Our experience of receiving public services from private companies: Who are the winners, who are the losers?

Use of private companies in providing healthcare functions is on the rise everywhere in the world. This is also true in the UK, that prides itself with a public and free healthcare system, provided by the National Health Service. Increasingly NHS services are provided by private companies.  Is this a good thing?

Before I start let’s get a few things clear. I heart the NHS. Even if we don’t like thinking about it, sickness, disability and death are universal. They are things that can happen to any of us when we least expect. The idea that a country provides its people quality health care free at the point of delivery is fantastic. In a word already so full of inequality  access to medical care shouldn’t be a privilege afforded to the few.

I’m also a private sector girl. I’ve built my career in private practice and have no professional experience in the public sector. I see good in private sector (in its best form private sector provides good quality services in a cost effective manner, providing employees an environment where they can progress their career according to their capabilities) and the bad (employers using their dominant position abusively, non accountability,  business practices prioritising profit over all other considerations).

I never knew the extent of private company involvement in our healthcare, but the case for NHS buying services from the private sector is clear: Outsourcing, for example, homecare, cuts down the need for the NHS Trusts to carry out recruitment, training and all kinds of time consuming and expensive HR functions.  But are these agencies providing a good value for money? Are cases where the services are not properly provided acted upon quickly enough, or at all?

From our experience the answer is a big fat NO. Our CCG (NHS area Clinical Commissioning Group, whose duty it is to provide and fund Freya’s care package) outsources all paediatric home care services. We have  received services from three care agencies.  With a child who needs 24 hour awake care we simply would not survive without having the support we get. We have some wonderful and very competent nurses and carers.  But the system in itself is far from perfect.

Firstly, combining outsourcing with complete lack of  meaningful oversight means that some care agencies take on packages in full knowledge that they are not able to cover the hours.

Care agencies are often keen only to cover the hours that are easy to cover.  Freya has been assessed to require Health Care Assistant level care (no formal training, some in-house and some practical training only).  These carers are then employed on a zero hour contract, the agency generally charging the CCG something in excess of £30 per hour, of which the carer sees about £12 per hour. Unsurprisingly many of these carers prefer longer night shifts, when the pay is slightly higher. When the supply is low and the profit margins for the shorter, cheaper day hours are thinner, we have experienced agencies making little or no effort to find cover for day hours.  Without active intervention, the inevitable result is shortfall in care hours.

So what happens then? It falls on parents to cover the shortfall. Often the only disadvantage to the agency is that they don’t get paid for the hours they don’t deliver, but why reach for apples further up, if the ones on lower branches are on easy reach?

The CCGs are, in principle, under an active duty to monitor care packages and intervene where the care is not been properly been delivered. I have heard of some that do, but unsurprisingly Haringey CCG isn’t one of them- we missed out on 600 care hours in our first year at home and despite me raising this repeatedly absolutely nothing was done.  There are several other families in our area who regularly miss out on a big chunk of care they are assessed to need.

The second issue is the quality of the care provided and how problems are dealt with. In the UK carers  are not required any specified  level of formal education nor is there standard across the board on-job training for them: Consequently many parents find that some agencies exaggerate or even lie about the experience they carers have. Where the CCGs would not normally provide extra funding for the training the temptation can be high on agencies to fast track carer training and cut corners. The results can be fatal.

As opposed to nurses, carers do not have a professional regulating body. This means that it is up to the agency to deal with instances of misconduct.  During the reign of our first agency we caught two of our carers fast asleep during the shift. The investigations that followed came across to us little more than rubber stamping exercises. One of the sleepers ended up working with another local trachy vented kid.

In many ways we have been lucky: Other trachy parents report serious incidents not being leading to any significant reprisals – from carers tying a child onto bed to restrain them, giving wrong medications and – the most bizarre one being – carers for a child requiring 2-to-1 care, leaving the child unattended to have sex with each other.

In absence of a regulator, even agencies taking a harder line with  misconduct have little they can do to prevent misbehaving carers simply moving onto another agency to continue working with vulnerable children.

This puts parents in a poor bargaining position when it comes to their child’s care.  Worries arise of whether raising issues will affect the service provided: If you rock the boat too much will the agency will they do work their hardest to cover all the shifts? If going gets too tough will they just give in their notice and move onto “easier parents”, disrupting your child’s care? This happened with us with our first agency, but diplomatically saying, it was a blessing in disguise (and in less diplomatic way: good f*cking riddance).

Who are the winners, who are the losers? The clear winners are care agencies who in some areas can pick and choose what hours they do at a good profit margin after paying their employees low wages on zero hour contracts. Whereas use of agencies is expensive, some CCGs benefit from agencies poorly delivering hours as they only pay for hours delivered. Not delivering can be as cheap as not granting hours and this way the CCGs maintain the illusion of meeting their legal duties. Combine it with not monitoring packages the CCGs can look like they are actually doing a good job, where this is far from the truth.

The real losers are the service users: The special need children who miss out education because cover is not found; the parents nearing breaking point juggling medically complex daytime and having to do cancelled nights too; the siblings of disabled kids who miss out activities and much needed alone time with their parents when plans have to be yet again cancelled because cover can’t be found. And if that does not pull on your heart strings then losers are the taxpayer whose money is poured onto pockets of private companies providing poor service. The NHS loses out having to pay for poorly delivered services (and when the services fail it is the NHS who needs to clean up the mess and pay for it).

What I think would make things better? Local Authorities and CCGs should take their legal obligations of monitoring care packages more seriously. Agencies failing to provide care they have contracted to do should be disciplined, even blacklisted for failures. Where kids have to be kept back at hospitals due to care agency inability to meet contracted services the cost of the NHS care should be passed onto them.

Currently parents have little options to raise their concerns – Care Quality Commission that regulates care agencies should have a complaints procedure for at least the biggest cases of mismanagement. Similarly there should be a way for parents to register cases of clear misconduct and for those carers to lose the DBS status of being able to work with vulnerable kids and adults.

After all of this I still believe that, properly managed,  private companies can help our public services to work better. But it takes gutsy strong willed public sector to keep their private sector chums on a short lead.  And the minds of both need to focus on the most important thing: that the service user’s needs are properly met. Otherwise what is the point?
P.s. Freya update. Our little lady has started nursery and she loves it.  Our Whittington Health led community team failed to arrange basic tracheostomy training for Freya’s key worker. Consequently their plan was to have  Freya to go to nursery with a paediatric nurse, having me to sit in the lobby in case the nurse needed a comfort break during her 3 hour shift until training could be arranged for mid March. A good example of incredibly poor planning and complete disregard by the Whitington team of what families like ours need. Fortunately our agency did step up and offer to carry out the training themselves. Well done private sector!



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