Will East: Open the NHS up to new providers, competing on price

Will East graduated from St John’s College, Oxford in 2005, and is training to become a barrister. He runs a political blog, John Wilkes, which focuses on civil liberties issues.

> Policy summary

Open the NHS up to new providers, competing on price

This would involve:

• Allowing private and voluntary sector providers to petition the NHS to let them provide better services
• Giving a statutory duty to primary care trusts, who commission NHS services, to consider each petition
• Changing the payment by results system, so that clinical providers can compete on price as well as quality.

> Policy explanation

Huge amounts of money have been pumped into the NHS over the last years - but there hasn't been an equivalent improvement in the service that patients receive. The health service is the third biggest employer in the world - after the Chinese state army and the Indian railways. But still it's nowhere near the best health service in the world. If we avoid reforming the NHS, then it will face a crisis: an increasingly elderly population and the higher costs of drugs and technology mean that the health service budget will be stretched more than ever before.

At the moment, we're failing to make use of the expertise that's out there among private and voluntary sector organisations, who have experience of providing healthcare efficiently and to a high standard. And, worst of all, there's often little or no stimulus for the hospitals, treatment centres and primary care clinics that make up the NHS to get any better. The government has done something about this, by introducing new providers into the health service - such as the privately run treatment centres that provide routine operations like cataract ops. But, it's nowhere near enough. Given recent form, and with the huge spending splurges of recent years drying out, the NHS will be facing a real financial crisis by the next election - and a Conservative government would need to do something about it.

The government's current reforms are building inefficiency into the system. The system of "payment by results" (by which hospitals are paid) is essentially a fixed price system, which makes hospitals compete on patients, but not on price. This means that there is no incentive for inefficient ways of working to be eradicated, and for costs to be driven down.

I propose that:

• Private and voluntary sector providers should be allowed to petition to run NHS services which are currently inefficient or poor in quality.

These organisations would petition primary care trusts, saying that they could run a service better than the present provider. Well performing NHS organisations, such as foundation trusts, would also be allowed to petition. If successful, they would then be able to take over that service. This principle could be applied to all NHS services, from back office work, such as payroll, to operations and general practice.

• Giving a statutory duty to primary care trusts, who commission NHS services, to consider each petition

There would need to be a statutory duty for primary care trusts, as commissioners of 75% of NHS services, to consider each petition they receive, examine the provider's proposals to see if they would provide better value for money and quality, and consult patients for their views. The PCTs would be required, at the same time, to announce that an offer has been made to take over the service in question, allowing other providers to also petition and try and beat the original offer.

At the end of this, the primary care trust would be required to make an objective assessment of the merits of the offers, and whether they would provide a better service than the existing provider. If so, the provider with the best offer would take over the service. Staff under employment with the incumbent provider would be transferred to the new provider initially if it so wishes. The new provider would have complete managerial power to reorganise the way the service is provided.

After a service has been taken over by a new provider, there would then be a moratorium on subsequent petitions for a period of 5 years. This would give more of an incentive for organisations to petition in the first place (as they would be guaranteed an income stream for 5 years if they won) and prevent constant petitioning from occurring.

• Changing payment by results, so that clinical providers can compete on price as well as quality.

At the moment, organisations which supply clinical services to the NHS (be they from the private, voluntary or public sector) are paid a fixed price known as the NHS tariff. The price paid for each type of operation is decided under the system and paid whenever the hospital provides that operation to a patient. This builds inefficiency into the system (see above). It would also prevent the idea of new providers petitioning to run services more efficiently, as these providers would only be able to compete on the basis of better quality services, not price.

I therefore propose that the fixed price system be abolished, in favour of a "benchmark" price that represents the average price of a particular operation across the NHS. New providers could offer to take over services, at prices that are lower than the benchmark price. Gradually, as these providers took over services, the "benchmark" price would come down, forcing incumbent providers like NHS hospital trusts to become more efficient. This would not be to the detriment of quality services for patients - as commissioners, when receiving petitions, would have to consider the effect of a new provider taking over on quality of service, as well as price.

> Political risks and opportunities

Opportunities:

• This would be a really radical solution to reforming the NHS, increasing efficiency for taxpayers and quality for patients
• It would be a solution which Labour would not be willing to adopt - making it a distinctive Conservative policy
• It would help pave the way for future tax cuts and the reduction of the £90bn plus health service budget

Risks:

• It would face a hail of protest from Labour and the unions, with accusations of "privatisation" and of the Conservative party returning to its "extremist" roots
• It would be a difficult policy to explain to voters, as Labour's policies on choice have been

> Questions for Conservativehome readers:

• Should patients be allowed to petition for new services to be provided, too?
• If so, what should be the mechanism for this?
• Should the moratorium period for subsequent petitions be longer than 5 years?
• What about services which are provided or commissioned on a national basis (eg the NHS IT programme)?

> Costs

Start-up costs

There would need to be extra employees within primary care trusts to consider the petitions in detail. As a policy affecting the whole of the healthcare system, the project would also require considerable resources to be devoted to it within the Department of Health and local NHS organisations. Having said that, there are already expert teams operating the payment by results system at national and local levels.

Running costs

The system would actually reduce the cost of the health service budget significantly, whilst improving quality for patients.

 

Comments

[ToMTom]

Be better if he told us how we could radically reform the legal profession including getting rid of barristers and their anachronistic way of life.

The loaded terms used in this little essay

to petition the NHS to let them provide better services

Changing the payment by results system, so that clinical providers can compete on price as well as quality.

I suggest this student acquaint himself with the current situation in the NHS - that PCTs are compelled to fund 15% budget to private providers but they in turn are not compelled to deliver contracted services viz ITCs

That he look at the DRG system introduced which sets a flat rate reimbursement for medical operations and which will bankrupt teaching hospitals especially in London

That he examine in detail PFI contracts

The trouble with this contribution is that it is cookie-cutter and lacks any academic rigour. I suggest he spends some time reading books by Professor Allyson Pollock to better understand how the NHS works, at present he displays that naivety and ignorance so common amongst the lawyerly class that has through its domnance in Parliament rendered most public institutions to the point of collapse.

The simple task of reading documentation to befuddle a semi-senile judge with the latest form of mendacity may be the stock in trade of lawyers, but once they leave the theatre and their costumes behind, the real world requires a lot more knowledge of detail than is common among our political class

[Will East]

ToMTom,

These ideas come from a period when I was actually studying and writing on NHS policy - yes I did do something before I decided to become a lawyer. Having worked in the healthcare industry and spent time talking to healthcare professionals of all persuasions on the reform programme, I do know something about how the NHS is organised.

If you are basing your opinions on Allyson Pollock's work, I'd be worried. Describing her work as academic is stretching the definition of the word to extremes - all objectivity goes out of the window in her writing, which is predicated only on her left-wing prejudices. Often her criticisms fly in the face of established evidence - such as the National Audit Office report that said that 70% of PFI projects are on time and on budget, compared to only 30% under the traditional procurement method.

On the 15% of PCTs' budgets going to private providers, this is complete rubbish. The government announced some time ago that they could see a limit of 15% of the money the NHS spends on elective care going to private work. This is not what PCTs actually spend and there is no requirement for them to spend it. It is also only on elective care, not emergency, maternity, mental health etc etc which takes up a huge proportion of the overall budget! If you know anything about the treatment centre programme, then you'll also be aware that under phase two, providers don't get guaranteed volumes, but are paid according to the patients they attract.

On the DRGs, this is simply a matter of tweaking the tariff under the present payment by results system to reward teaching hospitals better. The indications are that the government has moved towards this.

As for the "loaded terms" I've used, well I thought the idea of this was to present and promote a policy that I think should be adopted. I'm hardly likely to say "to let them provide terrible services", am I? If you don't like this policy, then I suggest you engage with the detail, rather than make a comment that, for 30% of its text, concentrates on the legal profession rather than the NHS.

[TomTom]

Yes because I am a strong advocate of modernising legal services and eradicating the Medieval Guilds.......

As for the NHS - the ITCs can only offer elective surgery because they cannot afford to provide A&E or Psychiatric care, but operate on a lean-factory approach of focusing on one operation - say orthopaedic.

The simple fact is that A&E is the complex part of Medicine not elective surgery, and it is A&E which drives the bed-utilisation in wards.

As for PFI - it is so bizarre - do read the piece by my friend Brooks Newmark about this. I could give you a very interesting assessment of how PFI has destroyed private pensions and thereby taxed the annuities of pensioners to enrich a select group of bankers and contractors.

It is not just vladimir Putin who has a State with Oligarchs, there are quite a few around New Labour siphoning huge components of public funds - the PFI hospital in Norwich is one to examine.

Maybe you should study Leveraged-Recapitalisation as a way to increasing ROE and the use of PFI to boost DCF with very high up-front cash returns thereby front-end loading the whole investment in a way people like Shriti Vadera probably appreciate but Lord Gordo of Goldman do not.

The fact is that a) 50% health spending focuses on the last 6 months of life b) most health spending goes on women
c) 33% hospital beds are occupied by pensioners

Now the way to make the NHS cost-effective is to exclude the old, women, and the sick. By systematically removing these groups in a series of salami-tactics healthcare budgets will fall.

In actual fact the NHS is not particularly expensive when you look at what the budget includes. German Health Care employs 2 million when you include the Krankenkassen like AOK and Barmer and HEK..............but German health care is terribly inefficient.

The NHS is extraordinarily cost-efficient because it operates a cost-reduction budget system rather than a revenue-generation system typical of insurance-based systems. It operates a Primary Care Gatekeeper to filter referrals to Consultants, which is a system alien to Europe and the USA - Germany is currently trying to introduce such a system of Family Doctors.

The PFI system is a manifest disaster because a) the hospitals are configured with fewer beds and after 30 years Hire Purchase the NHS still does not own the hospital - it is an Operating Lease not a Capital Lease which is how Brown keeps it off the books.

However under proper GAAP it should be classified as a Capital Lease since their is a Put Option and the contract is a sole-use contract. The stupidity was to sign PFI deals and then change the system of funding hospitals and permitting ITCs - the obvious thing is for a future Government to renege on PFI contracts if the hospital becomes surplus to requirements.

The fact is that PFI is a City-designed trick to siphon huge amounts of public money into the pockets of a few rather than the pension funds of many by selling Gilts.

The NHS is far superior to the German system because it has an integrated referrals system; whatever changes it requires will not be met by half-baked theories which started under a Health Secretary called Sir Keith Joseph in the Heath Governnment,. It was he who hired McKinsey to develop a Management Culture in the NHS and created a very bureaucratic structure...............no wonder that two Cabinet Ministers under Heath had their departments run away on costs - Health under Keith Joseph was one.

In short I care only for analysis, if Allyson Pollck was a Marxist and other analysts were Falangists I would not care; my interest is in the quality of analysis and yours is superficial.

[Will East]

TomTom - 100policies.com - reform the legal system! You go for it, I'm sure Tim would oblige.

At the heart of this debate should be the need to provide the best services - but your comments so far have concentrated on past programmes and controversies. Why shouldn't we allow the best organisations, whether from the public, private or voluntary sectors, to take over services? You'll notice in the text of the policy that I said that foundation hospital trusts should be able to expand and take over other services elsewhere. They are already doing this to a limited extent, with great success. Why shouldn't we allow this to go further and deeper?

As for the other stuff, well it's not hugely relevant to what I've proposed but I'm happy to engage with you on it.

"the ITCs can only offer elective surgery because they cannot afford to provide A+E or psychiatric care". I'm not sure what point you're making here. The whole point of the ISTC programme was to focus on elective care, not A+E. No one was asking the providers to do anything else. As for them concentrating on a "lean factory" style of working, well the whole point of modern medicine is to organise into specialisms so that you concentrate experience and technical expertise. This brings down costs and improves patient care, whilst upping efficiency. If you take BUPA's Redwood centre, the first ISTC, then you'll find that its theatre utilisation rate is at 81% compared to the NHS average of 59%. Some NHS operating theatres are used for less than 10 hours a week.

On PFI refinancing, I'm not pretending that everything is perfect with PFI. There are problems with refinancing, procurement negotiations, and the co-ordination of government policies around the programme. None of this affects what I'm proposing. Yet as with all large-scale procurements, you have to balance out the pros and cons. Do we want an entirely renewed hospital estate, or should we have just left ourselves with the Victorian era facilities that existed ten years ago? Something had to be done about the hospital sector. No government could have financed the present programme upfront, PFI was the only way to do it. They might have co-ordinated the programme better, but I'm not going to sit here and go through it with a tooth comb when we might as well look ahead and decide what we are going to do in the future.

I agree with you on the gatekeeper system. It's one of the great strengths of the NHS. My proposal has nothing to do with it, and I see it as a key component that must be retained. Nevertheless, to say that the NHS is highly cost-efficient is laughable. We all know that a huge proportion of the recent increases have gone into pay and administration, and you admitted yourself that the service has a bureaucratic structure . Even the government recently identified at least £2 billion that could come off the health service budget. Judging on their record on the Gershon report, the real figure is much higher. When the spending increases slow down, the NHS is going to have real trouble coping, and so something has to be done now to prepare the service for that reality.

As for academic analysis, well I doubt that any analysis can be good quality if it is predicated on ideology, and not on evidence.

[Mark Slater]

To some extent there is already private outsourcing within the NHS paid for by PCTs. My wife works for a co that provides such services and competes with other to provide care packages.

We've seen plenty of petitioning from patients desperate for Herceptin etc., but the bottom line is that when the money ain't there then tough choices have to be made. Sack nurses to provide more drugs?

I'm sorry, but the essential issue to my mind is whether PCTs should be the rationers of healthcare. PCTs have to balance their books and many seem incapable of doing so. Moreover, when private healthcare firms offer solutions such as generic prescribing some seem willfully negligent implementing cost saving measures that would sometimes amount to millions more being freed up.

Throwing petitions into this mix is not going to do much to provide better overall outcomes. Suing the PCT may be more likely to provide relief, especially if your life depends on it.

I think we are looking at a system where the state provides a tariff of what it will pay towards any treatment and costs in excess are paid by the patient or supplementary private insurance.

Look at Australia's Medicare system for instance. It is isn't perfect but it's more realistic in its provisions and stops abuse by foreigners etc.

At the end of the day I'd always prefer to give the patient the choice rather than a bureaucrat. Given the choice of no herceptin or paying for, say, 30% of the cost of treatment which would you choose?

[Will East]

Mark - I know what I'd choose (providing I'm not hounded out of the legal system by TomTom and left destitute!). But it's a question of whether other people would be able to make the same choice. Call me old-fashioned, but I think the best way to provide more money for drugs is to make the health service more efficient, not introduce substantial top-up payments. As I've argued, there's considerable scope for efficiencies and this would be one way of achieving them.

The funding debate is a useful one to have - I'm surprised no one has proposed changes on here yet. But even if your principles lead you to accept that healthcare provision should be based on the ability to pay, then I'd question the political wisdom of such a policy. If we fail to reform the NHS as it is, then it may become inevitable that we change the funding formula. In the meantime, proposing a social insurance scheme would present only a huge electoral opportunity for Brown and his acolytes to exploit.

[Ben Herbert]

I believe it is simply impossibly to even begin to sell policies such as this when so many hospitals, especially in Sussex & Surrey at the moment, are under threat of closure / downgrading.

You will just get back to the briliant LibDem line at the last general election when we were trying to sell 'choice', that people don't want choice, they just want a good local hospital.

[Will East]

Ben - I agree that you have to sell this policy carefully. It's not about choice though - this is all about improving the services that your local hospital provides.

[TomTom]

I said that foundation hospital trusts should be able to expand and take over other services elsewhere.

Really, as a Member of a Foundation Trust myself who expended some effort to get Monitor to remove the incompetent board, I am thoroughly unimpressed by the operation of hospitals such as these.

I wonder how this Foundation would acquire other hospitals........geography leaves them thin on the ground. London is a unique market being over-resourced with hospitals as is the South of England.

In the North of England which was where the Emergency Medical Service set up in WWII located most beds in the event of invasion, or Cold War attack; hospitals have been closed and beds shed long ago.

It is in fact the difficulty of finding a bed that is the constraint and why this choice of hospitals is such a joke. The over-resourcing of London hospitals may be resolved by the Government closure plan.

or should we have just left ourselves with the Victorian era facilities that existed ten years ago?

Ten years ago ? St James, Leeds is still based on a 19th Century Workhouse and LGI is in a redbrick Victorian building..........modern buildings are certainly more shoddily built as the catastrophe in Durham reveals.

We all know that a huge proportion of the recent increases have gone into pay and administration

Yes it is true that the Government negotiated new contracts with GPs, Consultants, and Dentists...........I think it is important to pay medical staff rather than ask them to be charity workers and solicit tips.

If London could improve its approach and stop using Agency Nurses which are costing c £600 million we would be better off, but I recall which Government proposed Agency Nurses as being more efficient and flexible and which was completely wrong.

I am quite prepared to think about a Catalogue of Treatments in the NHS with defined reimbursement - and would suggest outsourcing Abortion to private clinics, Cosmetic Surgery, Gender-Reassignment; and to abolition of Nursing Home Fees introduced by John Major, so pensioners can be released from NHS beds into nursing homes (pre-Conservative changes, Nursing Homes were part of the NHS).

Most of the problems in the NHS (and elsewhere) are due to politicians full of hubris who have created chaos and left poor people working there floundering as they try to make things function.

Dr Barnardos was once a Charity which reinvented itself as a Government contractor and now receives c 66% income from The Government...........it is ineffect simply another branch of government tied to its purse strings.

This is how the free society is subverted a la Hayek's warning; it is by bringing the State into every private foundation and charity until they cannot exist without The State

[Andrew Young]

At the risk of breaking up a fairly entertaining bitch fight here is my two cents worth.

The petitioning idea seems a little spurious and I imagine that a normal system of contracted services would be sufficient.

One question though, how would you stop the runaway market like that seen in the US where private companies, operating in a not truly competitive environment (some services just can't be done by a wide range of companies) have seen prices increase by 15% per annum?

As we all need healthcare whether we use it or not this is an effective 15% tax rise per year. How are you going to sell that to the voters?

[HF]

NO Wait until the 2nd term.

We need to leave the NHS alone and keep to our promise of "no more meddling".

The long term solution should be a wholly privately run "provision" service with competition driving up standards.

[aristeides]

I am with HF on this... can't be doing with a large scale tinkering operation.

The final statement has no doubt been written on many other good people's tombstones:

"The system would actually reduce the cost of the health service budget significantly, whilst improving quality for patients."

[Will East]

Andrew -

The idea of petitioning is that companies/ foundation trusts would identify possible efficiencies in different service areas and then bid to operate better services at a lower price. Bids would only be accepted where the new organisations could offer better value for money.

The whole drive of the project, therefore, would be to bring down costs. As I mentioned earlier, you would also still have GPs acting as gatekeepers and restricting access to secondary care.

TomTom -

"Most of the problems in the NHS (and elsewhere) are due to politicians full of hubris who have created chaos and left poor people working there floundering as they try to make things function."

I agree with you - the reorganisation of PCTs and SHAs has been a complete mess and the circularity of the position over GP fund holding/ practice based commissioning is something to behold. But, apart from your very limited outsourcing proposals, you don't seem to have any remedy for the current problems in the NHS except to leave things alone and hope they will all turn out ok. This is the problem with the whole political debate at the moment and the reason why I sought to propose something on the NHS at all.

The only other idea you've come up with is to renege on PFI deals, which would destroy market confidence so much that a) very few construction/healthcare companies would want to contract with the government and b) even if they did so, they'd all charge a huge risk premium, making the deals even more expensive!

On the foundation trusts point, there's nothing to stop the trusts from managing sites at the other end of the country - this is already happening. To talk of there being geographical limitations on this therefore seems rather curious.

[sjm]

I'm inclined, sadly, to think that the only way of dealing with the NHS is to let it implode, and then introduce a completely new system.

In all seriousness, trying to alter the way parts of it work will create further complications, which is surely the lesson of the last 30-40yrs.

We should be concentrating on developing a new model of health care provision and funding that would take into account an ageing population, medical advances and education - my first port of call for research would be Oregon.

[David Sergeant]

Just to draw attention to Will East's last paragraph. He makes the point that his proposals will need more administrators, indeed, "considerable resources". That should produce some interesting headlines in the Daily Mail! I really think that, at this stage, we should be sticking to the present line of reducing administration and relying on medical professionals.

[Rachel Joyce]

I think my policy is coming out tomorrow, but I'd like to comment on this one.
I am a doctor and a PCT director. Much of what Will suggests we are already doing.
Payment by results is only for secondary (acute hospital) care, and only when tariff applies. At present we are doing things such as "unbundling the tariff" so we can pull things out of hospitals and resupply using more cost effective organisations, or using it to "redesign the pathways" so unnecessary activity is avoided. We can use either private or community settings to do this work. We are also setting up a range of what is termed "tier 2" services so that we can commission services at a reduced price, and we put these out to tender. The hospitals are allowed to apply to provide these services as well as other providers (private hospitals, chambers, consortia etc etc).
I must however point out that this requires quite alot of bureaucracy to do effectively, however. Each service must comply with healthcare commission standards (must be safe), must also be cost effective. We also have to ascertain that the individuals providing the service are actually competent to do so. A pilot of some work in some parts of the country with non-British accredited staff led to high rates of complications after surgery and poor outcomes, ending up in unanticipated increased costs and risk of litigation. A service can offer an apparent saving, but hidden costs in a different patient pathway or uncosted side effects and perverse incentives can make a seemingly cheaper option less so. Also, "cherry picking" by private providers of the more routine work and less risky patients can actually increase the costs for the hospitals that are left with the more risky, more complex work - which can actually end up in increased costs overall.
The other risk is "fragmentation" of services, much of which is actually what is putting district general hospitals at risk at the moment - something that many Tory MPs are campaigning against. Patients could go to one place for one treatment, another for a different treatment, with poor communication between professionals, and no hospital that can provide comprehensive, 24/7 cover.
One particular risk also is that everyone wants to do the profitable work and not the risky work (from a clinical and cost perspective). We are trying to make sure no patients are put at risk, but this again requires constant negotiations.
We actually need to make the NHS system alot simpler -it has become so complicated that most NHS staff don't know how it is run. The bureaucratic steps involved in running the system are overwhelming. The accountability to the patients is minimal and there is not much chance that the average patient would understand how it is run. The NHS is full of perverse incentives to all sorts of people - professionals and managers alike.

[Richard]

"One question though, how would you stop the runaway market like that seen in the US where private companies, operating in a not truly competitive environment (some services just can't be done by a wide range of companies) have seen prices increase by 15% per annum?"

The US healthcare system is highly regulated and subsidised which makes it easier for various medical companies to increase their costs. That said, American healthcare is amongst the best in the world.

[Yet Another Anon]

Best just to reduce NHS capacity by selling off many of the new hospitals to the private sector, stop adding more expensive bureaucratic PFI projects and sell off a lot of excess land - then transfer the NHS to private charities limited by guarantee and phase out the funding with most treatment being funded by charging for services, there could be low interest loans repayable in the same way as Student Loans, there could be cross subsidy perhaps for elderly people, children and the severely disabled, if there were going to be public subsidies then it should be capped per person with obviously children, the elderly and the severely disabled being allowed a higher total limit per year.

The biggest factors in terms of personal health are actually things such as water and air quality, housing, access to information, good transport links etc... not Personal Healthcare but it has been so drilled into the public psyche about how important the NHS is that most people believe it.

Many other countries have charges for treatment, including many public hospitals around the world.

Actually the biggest health problems in this country and most of the developed world is hypochondria and the state undermining people's own confidence in themselves by suggesting that they might have some kind of medical problem.

[Yet Another Anon]

The health service is the third biggest employer in the world
Think it may be the fourth, the North Korean Army is bigger I think.

Most people don't need the NHS though, people bother doctors with conditions that are almost nothing - colds (not much doctors can do about colds), hypochondria (best place for a hypochondriac is far away from any medical practitioners) - people frequently go to the doctor as a first option when many times changing things that they are doing is the solution.

There is a lot of talk about choice as well - choice is expensive, surely the whole point is that at most it should be a minimum service and that if people want choice then if they have the money they can go private - the rate things are going the only private sector companies will be working in the NHS as why would people go outside the NHS if they get the choice and get their costs paid for them?

[ToMTom]

The only other idea you've come up with is to renege on PFI deals, which would destroy market confidence so much that a) very few construction/healthcare companies would want to contract with the government and b) even if they did so, they'd all charge a huge risk premium, making the deals even more expensive!

The Government reneges on contracts all the time - on Pensions, on AVCs, on Grant Maintained Schools, on Care Homes, on Funding for laptops etc. The Government is regularly reneging on agreements - just why should PFI be different ?

The PFI contracts could not be even more expensive! than at present - they are organised larceny on the Exchequer at present. PFI contracts in healthcare are a scandal.

[Paul Charlson]

My concerns
1. Quality and price do not always make good bed fellows
2. The process for tendering is so complex that it is difficult to make the system work
3. Nobody wants care for the mentally ill and elderly they all want to cherry pick
4. Local and national priorities will differ leading to tension and postcode problems