Privatising Urgent Care

Shropshire Defend Our NHS has always been concerned that the whole exercise of consultation around Future Fit has been a sham – and that the key decisions have already been made. The latest decision of Shropshire CCG is proving us right. The CCG are seeking approval for opening an Urgent Care Centre at the Royal Shrewsbury Hospital site with only a few days notice to the public, with the Shropshire Star of 10^th July reporting that “a decision will be made on July 14”. It is of huge concern, too, that the CCG have decided to give the work to a profit making private company, Malling Health. This is to be a new service, resulting in a fundamental change to how the existing A&E department at the Royal Shrewsbury Hospital works. This cannot be seen simply as the extension of an existing contract.

The absence of consultation is shocking. We have been told repeatedly that no decisions have been made yet about how to implement the local ‘Future Fit’ proposals for major reorganisation of NHS services. There is supposed to be public engagement about a short list of options in the autumn of this year, and a formal public consultation after next year’s General Election. Now, though, the CCG are simply bypassing all of their own commitments to consultation and are steamrollering ahead with their plans.

A major strand of Future Fit is the proposal to have a single Emergency Centre in Shropshire, with our existing A&E departments at either or both RSH and PRH being closed. (Campaigners fear that the Royal Shrewsbury Hospital is very strongly at risk). The Future Fit plan is that there will be “some” or “several” Urgent Care Centres in addition – the numbers, locations and services offered to be subject to formal public consultation. The Urgent Care Centres are intended to be gate keepers – no one will be able to go straight to the Emergency Centre unless they are in an ambulance.

The paper produced by Shropshire CCG for Shropshire Council’s Health and Adult Social Care Scrutiny Committee, asking the committee to support the proposal, quotes Professor Jonathan Benger  (National Clinical Director for Urgent Care for NHS England): “all Emergency Departments should have a co-located Urgent Care Centre”. The CCG paper does not explain the NHS England proposal that all current Walk-In Centres and Minor Injuries Units will be replaced by the Urgent Care Centres, and will therefore close down.

Setting up an Urgent Care Centre at RSH will pre-empt the Future Fit decisions on the location of Urgent Care Centres across Shropshire, and – with no acknowledgement at all – will have implications for the future of Shropshire’s Minor Injuries Units (currently at Ludlow, Oswestry, Bridgnorth and Whitchurch). If the model is an Urgent Care Centre at RSH, what is likely to happen to these existing Minor Injuries Units? The CCG suggests it is using a “prototype approach” but provides no criteria for determining the success of the prototype.

The CCG paper suggests that 60% of current attendees at A&E could be treated by a GP led walk-in service. But they forget the important statistic highlighted in a recent survey by the College of Emergency Medicine that 85% of patients who arrived at an A&E needed to be seen there. The disparity between the two figures is important. While not all patients need to be treated in A&E, the skilled clinicians there are better able to assess complex patients, diagnosing or excluding serious conditions.

The CCG have also to be questioned on why they are looking to a private profit-making company to provide the service. All the discussions around Future Fit have had an underlying assumption that the providers of the re-configured services would be the existing NHS Trusts and local GPs. At no stage has it been suggested that a major provider from the private sector will provide Urgent Care, with the risks here of undermining the financial viability of existing NHS providers. All of the clinicians have argued at Future Fit engagement events that they do not want to see any further fragmentation of healthcare – yet splitting provision of Urgent Care and Accident and Emergency Care between two providers quite clearly fragments the service.

So why Malling Health?

Malling Health’s current 5 year contract to provide the Shrewsbury Walk in Centre expires this August. The CCG are offering the company a 5 year extension – with no one else being offered the opportunity to bid. This is surprising, given that this is effectively a new service. Malling Health will then of course be in a prime position to run any other Urgent Care Centres coming out of Future Fit.

Malling Health is a rapidly expanding health services company. Formed in 2009, by 2012 their post-tax profits were £223,453. By March 2013 their profits had more than doubled to £460,752. The Daily Telegraph described Malling Health’s initial business model:

The company looks for “single-hander GPs”, offering “tailor-made solutions to enable the retiring GP to leave with dignity … Feel free to contact us.”

That’s a low cost way to build up a portfolio of GP practices.

Malling Health’s principal business is stated in its annual accounts as “tendering for and managing medical practices.” That doesn’t stop the company looking at other areas where it thinks it can make a profit – “(we) would love to hear about proposals concerning Dentistry, Pharmacy, Community Services and many more”. Their interests stretch much further than what most of us believe to be General Practice. A current job advertisement for a position with Malling Health reads:

“We are currently recruiting a GP for a private patient based in London & Zurich. You will be on call and working with the patient/client and travel as and when required with the client.”

The salary offered is up to £150,000, plus expenses and accommodation. This is healthcare for an immensely wealthy client – someone with far different priorities to those of most Shrewsbury patients.

Malling is quite clear that profits come first. Last year’s annual report included a complaint about the high cost of locums:

“This has led to some Practices returning lesser profits than expected, or even in some cases a loss. This is being addressed and we have now appointed someone to manage this whole area.”

We now know how Malling Health is addressing the issue.

In 2012 Malling closed its Sterling House practice in Luton, Kent. Malling’s rationale was described in a paper to the Medway Health and Adult Social Care Overview and Scrutiny Committee in May 2012:

“Their rationale is that they have not been able to register enough patients to make the surgery viable, and that being compelled to continue providing services from the site risks the stability of their other surgeries. Part of the reason for this may be that lower than expected patient numbers has led to Malling health reducing the number of GP and nurse appointments it offers at Sterling House. There are morning or afternoon GP sessions – not both. This in turn has made the surgery less attractive to patients.”

Similar events took place in Essex in August 2013. There it was the Brambles Surgery in Brentwood that was closed because it was “no longer financially viable.” Earlier this year, Malling gave up their contract for their surgery in Wednesbury, Sandwell. Although the formal reason given was accommodation issues, the business plan had been predicated on achieving a list of 6000; in practice, Malling only achieved a list of around 2500.

The pattern is the same in each case: closure or running down of services if Malling Health does not make what it considers to be an acceptable profit.

Shropshire CCG claim to have fully consulted about this proposal – but it was only discussed with the patients at the Walk In Centre at the end of June; with the wider public only through the pages of the Shropshire Star on 10^th July; and not at all with the majority of stake holder groups involved in Future Fit. This is inadequate.

The implications of this decision are enormous. A major strand of privatisation of the NHS is introduced, without discussion. Fragmentation of care is a real and immediate outcome. There is an additional risk of destabilising the local health economy by undermining the financial viability of existing providers. Patient access to urgent care is also likely to be affected. We know the overall number of Urgent Care Centres across Shropshire will be small. A decision at this stage to locate one Urgent Care Centre at Shrewsbury therefore reduces the opportunities for Urgent Care Centres to be located at the sites of our existing Minor Injuries Units or at our community hospitals (resulting in far worse access to urgent care for Shropshire people in rural areas, and potentially undermining the viability of existing services at community hospitals).

It is simply wrong for Shropshire CCG to attempt to push this decision through with such minimal consultation. This is no way to plan the future healthcare for Shropshire people.