It was with some alarm that I noted recently that in Bedfordshire a five year contract for musculoskeletal services had been agreed with a private provider. I only hope that the tendering process was thorough and that all possible clinical governance problems have been flagged and covered. My own experience has been that some providers have a rather cavalier attitude to that side of things, and may allow practitioners to exceed their competence (doing things they really need a lot of training for – for example, physiotherapists doing joint injections) or using unproven techniques often of the alternative medicine type.
However I have a more fundamental problem with this type of outsourcing. Consultants are appointed around the age of 35. This leaves them a professional life of 30 years, possibly more. How does this square with a contract life of only five years? We can assume that during a five year cycle the first will be spent consolidating the agreed contract, the second and third bedding down, and the fourth and fifth winding up to renegotiate and reapply for the contract. This will not only be time-consuming, but also will be a time of great uncertainty. What happens if the contract is awarded elsewhere? Could the site in current use be closed? Will current senior staff be taken on by a new contractor? Could they be re-deployed elsewhere in the contractor’s ambit? It will become impossible, particularly in the chronic disease field, for any long-term service planning to be meaningfully achieved. Rheumatology and orthopaedics cannot be treated the same.
I have seen examples of contracts not being applied for. One Trust I worked at had put together a comprehensive tender document to supply a primary care group with physiotherapy services only for a non-clinical manager to decide at the eleventh hour that the tender would not be submitted. I did wonder whether money had changed hands. The result was a need for significant and disruptive changes within the Trust’s own service. It also created yet another “service interface” , limiting opportunities for primary/secondary care communication, and caused significant damage to a well-established and effective back pain triage service.
Constant reorganisation and change is not just disruptive – it is demoralising. The setting of five year contracts is not appropriate to medicine but is predicated on the assumption that all medical care is short-term. Furthermore the partition of general services may result in patients’ care being fragmented. If one organisation runs the musculoskeletal service and another the cardiac service patients will be shuttled about and clinical information may not be exchanged effectively.
Contracts and tendering undoubtedly focus the mind and may have financial advantages. However there are substantial and risky downsides to the process. Short-term micromanagement based on money and not clinical excellence will replace long-term service planning. A further risk is that experienced staff subjected to these processes will examine options to relocate somewhere where this does not happen, and leave. The brain drain to Australia and New Zealand may speed up; I was alarmed, on a recent visit there, to see the horror and incomprehension on the faces of doctors, some from the UK, when I explained what was happening.
A further risk of contracting fragments of health care is that interprofessional communication will break up. In a hospital that provides all services it is easy for colleagues to seek quick opinions from other disciplines. For example, if a patient turns up in a rheumatology clinic with a ruptured tendon they can be whisked round the corner to see an orthopaedic surgeon, or if a patient is ill with breathing difficulties a chest physician can be consulted at once. This effective and rapid focus on acute problems becomes impossible when the services are scattered. As an example I had a patient in my clinic who appeared to be in the middle of a heart attack. My hospital had no A&E thanks to reorganisation and I suffered the indignity not only of having to ring for an ambulance to ship them out (there were no medical staff available to assess the patient, and no ECG facilities in outpatients) but wait over half an hour for the ambulance to arrive. My protests at the delay were met with a blithe remark that there was no rush as the patient was already in a hospital…
By all means look at the advantages of contract-setting, but before starting out look also for the possible problems. Indeed I would go so far as to suggest that the problem-seeking should come first. It will be a disaster if these are glossed over, only for it to become apparent that they are insuperable and dangerous. And believe me, I have seen that happen too.
The Wry Observer 