according to Bull, hospitals were running at a very inefficient level of occupancy.
'What the hospitals were doing was competing for the favours of consultants. Consultants were the customers of the hospitals ' not patients and not insurance companies. They would play the hospitals off against each other,' he says.
What PPP did in the middle of all this was to set up a contract with one hospital in each town, meaning specialists did not have a free-hand to take patients where they wanted, so insurers and, in turn, patients benefited from lower prices and more rigorously assessed care quality.
'I designed the programme, led the team, and did the negotiations with group offices and individual hospitals. Specialists were in uproar about it because we were suddenly shifting their position of influence. This marked a huge shift in the dynamics of the way private healthcare was operating,' he says.
Bull feels this change in purchasing strategy has helped the insurer make bolder moves in the market than its rival BUPA.
'BUPA is obviously compromised as a purchaser by the fact it has a significant provider market share, for which reason, it is concerned with upsetting specialists and protecting its hospital revenues as much as its insurer revenues,' he says.
It is still BUPA, along with PPP that holds the lion's share of the private medical insurance (PMI) market in the UK. Smaller providers often blame the sluggish market on the inflexibility of the two main players, saying it could be made more innovative if the market share was more evenly distributed. However, despite Bull's reservations about BUPA's purchasing strategy, he believes the unequal share of business is healthy for the market.
'If we had a fragmented private medical insurance market, with maximum market shares at 5% or 6%, provider costs would go through the roof,' he says.
Bull is leaving PPP to lead the healthcare division of Carillion, a building-to-services company, which is involved in private finance initiative programmes. This is an area in which Bull has a real interest and sees as presenting his next set of challenges.
'I have been given the opportunity of taking up a managing director's position in an exciting field, which I am obviously keen to do. I firmly believe the NHS has to move down the route of having a mixed economy of provision. I also think there needs to be mixed funding. The area of private finance initiatives is interesting and it is clear this is the way the public sector is going to continue to develop.
'I am leaving some good friends behind at PPP, but I am indeed looking forward to the next phase of my career.'
