'Healthcare must remain a public service'; NHS The Critical Debate;

Alan Forster is a consultant general surgeon at Ayr Hospital. He has worked in the NHS for the past 20 years and, unlike many in his profession, believes the service has actually improved over this time. He insists patients are seen more quickly and that the standard of their care continues to improve.

As Forster watches the encroaching involvement of the private sector in the running of the NHS, he fears that the health service which he has seen strengthen will now be dismantled. "My view is that the NHS has gone from strength to strength. My experience in Ayrshire is that the service has got incomparably better.

"I've been in practice for 20 years. Given the increase in public expectation I still think the NHS is strong, at least it is where I work in Ayrshire. I think we provide a good service. People don't wait as long - waiting lists in Scotland 20 years ago were appalling. I just feel the NHS is not as bad as it has been painted.

"I certainly feel the health service should be run on a non- profit basis. I don't think introducing profit into medicine is a good thing."

Forster's confidence in the NHS, described by some of his colleagues as of third world standard, is shared by a group of senior doctors called the NHS Consultants' Association (NHSCA). The NHSCA, which has a membership of 600 consultants, has prepared a report warning the government that its present policies of making greater use of private wards and theatres and using private finance to build new hospitals at the public's expense is eroding the NHS and will ultimately result in poorer care for the majority of patients.

The report, submitted to the Commons Select Committee on the Role of the Private Sector in the NHS, states: "The large scale involvement of the private sector in the form of the Private Finance Initiative for capital developments, the concordat with the private sector for provision of care and public private partnerships in both is unproven and is likely to lead to higher expenditure from tax- funded resources than the planned development of NHS facilities.

"There is no evidence so far that suggests that greater involvement of the private sector in NHS care provides improved quality, greater efficiency, or better value for money. In the absence of this evidence, further involvement should be viewed as short-term whilst NHS facilities are developed. In the longer term, the future of the National Health Service is threatened if there is a progressive transfer of work into the non-NHS sector."

One of the most contentious policies adopted by the government over the last 18 months has been the concordat signed between the NHS and the private sector, an agreement that NHS patients will be treated in private hospitals when there is no space on NHS wards.

Last month England's department of health announced a deal with Bupa to turn one of its hospitals in southeast England into a centre exclusively servicing the NHS, a move which will create capacity for an extra 5000 operations a year for patients not paying for their treatment. Milburn's department plans 20 such fast-track diagnostic treatment centres over the next few years.

The Scottish Executive has so far resisted signing a concordat north of the Border, insisting that Scotland does not have the same need for private beds and that, even if it did, there is not the same amount of spare capacity in Scottish private hospitals. Malcolm Chisholm has hinted, however, that unused wards and operating theatres at HCI hospital in Clydebank could be staffed by NHS nurses and doctors in a bid to bring down waiting times.

The report by the NHS consultants points out that the concordat will be a drain on NHS staff. The organisation also warns the government that the policy will take much-needed cash away from the NHS while leaving state hospitals to do all the difficult work.

It states: "The acknowledged shortages of clinical staff within the NHS can only be worsened if there is increasing diversion of their activity to the private sector."

Dr Guy Routh, a consultant anaesthetist at Cheltenham General Hospital and chair of the NHS Consultants' Association, explained that when trust managers in one English hospital arranged for a consultant surgeon and a consultant anaesthetist to undertake an NHS list in a private hospital, the time taken up travelling between sites resulted in the surgical team only managing half its normal volume of work during the sessions.

The report also argues that, while working in the private sector, the medics are not available for ward and post-operative care on patients in their own hospital nor for the supervision and training of junior doctors. And they are concerned that, as private hospitals rarely have intensive care units, critically ill patients will be sent back to the NHS.

It states: "In the majority of private hospitals, especially outside London, intensive care units are unable to provide the same complexity and extent of care as in the NHS and often transfer patients into the local District General Hospital for this sort of care. Resident staff in private hospitals, if present, rarely have the skill levels required for the care of critically ill patients."

The consultants are particularly concerned about the use of private hospitals to cut down on elective [non-urgent] surgery. They point out that when NHS hospitals are under pressure they cope by cutting back on non-urgent operations such as hip replacements. If this routine surgery is taken out of the NHS - leaving urgent operations, accident and emergency and cancer treatment - state hospitals would have nothing left to cut back on during busy periods.

The report states: "The history of private managers working in the NHS since the early 1980s suggests that most struggle and fail when faced with the complexities of NHS management. To remove easily managed sections of care from the NHS to private management only makes the NHS more difficult to manage. The proposals for free- standing elective surgery units, in particular, should only be considered when more medical and nursing staff are available and these units must be managed co-operatively rather than competitively with other health services."

Dr Routh added: "The money for routine surgery would go to the private sector and the NHS would be left with the difficult parts. The evidence is that if you take a patient list out of an NHS hospital and do it in a private hospital it will cost substantially more."

The organisation also makes the case against the increasing use of Private Finance Initiatives to build new hospitals.

It summarises its opposition to the controversial policy by saying: "Experience so far suggests that estimates of hospital size, including bed numbers, management efficiency, and quality of building requirements are hopelessly inadequate in many PFI developments."

Dr Matthew Dunnigan, a retired Glasgow consultant physician, prepared a report for the NHS Consultants' Association on the cost to the NHS of PFI in Scotland. His study of the new privately-financed Edinburgh Royal Infirmary claims that the showpiece (pounds) 184 million hospital will be too small to cope with demand and leave Lothian 850 beds short. In a 262 page report, Dr Dunnigan says the consequences of the shortfall will be more spending on NHS patients being treated in private hospitals. He also warns of patients in the area having to be sicker before being admitted to hospital, increased delays in patients being admitted from accident and emergency departments and longer waiting lists for operations.

The new ERI will cost taxpayers close to (pounds) 1 billion over the next 30 years, according to Dr Dunnigan. Lothian NHS Board has dismissed the concerns saying that the ERI plans have been thoroughly worked through.

But Professor Allyson Pollock, head of health policy at University College London, has published extensive research on the PFI initiative and concludes that the high cost of repayments will mean less money to spend on care.

She said: "The high costs of public private partnerships will reduce the quality and accessibility to care. This is tying the public into 30 years of debt and Scotland has more public private partnerships per head of the population than England.

"The budget for Lothian Health Board will be tied up with Private Finance Initiatives and it will make it very difficult for them to balance their budget."

Forster hasn't carried out any of the economic assessments of concordat deals or PFI initiatives but as a practising surgeon in an NHS hospital he sees them bringing short-term political gain rather than contributing to sustainable improvements in care.

"I'm not an economist but the concept of private involvement in the NHS seems to me to be short-term.

"I am not sympathetic to PFI - it is going to end up costing people a lot more. The private rail network has shown that privatisation does not necessarily work - I do not think it does make people more efficient."

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