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Drive-By Surgery

Posted by Dr No on 08 June 2011

snip.jpgDavid ‘Ozymandias’ Cameron’s five NHS pledges – worthy of only the briefest flash in the news-pan yesterday – are already showing all the substance of five brown ballerinas. Even as he made his speech, the smart finger was on the money. PCTs have been running rings round the fixed national tariff for months, allowing private providers to compete on price.

The Bureau of Investigative Journalism has spotted a loophole, a loophole, we might add, that is as wide, open and inviting as a barn door, that allows – forgive the jargon – community services provided under the any willing provider procurement process to escape the national tariff. Since this is the kind of terminology that gives the rest of us a migraine, we may translate this to mean stuff done outside hospital, excluding normal general practice, that is not subject to fixed prices.

If we grab an orthopod, and stick him in a van with some kit, and have him offer drive-by carpel tunnel surgery, that fits the bill. So to does the gynaecologist doing his colposcopies in a Nissen hut, and the gastroenterologist shoving his camera where the sun don’t shine in a bike shed. Because these procedures are being done outside hospital, they all fit the bill, very nicely indeed, thank you very much, because community services are not covered by the mandatory national tariff – and that means commissioners can – and do - invite providers to compete on price.

Nonesense, I hear you say? Didn't the Tories say no competition on price? Not a bit of it. Dr No had a quick poke around the snazzily named Supply2Health website, and it seems they are all at it. Here is the ad for orthopaedic services:

“NHS Leicestershire County and Rutland and NHS Leicester City is looking to procure services from up to 4 providers or consortia of providers to provide the following healthcare services – Community Minor Hand Surgery…The total indicative contract value is cumulative…Bidders will be required to submit a unit cost for each of the procedures detailed in the specification. The maximum cost that the PCT will pay for each patient pathway is £570.”

And the one for the ladies: “North Somerset PCT: Community based Gynaecology service, for conditions suitable for diagnosis and treatment within a community setting…to provide assessment, diagnosis and treatment of defined gynaecology conditions…in the community setting, which equals or exceeds in quality that provided in secondary care at less cost.

And the sigmoidoscopy service: “NHS Western Cheshire is currently conducting a scoping exercise to determine the potential for a community Endoscopy service through the Any Willing Provider Process (AWP)…to scope non urgent patients for Upper and Lower GI conditions i.e. Gastroscopy and Flexible Sigmoidoscopy…To provide this service at an affordable, reduced Tariff. This non-tariff local price is anticipated to be between 50% and 75% of current NHS non mandatory PbR Tariff.” One hopes they know where to stick their scoping exercise.

And – just in case the chaps are feeling left out: “South Staffordshire PCT is seeking Expressions of interest (EOI) for the delivery of a high quality community based vasectomy service…The service will be delivered under an AWP (Any Willing provider) model…The maximum price for which the PCT will commission the service is £220 per completed pathway…”

Although the menfolk of South Staffordshire may envy those of Sheffield, who it seems may be offered an altogether better class of vasectomy based on a higher price point: “NHS Sheffield is seeking Expressions of Interest from suitably qualified and experienced providers to deliver a high quality and safe one or two stage, no-scalpel technique vasectomy…in a community setting…This is an Any Willing PCT Accredited Provider (AWPP) procurement…The maximum price the PCT will commission the service for is £290 per treatment.” Why the home of British cutting steel should elect to offer non-scalpel vasectomies at a higher price is – it seems to Dr No – quite beyond commercial logic.

Note in each ad the inclusion of the crucial words ‘community’ and ‘service’; and how in each case the wording in italics subtly – or not so subtly – invites providers to compete on price.

Expect a large NHS branded articulated community lorry to turn up in a car-park near you any time soon…


Dr No respect.

You have realized what PCTs have done for a while that the market is fixed in that hospitals cannot vary prices but general practice can and it is seen as cheap and therefore secondary care work can be dumped there.

This, as is so often the case, leads to PCTs shooting themselves in the foot for they then seek to reduce further the price they pay to the point where the work done becomes loss making and then returns to secondary care.

History surely will not repeat itself with any of these new fangled schemes?

ND and the team.

My Black Cat, always the helpful one, has noted that a private healthcare company utilizes the local scout hall for their health screening sessions. She knows this, because pamphlets come round the doors indicating that attending one of these screening sessions in the scout hall (at a cost, because it iis outside the NHS) might save your life.

Since most towns have a scout hall, and perhaps even a guide hall too, then MBC suggests that those private companies working under the NHS Kitemark make use of these facilities because the small rent they will be charged will contribute towards "The Big Voluntary Society." Goodness, these companies may even be able to negotiate that some senior scouts or guides volunteer to deliver 'educational' leaflets round the doors, clean up the hall before and afterwards, and are trained in a few competencies like administering local anaesthetics or holding retractors.

Free labour, cheap premises, and the private sector embracing The Big Society in a big bear hug.

Almost Utopia!


Thanks ND and team. There's two sides to this coin, so to speak. Initially this post had an additional sentence at the end of the first paragraph (it got dumped because Dr No prefers to stick to one theme per post):

Meanwhile, groups of GPs have been tooling up to become not just any willing provider, but very willing providers.

In other words often the AWP/VWP is guess who? Surely not a bunch of likeminded GPs from down the road?

A bit like the 'community service' ads, these links are everywhere once one starts to look for them. A quick google yesterday turned up a Dr BH, a GP from Sutton. Beyond that I know nothing about him, except his list of interests suggests he is a pillar of the local community. Indeed, so integrated into Sutton life is the good doctor that one fears that when he is out of town, Sutton ceases to exist.

The point about Dr BH is not who he is - he happened to turn up on the throw of the google dice, and there are many many more like him - but his network of connections. His list of interests can be read here. It is a long interesting and worthy list but entries one two and three are the ones that concern us here:

GP partner at the Grove Road Practice.

Joint Chair, Sutton Horizon GP Consortium, now the Sutton Consortium (Its website was live yesterday but has disappeared for now, although it is still in goggle's cache here).

Partner, Assura Wandle LLP, a GP-led provider Company (GPCo). Assura is the company that got shagged by Virgin just over a year ago.

Like many others, Dr BH has his finger in both the purchasing and the providing pies. Dr No has been heard saying for some time that until these folk work out how they are really going to manage accusations of conflicts of interest (beyond the current blandishments) they risk being seen as snouts stuck in troughs.

Our excellent resident pest control officer has picked up on the other tariff dodging wheeze spotted by Bureau of Investigative Journalism: non-doctor clinics. These are not as some might suspect, for the orgasmically-bereft. Instead, they are clinics run by nurses and other movers and shakers - and as such the fall outside the remit of the mandatory tariff. Dr No was less successful in tracking down real world examples of such 'innovations' but no doubt they are there. Perhaps the WD's black cat is already sniffing them out!

"stuff done outside hospital, excluding normal general practice, is not subject to fixed prices. "

Well, what do you know! And those providers, who makes sure they are qualified? ... and does that mean that any GP, hospital doc, nurse, etc, can just go get themselves a truck, kit it out and go into business? Do those have to be medical at all?

Long live 'our NHS' .. hehe! :-D

When will we be able to deliver 'drive through' surgery for minor ops?

It is so clear now.

It is going to be a two tier system. Two for the well off and none for all others.

The Cockroach Catcher