Posts Tagged ‘Privatisation’

Firms to bid to run GP consortia if they fail

Healthcare Republic - 6th August 2010 2:30 pm

GP consortia are “odds-on” to fall into deficit and be taken over by private firms when they take on commissioning, according to one leading GP.

The warning comes as private companies confirm they hope to run consortia if local GPs fail. Firms are also bidding to provide data the NHS Commissioning Board will use to performance manage consortia.

Dr Kambiz Boomla, a GP in east London and lecturer at London’s Queen Mary University, said there was little evidence GPs would be able to balance constrained NHS budgets, and the DoH would replace them with private firms if they failed.

“A few years ago almost all PCTs were in financial difficulties and that was during years of growth,” he said.

Read more at Healthcare Republic.

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The coalition government’s priorities on healthcare

By Mike Broad - 24th May 2010 10:06 am

The government has published its plans for the NHS, merging the policy commitments of the two parties.

The document, called The coalition: our plans for government, starts by saying the NHS is an important expression of our national values and the government is committed to an NHS that is free at the point of use and available to everyone based on need, not the ability to pay.

The government wants to free NHS staff from political micromanagement, increase democratic participation in the NHS and make the NHS more accountable to the patients that it serves.

“That way we will drive up standards, support professional responsibility, deliver better value for money and create a healthier nation,” it says.

The following are the commitments it makes on the NHS:

• We will guarantee that health spending increases in real terms in each year of the Parliament, while recognising the impact this decision will have on other departments.

• We will stop the top-down reorganisations of the NHS that have got in the way of patient care. We are committed to reducing duplication and the resources spent on administration, and diverting these resources back to front-line care.

• We will significantly cut the number of health quangos.

• We will cut the cost of NHS administration by a third and transfer resources to support doctors and nurses on the front line.

• We will stop the centrally dictated closure of A&E and maternity wards, so that people have better access to local services.

• We will strengthen the power of GPs as patients’ expert guides through the health system by enabling them to commission care on their behalf.

• We will ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local PCT. The remainder of the PCT’s board will be appointed by the relevant local authority or authorities, and the chief executive and principal officers will be appointed by the Secretary of State on the advice of the new independent NHS board. This will ensure the right balance between locally accountable individuals and technical expertise.

• The local PCT will act as a champion for patients and commission those residual services that are best undertaken at a wider level, rather than directly by GPs. It will also take responsibility for improving public health for people in their area, working closely with the local authority and other local organisations.

• If a local authority has concerns about a significant proposed closure of local services, for example an A&E department, it will have the right to challenge health organisations, and refer the case to the Independent Reconfiguration Panel. The Panel would then provide advice to the Secretary of State for Health.

• We will give every patient the right to choose to register with the GP they want, without being restricted by where they live.

• We will develop a 24/7 urgent care service in every area of England, including GP out-of-hours services, and ensure every patient can access a local GP. We will make care more accessible by introducing a single number for every kind of urgent care and by using technology to help people communicate with their doctors.

• We will renegotiate the GP contract and incentivise ways of improving access to primary care in disadvantaged areas.

• We will make the NHS work better by extending best practice on improving discharge from hospital, maximising the number of day care operations, reducing delays prior to operations, and where possible enabling community access to care and treatments.

• We will help elderly people live at home for longer through solutions such as home adaptations and community support programmes.

• We will prioritise dementia research within the health research and development budget.

• We will seek to stop foreign healthcare professionals working in the NHS unless they have passed robust language and competence tests.

• Doctors and nurses need to be able to use their professional judgement about what is right for patients and we will support this by giving front-line staff more control of their working environment.

• We will strengthen the role of the Care Quality Commission so it becomes an effective quality inspectorate. We will develop Monitor into an economic regulator that will oversee aspects of access, competition and price-setting in the NHS.

• We will establish an independent NHS board to allocate resources and provide commissioning guidelines.

• We will enable patients to rate hospitals and doctors according to the quality of care they received, and we will require hospitals to be open about mistakes and always tell patients if something has gone wrong.

• We will measure our success on the health results that really matter - such as improving cancer and stroke survival rates or reducing hospital infections.

• We will publish detailed data about the performance of healthcare providers online, so everyone will know who is providing a good service and who is falling behind.

• We will put patients in charge of making decisions about their care, including control of their health records.

• We will create a Cancer Drugs Fund to enable patients to access the cancer drugs their doctors think will help them, paid for using money saved by the NHS through our pledge to stop the rise in employer National Insurance contributions from April 2011.

• We will reform NICE and move to a system of value-based pricing, so that all patients can access the drugs and treatments their doctors think they need.

• We will introduce a new dentistry contract that will focus on achieving good dental health and increasing access to NHS dentistry, with an additional focus on the oral health of schoolchildren.

• We will provide £10 million a year beyond 2011 from within the budget of the Department of Health to support children’s hospices in their vital work. And so that proper support for the most sick children and adults can continue in the setting of their choice, we will introduce a new per-patient funding system for all hospices and providers of palliative care.

• We will encourage NHS organisations to work better with their local police forces to clamp down on anyone who is aggressive and abusive to staff.

• We are committed to the continuous improvement of the quality of services to patients, and to achieving this through much greater involvement of independent and voluntary providers.

• We will give every patient the power to choose any healthcare provider that meets NHS standards, within NHS prices. This includes independent, voluntary and community sector providers.

Read the BMA’s response.

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Harnessing the benefits of the independent sector - a briefing

By Mike Broad - 30th April 2010 11:57 am

NHS Partners Network, which represents independent sector health organisations, has launched a briefing document entitled Harnessing the benefits of the independent sector: priorities for the next government.

The document claims that the independent sector is uniquely placed to help develop innovative approaches to healthcare that drive quality and patient satisfaction up, increase productivity, and thus ensure that the unprecedented funding pressures on the NHS do not lead to a decline in quality.

But NHSPN demands that the process of market reform instituted during the Blair government needs revitalisation. The following is a summary of the changes that NHSPN believes are needed:

1. Publication of comparative quality data to support choice

All the main political parties are committed to improving patient information. NHS Choices website should be run by an independent organisation, and multiple sources of information should be encouraged.

The first published outputs from the independent sector’s data benchmarking project will be launched this summer. It is also important that data collected by the Department of Health itself is made fully available. It is wrong that data collected by the government, at considerable expense to the providers, should be withheld from the public and from analysts who can help the public make sense of it.

2. Abandon the preferred provider policy and require periodic competitive challenge

The government’s preferred provider policy is anti-competitive. The principle of value for money should be the overriding one guiding NHS commissioners. Any willing provider who meets NHS standards should be eligible.

There should be a commitment that, over appropriate periods of time, all NHS services should be exposed to competitive challenge so as to ensure that opportunities for maximising value and embracing innovation are not overlooked.

The provider market is still underdeveloped. This should be objectively recognised and reflected in practice, but not abused or used as an excuse for restricting the use of competition.

There will be circumstances when taking a broader view of alternative ways in which services can be provided may well result in there being a wider pool of potential providers than is at first apparent.

Commissioners need to be more aware that the surest way of demonstrating they have secured best value is by using open, non-discriminatory tendering processes wherever practical.

3. Create a level playing field

With increasing pressure on tariffs, and the likelihood of some form of renewed price competition in the future, resolving the major outstanding level playing field issues is a strategic necessity if independent sector and investor participation in the NHS is to be sustainable.

Independent economic analysis has established that the independent sector currently has to operate with a cost disadvantage of around 14% relative to public sector providers. The NHS pension scheme is the biggest problem. Unless this aspect of the playing field is levelled it is likely that over time the pitch will become unplayable for the independent sector.

A substantial part of the pension costs are carried by central government not by NHS provider organisations themselves. This puts the public sector at a competitive advantage over the independent sector.

To deal with this it will be necessary to ensure that public sector bidders are assessed on the basis of their full cost to the taxpayer. This might be done either by increasing the percentage of their pension costs which they have to bear directly or by applying a ‘shadow’ weighting factor which forces commissioners into making a truer comparison when assessing bids.

Internal accounting and cost allocation is weak within the NHS. Full cost allocation and accounting should be enforced.

4. Putting the NHS competition regime and the Cooperation and Competition Panel onto a statutory basis

The CCP has no statutory powers or legal teeth and can only make recommendations, and in recent months it has become clear that its rules can be rewritten by its sponsors.

The CCP needs to have teeth and become independent of political influence. A firmly established regime for managed competition has emerged as one of the vital reforms needed if investors are to be persuaded to the UK NHS market.

5. Establish proportionate, even-handed regulation

The Care Quality Commission must regulate the independent sector to the same standards and proportionality of all types of provider.

6. Build a new relationship with GPs

GPs will face an increasing conflict of interest. Inherent in the GP model is a perpetuation of commissioner-provider integration, rather than the split which is generally seen as beneficial for healthcare systems.

GP practices that scale up to carry out broader commissioning functions will become more dominant in their local markets, thus reducing patient choice, making market entry more difficult and further reinforcing their advantages. And the GP contract fails to incentivise them to drive change.

There will need to be a new GP contract which incentivises change and high performance, with corresponding measures of quality, thus recognising that the structure of primary care needs to move with the times.

The OFT should look into the changing nature of the GP market and consider what changes might be appropriate to avoid excessive market dominance and reduce barriers to entry.

7. Simplify contracting arrangements

There is a need for simpler, more proportionate contracts for services that genuinely differ from the core NHS circumstances. Problems include disproportionate requirements, models perpetuating historic delivery patterns, undeliverable insurance requirements and failure to recognise the position of national providers operating across multiple trusts.

8. Promote the adoption of new technologies to provide advice and assistance to patients

Increased financial pressures on the NHS mean that it is important that individuals actively manage their health and adopt healthy behaviours. New communication channels need to be harnessed that can catalyse action in the public and private sector experience drawn upon.

Read the full briefing.

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Politicians clash over use of private providers

By Francesca Robinson - 28th April 2010 8:46 am

Health spokesmen from the three main political parties clashed over the use of private providers to deliver NHS care in the first national election debate on health. 

Health Secretary Andy Burnham reiterated his support for the NHS to be given priority as the preferred provider of care saying this was a “common sense” policy at a time when it was important to give stability to staff.

He was responding to a question by BMA chairman Hamish Meldrum who asked why the three main political parties were continuing to push for NHS care to be delivered by competing commercial organisations when three quarters of the public said they did not want it.

 

“The evidence is that this leads to fragmentation, loss of accountability and an increase in costs,” said Meldrum.

 

Burnham said they had brought in new providers in last decade to give people choice at a time when they were expanding capacity. 

 

But now he was signalling change to prevent alienating staff from the process of change which could threaten the progress the NHS needed to make.  

 

The NHS had to be ruthless in challenging underperformance but should be given the first chance to rise to the challenge, he declared.

 

Conservative shadow health secretary Andrew Lansley argued: “Patients have a right to expect that the NHS can secure best possible care wherever it can be found and that will be in NHS services and institutions but also with any other providers who can deliver it and we have seen many good examples of that.”

 

Liberal Democrat health spokesman Norman Lamb said he had been really impressed by the work of an NHS treatment centre in Nottingham where NHS surgeons were delivering a 20% increase in productivity.

“Sometimes using a competitive challenge in the way services are provided can be a good thing. Sometimes it would be necessary in the very tough financial climate that we face. When improving the quality of care there must be no special favours,” he said.

There were further angry skirmishes over local closures of A&E and maternity units. Burnham - annoyed that Lansley had been campaigning in his Greater Manchester constituency where there are controversial plans to reorganise children’s and maternity care - accused his rival of saying what people wanted to hear by promising to stop forced closures.

Lansley responded that he was not against change but proposals needed reviewing to ensure they were not against the interests of patients. 

 

Lamb said sometimes difficult decisions had to be taken and the key was to ensure local accountability. This was something that could be delivered by a Lib Dem proposal to establish locally elected health boards.

All three politicians promised to protect frontline jobs except those of managers and bureaucrats. 

The hustings were organised by the BMA, the Royal College of Nursing, the King’s Fund and the NHS Confederation.

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“Let’s make the most of the independent sector”

By Mike Broad - 26th April 2010 2:34 pm

The government’s preferred provider policy should be abandoned and NHS services should face periodic competitive challenge from the independent sector, a body has claimed.

The NHS Partners Network, which represents independent sector healthcare companies, also calls on the next government to create a level playing field in tendering in a new briefing document, which is being seen as a blueprint for a Conservative government.

The body lists a series of policy changes to enable the independent sector play a greater role in NHS service delivery. It claims independent providers are uniquely place to drive productivity and raise quality during a tough funding period.

NHSPN says the provider market is still underdeveloped and a level playing field needs to be created for healthcare providers. “Commissioners need to be more aware that the surest way of demonstrating they have secured best value is by using open, non-discriminatory tendering processes wherever practical,” the document says.

It claims that independent economic analysis shows that the independent sector currently has to operate with a 14% cost disadvantage to public sector providers.

The NHS pension scheme is blamed. NHSPN says a substantial part of the pension costs are carried by central government not by NHS provider organisations themselves, which puts the public sector at a competitive advantage.

“To deal with this it will be necessary to ensure that public sector bidders are assessed on the basis of their full cost to the taxpayer,” it says.

“This might be done either by increasing the percentage of their pension costs which they have to bear directly or by applying a ‘shadow’ weighting factor which forces commissioners into making a truer comparison when assessing bids.

“Unless this aspect of the playing field is levelled it is likely that over time the pitch will become unplayable for the independent sector.”

The NHSPN also calls for the publication of comparative quality data to support choice, and says the independent sector is already committed to publishing its own data relating to clinical outcomes from the summer.

It says the NHS competition regime and the Cooperation and Competition Panel (CCP) have to be put onto a statutory basis; full cost allocation and accounting in public sector providers has to be enforced and even-handed regulation developed.

Last month the Department of Health pulled the plug on an investigation into the preferred provider policy by the CCP.

Commenting on the document, Dr Mark Porter, chairman of the BMA’s consultants’ committee, said: “Many of the companies now arguing for a level playing field were quite happy to accept preferential contracts when the NHS was being opened up to competition. Private providers continue to enjoy competitive advantages that the NHS does not - the ability to cherry-pick, to set exclusion criteria, and to not have to deal with the consequences when problems arise.

“The preferred provider policy, while it does not fully address the fragmentation and waste caused by market reforms, goes some way to recognising the benefits of NHS care being delivered by NHS providers.”

NHSPN claims that private sector productivity has outstripped that of the public sector in healthcare delivery. Between 1997 and 2007, NHS productivity declined by 4% whereas that in the private sector increased by 23%.

Despite this, in 2007/2008, PCTs spent less than 5% of a £71.2bn commissioning budget on independent sector care.

On value for money, however, Dr Porter said that every eight cases diverted to an Independent Sector Treatment Centre costs the taxpayer the equivalent of almost ten cases dealt with by the NHS.

The BMA is currently running a campaign against further marketisation of the NHS.  

Read the full NHSPN briefing document.

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Demonstrating our support for the NHS

Dr Kate Bullen, deputy chairman of council at the BMA and an associate specialist in Bristol - 18th April 2010 6:32 pm

I didn’t expect to spend the first really good day of glorious spring weather marching along the Thames, but I’m glad I did.

I joined with 10,000 other people demonstrating their support for the NHS and the welfare state.

The BMA’s Look After Our NHS campaign, conducted over the last 12 months, has met with an overwhelmingly positive response from doctors and members of the public.

It has, however, drawn some vitriolic criticism - almost entirely from pro-business pressure groups - who have variously attacked it as inaccurate, alarmist and excessively critical.

It was reassuring and invigorating, therefore, to join with railway workers, prison officers, pensioners, teachers, patients and others who deliver and rely on essential services and who share our concerns about the future delivery of healthcare.

It was dispiriting to hear that so many other public services are being eroded and face financial threats. Time and again we heard about potential job losses, service cuts, threats to pensions and reduction in quality of service - all proposed in the name of ‘efficiency savings’ to address the national debt. 

The marchers on Saturday were not among those who took high risk financial gambles; they didn’t sell our gold reserves at rock bottom prices; they didn’t raid private pension funds for the benefit of the exchequer and they didn’t squander tax revenue on ill-conceived contracts and costly wars. They are the workers and tax payers of today and yesterday who have already seen their taxes used to shore up a disreputable financial industry and are now see themselves once more the target for further deprivation.

All the doctors who came to the demo should feel proud to have stood alongside so many caring and concerned members of society on a day when the good weather was not the only remarkable event.

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Protect the NHS by joining a BMA march

BMA - 9th April 2010 11:02 am

Just days into the general election campaign and thousands of pensioners, students, disabled campaigners, community activists, health professionals and trade unionists are expected to take part in a march and rally in central London on 10 April in support of the welfare state and publically-delivered public services.

The demonstration has been called in opposition to promises made by all the major political parties that after the general election, widespread cuts will have to be made in public spending in order to pay for the mistakes of the banking industry and an unregulated free market.
 
The event is supported by over 30 organisations, including the TUC, BMA, National Pensioners Convention, RADAR, Keep Our NHS Public, Carers Poverty Alliance, Defend Council Housing and over 20 individual trade unions.

The march will assemble at Temple Place, Embankment at 12 noon and move off at 1pm.

Dr David Wrigley, a member of Council at the BMA, said: “This is a great opportunity for doctors and medical students to show their commitment to the NHS and other public services. We’ve seen first-hand the damaging effects of market reforms.

“It is vital we ensure the NHS is the best it can be for our patients and that taxpayers money is used on frontline NHS services and not siphoned off to big businesses in the City. Reforms such as PFI and ISTCs have diverted large amounts of money from frontline services. In addition to ongoing problems created by these reforms, we face additional funding squeezes. Whoever wins the next election, the whole NHS is facing the threat of further cuts.”

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Government U-turn on preferred provider policy

By Francesca Robinson - 30th March 2010 9:08 am

The government has rowed back from a promise to prioritise the NHS as the ‘preferred provider’ of health services, opening the way for increased privatisation.

The preferred provider pledge, made by health secretary Andy Burnham in September, has been “essentially neutered” by new guidance on procurement and commercial practice, claim independent sector and charity organisations.

Three new guidance documents make it clear that PCT commissioners  should engage with a range of potential providers before deciding whether to issue an open tender.

The new rules state that the commissioning process, including any form of procurement, should be “non-discriminatory and transparent at all times” and should not give an advantage to any sector (public, private, third sector/social enterprise). PCTs are now required to “give all providers fair and equal opportunity to bid”.

“The guidance provides the clarity to ensure we get the best provider offering the best quality care for patients at the best price for taxpayers,” explained Burnham.

“Independent and third sector organisations will continue to make a valued contribution to providing treatment and care, helping to add capacity, improve quality, increase patient choice and drive innovative practice,” he said.

But he also made it clear that where existing NHS services were delivering a good standard of care for patients, “there is no need to look to the market”.

The guidance also stresses that where existing NHS providers are failing they must be given two chances to improve before contracts are terminated.

David Worskett, director of the NHS Partners Network, the organisation representing independent providers, said the new guidance marked a move towards a more open and competitive market with lower barriers to entry.

“The guidelines stress the importance of non-discrimination between providers, make a fresh commitment to the use of the independent sector and are clear about the need to use robust procurement to tackle under-performance. They effectively concede that while mainstream NHS organisations and their staff will inevitably continue to be the principle providers of healthcare, the unwise and anti-competitive concept of preferred provider has essentially been neutered.”

Stephen Bubb, chief executive of ACEVO, which represents charities, said: “This guidance is the final nail in the coffin for the preferred provider policy, which has been well and truly neutered. The Department of Health has explicitly told NHS commissioners that they must not prefer providers from any one sector, and should instead be non-discriminatory and seek to remove barriers to third sector participation.”

The BMA, which has been running a campaign highlighting the threat of the market to the NHS in England, gave a muted response to the new guidance. A spokesman said: “While we would have welcomed a more explicit commitment to the NHS as preferred provider, this guidance does keep the principle intact. The BMA will continue to work to highlight the benefits of public provision of NHS care, and the problems and waste created by competition.” 

The new guidance is called revised Principles and Rules for Cooperation and Competition; revised PCT Procurement Guide, and Commercial Skills for the NHS.

Meanwhile, three private sector bidders have been shortlisted to win the franchise to run a DGH in Cambridgeshire. The companies seeking to run Hinchingbrooke Health Care Trust include Circle, Ramsay Health Care UK, and a partnership between Serco Health and Peterborough and Stamford Hospitals Foundation Trust. They have been invited to discuss their proposals for the heavily indebted Hinchingbrooke Hospital with NHS East of England, commissioners, hospital staff and others.

Read a blog on the preferred provider issue.

 

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Marketisation of the NHS only going one way

By Mike Broad - 16th March 2010 7:59 pm

Confusion reigns over private sector participation in the NHS.

On the one hand you have Hinchingbrooke Hospital, which is being lined up to be run by the private sector, and on the other you have NHS Great Yarmouth and Waveney, which didn’t even allow the independent sector to bid for its community services tender because it wants to keep them NHS run.

So, why are some trusts ushering in the private sector with impolite haste, while others are actively excluding them?

The answers lie in health secretary Andy Burnham’s autumnal speech on the NHS being the ‘preferred provider’ of healthcare. He signalled a dramatic change in thinking by suggesting that NHS units would be given every chance to turn around failing services, before private or independent would even be considered.

Everyone got excited about this. Too excited. Was this a U-turn? How did this sit with existing policy and guidance? Was this the beginning of the end for private sector involvement in NHS delivery? The BMA had been running a high profile campaign trying to achieve just that and there were a fair few doctors rubbing their hands with glee.

But, as the weeks passed and no new guidance appeared on what this actually meant, we started to realise this was policy on the hoof (apparently it’s now due any day…). In the meantime, trusts interpreted it themselves. Great Yarmouth’s decision led to a challenge through the Cooperation and Competition Panel. And, just as it was about to make its decision, the government cancelled all tendering of community services in the Eastern region.

Surely it couldn’t have done this because it feared the CCP’s decision. The government is now facing multiple freedom of information requests on the move and potential investigation by he Office of Fair Trading.

Funnily enough, Burnham is now saying his original speech was misinterpreted. Silly us. He wasn’t trying to deter private or voluntary sector providers, just point out that public services should be given a chance to improve.

From my position, it looks like Burnham wanted to curry some favour with the unions and thought a pro publicly delivered NHS speech would help achieve it in the run up to the election. He underestimated the momentum behind the marketisation of the NHS and the potential backlash from wannabe providers.

I’m sure Gordon has had a little word.

This little escapade has offered some insight. For better, or for worse, an increasing proportion of NHS services are going to be delivered by private and third sector providers and it’s going to take more than a secretary of state for health to put the brakes on it. 

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Preferred provider rule faces more challenge

By Francesca Robinson - 12th March 2010 6:43 pm

The Office of Fair Trading has been asked to investigate the government’s policy that NHS organisations should be the ‘preferred provider’ of care.

The policy was announced by health secretary Andy Burnham in September to the dismay of private providers.  

The request to the competition watchdog has been made by shadow health secretary Andrew Lansley. 

It follows a move by the Department of Health to pull the plug on an investigation into the policy by the Cooperation and Competition Panel (CCP).

The CCP had been scrutinising a decision by NHS Great Yarmouth and Waveney to exclude non-NHS providers from a £25m procurement to run its community services arm. Private and voluntary sector providers had lodged a complaint about the PCT’s anti competitive behaviour.

But on the day the CCP’s report was due to be published the DoH cancelled the entire procurement process in the East of England.

ACEVO, a body representing charities, has now lodged freedom of information requests to the DoH and the CCP to force publication of the report in a bid to shed light on the “backroom dealings”.

Stephen Bubb, chief executive of ACEVO, has also written to the Prime Minister calling for the CCP to be made independent of the DoH.

He said the DoH’s move had undermined the independence of the CCP and threw doubt on the government’s intention to encourage third sector provision.

ACEVO members were reporting a wide range of instances where PCT commissioners were discouraging provision of the third sector, he claimed.

“We believe this new policy of treating the NHS as preferred provider is a direct breach of the government’s manifesto pledge to treat the third sector on equal terms.  We urge you strongly to reverse this policy,” wrote Bubb.

Mike Parish, chair of the NHS Partners Network, the organisation that represents independent healthcare providers working within the NHS, said “NHS only” procurement was unacceptable and potentially unlawful. 

The failure of the competition panel to publish its report meant that a significant opportunity to clarify the validity of the policy had been lost.

“The behind the scenes compromise inevitably suggests that the CCP as a mechanism for maintaining a rules-based system may not be sufficiently independent of ministers and of the system it is meant to regulate,” he said.

Parish has called for the competition panel to be given genuine independence with powers aligned more closely with those of other competition authorities.

“We remain convinced that the ‘preferred provider’ concept and policy is in itself anti-competitive and will result in a failure across the NHS to secure value for money or to drive continuing improvements in quality and encourage innovation,” he said.

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