NHS saw opportunity for income generation from first child gender clinic in Belfast

[WarriorN]

Northern Ireland’s health authorities believed there was a possibility for “income generation” when Belfast Trust set up a new child gender clinic offering medical interventions, documents seen by the News Letter reveal.

rt by Nick Wallis.
https://www.newsletter.co.uk/news/politics/exclusive-nhs-saw-an-opportunity-for-income-generation-from-first-child-gender-clinic-in-belfast-5614982

The internal market goes back much further than Cameron: 1989 under Thatcher with the 'Working for Patients' white paper that introduced the "Purchaser Provider Spilt".

navigator.health.org.uk/theme/working-patients-white-paper

Also in 1989, in preparation for the National Health Service and Community Care Act 1990, the Dept of Health published a document called "Financial Turbulence in the NHS". This identified nine low-incidence, specialist services that would go to the wall unless they were protected by special purchasing arrangements coordinated at Regional level.

They included Regional Genetics, Regional Drug and Alcohol Services, Specialist Wheelchair Services, Communication Aid Centres and "Gender Identity Services". (I can't recall the exact term they used for "Gender Identity Services" and I can't recall what the other four services were.)

These were often referred to as "Fire Station Services", ie. you are rarely if ever going to need a Fire Engine turn out but if you do it is important that there is one available.

The purchasing and then commissioning arrangements changed over time. Service Contracts (a fixed sum for an agreed level of activity, re-negotiated annually) were supplemented at some point (well before 2013) by Extra-Contractual Referrals (ECRs), ie. funding for individual patients, negotiated case by case, where there was no existing contract.

ECRs were "income generation", ie. income over and above Service Contracts, but they did not represent excess income over and above what was required to deliver the activity specified in service contracts.

That is, Service Contracts did not cover the full cost of delivering the contract and ECR targets were set as part of the contract in order meet full costs.

(I am putting all this in the past tense because while I worked in that system for 20 years, writing Service Contracts, doing annual Marketing Planning exercises and discussing potential ECRs with referrers, I have no idea if that is how the system still works.)

Anyway, this is the way that the NHS worked for decades and was certainly standard practice long before 2013, the date cited in the article.

All that the article "exposes", which I do not imagine was ever a secret, is that the Health Service in Northern Ireland in 2013 was using the same system of Extra Contractual Referrals as the NHS.

The only thing that would be surprising would be if other specialist health services in Northern Ireland did not rely on ECRs to top-up Service Contract funding in order to meet the full costs of those services.

ps. I should have added that the official rationale for deliberate under-funding of specialist services in Service Contracts was that the ECR income-generation target, to top-up the funding, would enable "wider access", ie. for patients not covered by the Service Contract.

For example, using easy figures:

Service Contract for 100 patients

• funded for 90 patients
• to meet 90% of the cost of delivering the service to 100 patients
• ECR target in the Service contract = 10 patients
• to top-up the missing 10% of funding.

ECR patients would live outside the geographical area covered by the Service Contracts, rather than being extra patients from within the Service Contract area.

The Service Contract should be set at a level that predicts the number of patients needing the service within the Contract area, so there should not be any extra patients needing to be seen within the Service Contract area who miss out.

That is the theory. In practice, there might well be more patients needing to be seen under contract than can be accommodated, eg. 95 rather than 90.

The extra 5 cannot be seen in-year, however, otherwise the service would be missing ECR x 5 and would be underfunded by 5%.

I don't know how it works these days but there was also always an overall "productivity target" of NHS deliberate underfunding of (in my time) 3% to 4% annually recurring.

Year 1 = 100% funding
Year 2 = 100 - 4% = 96% (the new 100% funding)
Year 3 = 96% - 4% = 92% (the new 100% funding)
etc.

That was (is?) a way of cutting NHS funding by stealth, leading to recruitment of lower grade staff and/or on shorter hours, selling-off of estates assets, building repairs delayed for years, etc.

I find it absolutely sickening that NHS funds are now frittered away on highly paid EDI staff and that staff time is diverted from actual work to time spent on dubious non-clinical training, staff "affinity networks", etc.

Apologies - drifted off into an underfunding tangent then a rant!

I don’t know the answer but in NI isn’t there a certain amount of buying and selling of specialist services with the republic. So a specialist unit (though not a gender clinic) might be financially justifiable if some patients will be coming from the south or from Donegal.

Follow the money. First in the promotion of this butchery.
Then in the lawsuits which will inevitably follow.

Yes, there are policies in place for cross border health care.

Patients from both jurisdictions can have treatment in each other's public health system, paid for by their respective health services. 20 years ago it was more often patients coming from the ROI to have treatment in NI Health Trusts, nowadays they're more likely to have treatment in private hospitals here.

Various NI Health Trusts, in an attempt to reduce the ridiculously years-long waiting lists here, are sending patients to private hospitals in Dublin for certain procedures.

I've read (in the papers) that patients from the gender service in ROI were sent to the Tavistock for 'treatment' but since Brexit, and the closure of the Tavistock GIDS, I believe that their options are now European countries that are part of the EU reciprocal health cover agreement.

I haven't come across any reporting that addresses whether or not ROI patients will be sent to the new GB regional replacements for GIDS.

Thanks. .I was trying to unpick the word ‘profit’. It would be reasonable for the NHS in NI to factor in revenue from the Republic and reasonable for the Republic to select treatment in NI rather than elsewhere in Europe, for language reasons if nothing else.(Set aside the fact that many believe it is one country!) Thus it would be sensible the NHS to include potential profit when costing new services.