NHS up for Grabs
The National Health Service system in Britain, as indeed in many other West European countries, is a product of the special conditions arising from the aftermath of the Second World War. The victories of the Red Army, the creation of an entire new block of Eastern and Central European Peoples Democracies, the ferment in the working-class movement in Western Europe, and the existence of socialised medicine in the Soviet Union, forced the bourgeoisie of Western Europe to put in place a national health service system. With failing social provision in the areas of national health, education, old age pensions and unemployment benefits, the bourgeoisie seriously risked social unrest, if not revolution. Naturally it opted for the so-called Welfare State.
As the Keynesian consensus came to an end by the 1960s, the bourgeoisie of Britain, represented by Labour or Tory, has wanted to restrict, if not abolish altogether, the welfare system including the NHS. The attempt by the present Con-Lib Coalition is the latest example of this attempt. As a result of fierce opposition from the medical profession, as well as the general public, the government has been forced to retreat and alter somewhat its original proposals.
This, however, is only a tactical forced retreat. Attempts will be made in the coming years to mutilate the NHS. It is for this reason that we are publishing this article (written for the CPGB-ML’s organ, Proletarian, but not published there for lack of space), which is still relevant although some of the specific points it makes have been overtaken by events. It is still the case, that the bourgeoisie, which has already introduced many profiteering elements into the NHS, ardently desires to subject the entire service to the market – run by the racketeering profiteers for the maximisation of monopolist profits and not in the interests of the patients. Very different is the case in socialist societies, past and present, where medical provision is totally at the service of the people, and where the emphasis is on health and prevention rather than just cure.
The government plans to replace the NHS system of public funding and mainly public provision and public administration with a competitive market of corporate providers in which government finances but does not provide healthcare.
As incorporated bodies, GP consortia will not be directly controlled by the secretary of state for health and may enter into commercial contracts with “any willing provider” for all health services – and will set terms and conditions locally for their staff. They will have extraordinary discretionary powers to define entitlement to NHS provision and charge patients.
Direct management and control of NHS providers will cease as foundation trust status becomes mandatory for all trusts. Provider regulation will be overseen by a market regulator, Monitor.
Since its establishment in July 1948, the aim of the NHS has been to provide comprehensive health care free at the point of delivery. A patchwork provision of charitable and private health care establishments was nationalised so that health care would be free, available to all and of uniform quality, no matter where people lived or what their background.
Health care for all, for free, was the founding ethos and philosophy of the NHS. In July 1948, in an editorial entitled ‘Our service’, The Lancet commented: “Now that everyone is entitled to full medical care, the doctor can provide that care without thinking of his own profit or his patient’s loss, and can allocate his efforts more according to medical priority. The money barrier has of course protected him against people who do not really require help, but it has also separated him from people who really do.”
The newly-established health service was run as a single system, administered by regional and district health authorities, until the first big change came with the introduction of the internal market by the Conservative government in the 1990s. The service was split into ‘purchasers’ of care and ‘providers’ of care: the NHS was made to buy services from itself – a classic first step towards outsourcing and privatisation.
At this time, there was also an experiment with ‘GP fund-holding’, where instead of the local health authority purchasing services, GP practices could buy services directly for their patients. After 2001, the Labour government entrenched and extended the internal market. The Department of Health (DH) is not open about the figures, but the Health Select Committee has recently estimated that the transaction costs of the NHS (ie, the overheads incurred through the need to source externally) have gone up from 5 percent of total NHS expenditure to 14 percent over the 20 years in which this market has been operating.
In 2000, the UK was spending just 6 percent of GDP on health. The Labour government pledged to increase this up to the EU average of 8 percent, and spending went up from £35bn in 1997/98 to around £98bn in 2009/10 and will be £102bn in 2010/11. However, we still lag behind the Organisation of Economic Co-operation and Development (OECD) average, because expenditure has risen in other countries too.
Of course, this absolute increase in spending has masked a bigger truth about cuts in services and staff, since most of the extra money has in fact been used to fund the notorious rip-off Public Finance Initiative (PFI) schemes. Under PFI, the public pays a private construction company many times over for a new hospital that has fewer beds and often reduced services (the classic set-up being that A&E departments close, staff and bed numbers are cut and interest payments on the building debts spiral).
The increase in health expenditure coincided with a number of other policies such as targets on waiting times, and the introduction of evidence-based policies such as those recommended by the National Institute for Clinical Excellence (NICE, popular with clinicians), which saw patient satisfaction levels soar from a low of 35 percent (quite or very satisfied) in 1997 to an all time high of 64 percent in 2009 (the latest reported survey). Politicians commented that the NHS was not an issue during the election campaign of 2010, because people were generally happy.
Despite this, and despite the Conservative pre-election promise of “no top-down reorganisation of the NHS”, Andrew Lansley is proposing reforms in the NHS which will be so big that they will be “visible from space” (according to David Nicholson, NHS Chief Executive). The coalition government has now been in power for about 12 months. Neither the Conservatives nor the Liberal Democrats included the formation of an NHS commissioning board, or GPs’ commissioning consortia, in their health manifestos on which the electorate voted.
The speed of the introduction of the Health and Social Care Bill is surprising, especially given the absence of relevant detail in the parties’ health manifestos. The Conservatives promised, if elected, to scrap “politically motivated targets that have no clinical justification” and called themselves the “party of the NHS”, a commitment that has now been revealed as being utterly hollow.
The Health and Social Care Bill, with its plans to abolish Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs) and herd GPs en masse into commissioning consortia represents the most radical reform of the health service since 1948. This reform will impact on all those who deliver and receive NHS services.
“Looking forward to a world where the health department does not own hospitals” – this is the mantra chanted by Andrew Lansley at the launching of the controversial white paper on NHS reforms (Equity and Excellence: Liberating the NHS). The aim to “create the largest social enterprise sector in the world” by entrusting the provision of national healthcare services to the hands of private-sector enterprises is essentially turning the NHS into a national health market, with the government diminishing its role to that of payer and regulator.
Such confidence in market-based reforms and solutions is based on political ideals and dogmas rather than any form of evidence or experience. If anything, the healthcare system in the US should have provided a vivid indication of the appalling outcomes (high cost, poor health equity) of a health system ridden with elements of commercialisation and business incentives in the provision of care.
Andrew Lansley and David Cameron have said that the bill is necessary because outcomes in the NHS are not as good as in some other countries. This is true of the outcome they picked out (death rates after a heart attack are lower in France than in any other European country), but you can pick out many figures in international comparisons, and easily find others in which the UK performs better than France. In fact, on trends since 1979, the UK rate of death after a heart attack will fall below the French rate by 2012.
Overall, life expectancy at birth in the UK in 2007 was 79.5 years, similar to most European countries and slightly above the OECD (Organisation for Economic Co-operation and Development) average of 79.1 years. European countries have healthcare systems which are called insurance based, but they are all compulsory and to a great extent underwritten by governments, which makes them effectively funded by taxation. The OECD country which has the most developed market and least socialised system is the United States. It stands out from the other countries in having a below average life expectancy of 78.1 years, and by having spent over $9,000 per capita to achieve this in 2007 while most other OECD countries spent $2,000-4,000 per capita. The UK spent about $3,000 per capita.
The proposed reforms
The media headlines have all been about GP commissioning, but this huge piece of legislation (288 clauses) changes every aspect of the NHS. At the same time, there are white papers proposing major changes to the public health service, and to the training of doctors.
The main proposed changes are as follows:
1. 150 Primary Care Trusts and 10 Strategic Health Authorities will be abolished by 2013. The previous government’s attempts to move healthcare provision away from centralised provision partially failed, as PCTs and SHAs merged in order to improve healthcare provision planning and distribution. These large bodies are now to be abolished, so that:
2. General Practitioners will have the main responsibility for commissioning healthcare services. GPs are expected to sign up to consortia of two or more GP practices. These consortia will be given control over the majority of the health budget (£80bn) to commission the health care they deem appropriate for their patients. This sees a return to the GP fundholding experiment of the 1990s, when individual GP practices were given budgets to buy the specialist care their patients required. Fund-holding allowed GPs to make savings by lowering the demand for clinical service and saw an increase in managerial and transaction costs. Surpluses were simply pocketed by some GPs. Patient satisfaction was extremely low during this period.
Ministers say that putting GPs in charge of such decisions will make the NHS become more responsive to the needs of patients. In particular, we are told that they will help set up more services in the community, which tends to be cheaper than seeing patients in hospital. In reality, small groupings of GPs will be completely unarmed against the anticipated private-sector onslaught if the bill is passed.
Not only will it be more likely for funds to be channelled into the private sector through commissioning of health services, but the business management of GP consortia will likely be contracted out to private companies. By passing the majority of the health budget back into GPs’ hands, the government is opening the way for even more public money to be transferred into the hands of the private profiteers.
Although Lansley’s bill retains the secretary of state’s duty to promote a comprehensive service, the duty to provide a comprehensive health service in England is abolished. It is replaced with a duty to “act with a view to securing” comprehensive services. The health secretary’s general powers of direction over NHS bodies and providers are also abolished, and the focus of his or her role is shifted to public health functions, which become the responsibility of local authorities.
If the bill becomes law, a consortium will not have a duty to provide a comprehensive range of services but only “such services or facilities as it considers appropriate”. Consortia may join together to form a single commissioning group for England, but they are not required to cover all persons or provide comprehensive health care when doing so.
The commissioning consortia’s duty to arrange for health service provision will apply to their enrolled population. In contrast to Primary Care Trusts, the populations of consortia will be drawn from the patient lists of member general practices rather than taking in all residents living within a defined geographical area. Practice boundaries may be abolished as part of ‘patient choice’, which means that “practices can accept patients regardless of where they live, effectively allowing patients to choose their commissioner” – or commissioners to choose their patients. If this happens, practices and consortia will be able to compete (and advertise) for patients from across the whole country just as private healthcare corporations and health insurers do now.
‘Parental choice’ was the mantra chosen to sell education reforms that were merely a cover for service privatisations and cost cutting. The result has been to leave very little for parents to ‘choose’ from, so that today not only do thousands of children not get their choice of school, but they are often allocated to schools miles from their homes, having been deprived of the right to attend their nearest one. It is certain that ‘patient choice’ will be used in a similar manner, so that many patients will find themselves with very little choice and quite possibly with no practical choices.
3. The bill provides for a new NHS Commissioning Board to oversee these GP consortia, but its role is decidedly limited. It will work only on an annual mandate with the specific task of ensuring that the GP consortia together cover the whole of England and do not coincide or overlap. The board will not have a power of general direction over the health services for which consortia contract, or over patients’ entitlements. The annual mandate means that there will be little or no scope for long-term planning to meet the health needs of the nation.
4. All hospitals are to achieve Foundation Trust status, semi-independent of Whitehall control, with no obligation to observe national pay and conditions, and removal of the cap on a hospital’s private earnings. The introduction of Foundation Trusts under Labour was one of the most significant methods by which market mechanisms were accelerated within the NHS. Currently, around half of NHS trusts already have Foundation Trust status.
5. Provider regulation will be overseen by Monitor, whose primary duty will be to promote competition. Controversially, regulation by Monitor and the Quality Care Commission will be chiefly through commercial licensing and contracting and limited by a duty of “maximising the autonomy of individual commissioners and providers and minimising the obligations placed upon them”. Regulators are required not to impose “unnecessary burdens” and regulation will be dispensed with as more providers enter the market place.
The “necessity” for public regulation will be open to challenge by corporations in the courts. Proposals by the European Commission to introduce such tests to health services created Europe-wide controversy in 2004 and had to be withdrawn because they were deemed to conflict with public health policies such as controls over market access. However, conflict between competition policy and the health secretary’s duty to promote a comprehensive service will be resolved not by parliament but by Monitor, “in the manner it considers best”. We have no doubt that it is balance-sheet health that will normally prevail over patient health.
6. Hospital procedures will be paid for on a local or a national tariff (as brought in by Labour under the so-called ‘payment by results’ initiative – actually a payment for activity).
7. There will be continued commitment to ‘patient choice’, ‘any willing provider’ policies and competitive tendering, and the secretary of state will have the power to create regulations to ensure that these happen, ie, that no steps are made to rationalise provision in such a way that cuts out, or cuts down, profiteering.
Patient Choice, a system by which patients are allowed to choose who provides their specialist care (including selected private-sector services), was another mechanism by which competition was introduced by the previous Labour government into the healthcare system. The inevitable ranking of healthcare providers (hospital league tables), resulted in some trusts being identified as poor performers, with a subsequent loss in funding from commissioning and reduced public confidence.
This has been a factor driving the further reduction of NHS services in some trusts (closure of wards, departments and even of entire hospitals). In fact, all patients should be entitled to high-quality care that is standardised across the NHS, so that a phenomenon such as Patient Choice (in reality a mask for rationing by postcode) becomes unnecessary.
The reforms will be expensive
In the context of the current economic recession, it has already been recognised that health expenditure is going to be a ‘problem’ for the government. Taking on board the ruling class’s determination to pass the brunt of the crisis onto the working class, NHS chief executive David Nicholson’s 2008/09 annual report abjectly declared that the health service should expect to have to make ‘unprecedented’ efficiency savings of £15-20bn between 2011 and 2014. He wrote: “This is so that we can deal with changing demographics, the implementation of the [NHS next stage review strategic health authority] regional visions and cost pressures in the system.”
This has become known as ‘The Nicholson Challenge’. It means that although the coalition has promised not to cut NHS spending in real terms, because there will be more older people, and because healthcare inflation is more than consumer or retail inflation, £20bn has to be saved over the next three years, from a budget of about £300bn.
The DH estimates that the proposed reforms will cost £1.3bn to implement. Independent academics have estimated it could easily cost as much as £3bn. This is on top of the £20bn already identified by Nicholson. And, as noted in the introduction, the more marketised a system is, the higher the transaction costs become, the lower of the proportion of the budget that is actually spent on treating patients.
As Tim Ellis, Unison’s regional organiser for health, put it: “the NHS, at a time of grave cuts, does not need another top-down, expensive reorganisation which will threaten the present improvement of NHS services and care closer to home”.
The proposals are risky
Health managers have said the scale of the changes could destabilise hospitals and force some units to close. How can we prevent the piecemeal selling off of services and facilities to a variety of providers from damaging the integration of healthcare provision?
The whole process is very risky: changing all the structures at once means that there will be no safety net if one of them fails. Indeed, in the market the expectation is that some consortia and hospitals will fail. The presumption is that other consortia or hospitals (or private providers) will take over the failing bodies, or they will close. Where will patient choice be in all this? Or, indeed, any patient rights?
The bill promotes further and extensive privatisation of the NHS
Although the NHS Commissioning Board will have a duty to “secure the provision of primary medical services throughout England to the extent that it considers necessary”, consortia will become budget holders and determine which primary services they contract, from whom, and at what cost. Patients may therefore be exposed to a plurality of primary care contractors for different services. All general practices will be required to join a commissioning consortium, but, in addition, various other bodies will be allowed to apply to become commissioning consortia, including Foundation Trusts and for-profit organisations that run general practices.
Competition between a plurality of ‘willing providers’ is the fundamental policy underpinning Lansley’s market-driven proposals. Lansley himself has stated that: “The first guiding principle is this: maximise competition.” In reality, no service will be provided unless it generates a profit for the provider; and the quality of all services will be constantly undermined by the penny pinching that will be necessary in order to transfer as much as possible of the government’s reduced health spending into private pockets.
Many of the other policies in the bill are designed to promote competition. For example, empowering Monitor to be “a strong, pro-competitive regulator”, which will be “geared to maximising competition or enforcing contestability where competition is absent or limited”. Monitor will also have concurrent powers with the Office of Fair Trading to apply competition law to prevent anti-competitive behaviour. In addition, the NHS Commissioning Board will also have a duty to promote competition.
To date, the involvement of private companies in direct public health provision (as opposed to contracted out NHS services such as cleaning, buildings, maintenance, equipment provision etc) has been limited. Some groups have contracts to run minor treatment clinics, which were set up under Labour on the pretext of getting waiting lists down in areas such as hip and knee replacement and eye surgery (where waiting lists only rose in the first place because of inadequate government funding). Meanwhile, under ‘Patient Choice’, people can chose from a list of approved private hospitals that have agreed to treat people at NHS cost. However, only about 30,000 patients a month currently take up this option, a fraction of the total numbers undergoing treatment.
But under the changes being proposed, private hospitals will be able to compete for patients on an equal footing with NHS trusts. There will be new mechanisms to introduce charges and privately-funded health care. The secretary of state’s duty to provide free services that are “part of the health service in England”, except where charges are expressly allowed, will be undermined because the power under the Health and Medicines Act 1988 to impose charges will be transferred from the secretary of state to consortia. Consortia will determine which services are part of the health service and which are chargeable, and they will be given a general power to charge.
The cap on Foundation Trusts’ ability to generate income from private care will be abolished. They will be able to charge for hospital accommodation and, without reference to Monitor, amend their primary purpose of providing services to the NHS. The government has signalled elsewhere that the introduction of personal health budgets is “a high priority”, and pilots show they are linked to top-up charges.
The bill explicitly authorises the creation of surpluses from the patient care budget and their distribution to staff and shareholders as part of financial incentive or bonus schemes. Surpluses could be generated by selecting patients or services, by denying care, or by reductions in staff overheads (ie, downgrading terms and conditions), responsibility for which will be transferred to corporate bodies. The secretary of state will not be held to account for the diversion of NHS funds from patient care to staff or investors. A ‘financially responsible’ hospital (the only ones likely to survive) will need to allocate more of its resources to profitable ventures such as cosmetic surgery, thereby reducing services available at NHS prices.
Increasingly, general practice and commissioning functions will be operated and managed by for-profit companies, 23 of which (including Virgin, Care UK, and Chilvers McCrae) reportedly already run 227 general practices. Professional autonomy will be eroded if, for example, referral management centres run by corporate providers are used to ensure referral and prescribing practices conform to corporate budgets and the needs of shareholders and bonus-driven managers.
These centres are currently rejecting one in eight general practitioner referrals and seem to operate along the lines of ‘prior authorisation’ arrangements in the United States, whereby doctors are required to obtain approval from a higher authority before making a referral for treatment or investigation. Some of the centres, such as UnitedHealth UK’s recently established ‘referral facilitation service’ in Hounslow, London, are run by subsidiaries of US multinationals.
The problems with the proposals
The proposed changes have not been tested nor piloted. There is some evidence to indicate what might happen, eg, what happened with fund-holding, as described earlier. There is evidence from health economists to show that competition on price reduces quality. Inevitably, we would expect to see a spiral of declining standards as services are given to the cheapest bidder.
The government proposes to regulate providers through commercial contracts. Most economists agree health services cannot be sufficiently controlled through market regulation because the complexity and unpredictability of treatment makes it impossible to set out all eventualities in a contract.
This problem of incomplete contracts was first described by the founding father of health economics and Nobel laureate, Kenneth Arrow. He argued in 1963 that providers of healthcare services will always have more information than purchasers, who will never be able fully to evaluate the likely consequences of different services and so will never be completely certain that they have chosen the best provider or that the outcome is optimal. According to Arrow, incomplete contracts can explain why “the association of profit-making with the supply of medical services arouses antagonism and suspicion on the part of patients and referring physicians”.
Further, when market contracts are used to regulate providers and commissioners, managers have an incentive to exploit the information deficit on the part of patients and government by reducing service quality in order to maximise profits. Put in simple terms, competition when the user (patient) is not paying, means that the provider will do everything in their power to increase profit by charging the payer (UK taxpayer) as much as they can possibly get away with. The patient doesn’t care because they are not paying for their care, and want their care to be the best possible. The taxpayer has no real knowledge of what is going on.
The GP consortia will plead poverty and demand an increase in budget. The provider (hospitals) will continue to press costs higher and higher. This is the process by which the MoD ended up paying £6.40 for 25p light bulbs. David Cameron highlighted Private Finance Initiative contracts as an example of Labour’s wastefulness, claiming that in one hospital it cost £333 to change a light bulb.
The process of GP commissioning carries inherent conflicts of interest, since GPs will be commissioning services which overlap with the services that they themselves provide. For example, a diabetic may be cared for at the GP surgery, or may be referred to hospital. This is even before one considers the problems when GPs set up companies to provide services such as physiotherapy, or to treat minor injuries (which is already happening); or if GPs are rewarded for saving money on prescribing or referral budgets.
All the evidence suggests that running a full market is not a cheaper way of delivering health care. The USA has the best example of a market-driven health model and is therefore most useful for drawing direction comparisons. The administration costs in the USA are generated by high transaction costs of insurance (reaching up to 60 percent), the requirement for every health event to be itemised (whether drugs, procedures, surgery, consultations, stationery, equipment etc), and the additional employment of reviewers who make the decision of care provision (or refusal).
The UK was spending around £1,000 per capita on health care, of which about 4 percent or £40 went on management and administration. In contrast the US was spending the equivalent of £2,500 per year, of which 20 percent or £500 per capita – half of the entire UK per capita allocation – went on management. This translates to a laparoscopic appendicectomy costing $25,000 in the USA compared to €5,400 in Europe.
Competition between the NHS and private companies will be highly skewed in favour of private providers. GPs, whose budgets will be increasingly constrained, will not be able to commission services based on assessment of quality, as GP fund-holding has already demonstrated, but on price. Used to working in competitive, profit-driven environments, private companies will inevitably offer cheaper services than their NHS counterparts by cherry-picking those that are profitable to provide. This will inevitably have a detrimental effect on NHS providers who are left with difficult, chronic, non-profitable cases and on trainees who miss out on training opportunities.
A good example of this is in the sphere of general surgery, where the day-case procedures such as hernia repairs and cataract operations which form the bread and butter of a trainee’s portfolio are likely to be targeted by private providers as profitable procedures. As more junior doctors and other healthcare staff are pulled into service provision in the private sector, there will be no control over what, if any, training the private sector will see fit to provide.
Provider of last resort
Because the secretary of state will no longer be able to ensure comprehensive, universal cover to all residents in geographically defined areas, the legislators have drafted a safety net, whereby local authorities can be required to undertake NHS functions. Under section 8 of the bill, the health secretary can require councils to provide “services or facilities for the prevention, diagnosis or treatment of illness”.
Thus local authorities alone will have a duty to provide for geographical populations. Healthcare services that consortia and market providers deem will threaten their financial viability will therefore be transferred out of the NHS in much the same way as long-term care and continuing care responsibilities were transferred out in 1996, without of course local authorities being adequately funded to provide these services to an acceptable level. They are, however, able to charge for these services where the recipient has any assets, such as a house, that can be sold to pay for them. Patients who cannot get access to general practices or the services of commissioning consortia may have to default to local authorities, which would thereby become the providers of last resort, and the core functions of the health secretary will shift to the chargeable local authority sector.
The duty to provide free and comprehensive health care was underpinned by structures, systems and mechanisms that were originally designed to promote fairness and efficiency in resource allocation and to facilitate the planning of services according to geographical healthcare needs through risk pooling and service integration. These mechanisms have been eroded by a succession of major regulatory changes, including the revision of funding and responsibility for provision of long-term care; the creation of an internal market; the introduction of private providers and capital through the private finance initiative, independent treatment centres, foundation trusts, and the 2004 general practice contract; and the creation of a tariff system of payment for providers.
The Health and Social Care Bill proposes a plethora of market-based changes that are set to destroy the bedrock on which the spirit of universality of the NHS is based. The NHS was the pioneer of universal, publicly-financed health insurance in western Europe, and is credited with much of the improvement in the health of the British population since its creation. It is admired and imitated to varying degrees worldwide and, notwithstanding all the attacks it has suffered over the years, remains an example of what socialised medical care can achieve.
Letting market forces decide, through archaic rules of supply and demand, to shape the provision of healthcare services correlates with the notion of ‘patient choice’; a highly emphasised doctrine that a ‘liberated’ NHS will be able to provide. But when private markets dictate healthcare access, quality, and cost, is there really a choice for patients who are chronically ill and poor? Local authorities are set to be providers of last resort, but they mainly run nursing homes for long-term care and lack adequate hospital facilities.
‘Liberating the NHS’ is thus akin to releasing an immensely popular public institution into the wild jungles of capitalism, where global private investors are ready to pounce. The current bill proposes to turn the basic human right of access to good quality health care into a trading commodity, and patients into customers, whose value depends on what they can pay.
Opportunities for health profiteers created by the bill
1. Investor-run commissioners and providers will be free to:
2. Invest in and form healthcare companies
3. Use commercial contracts to bring in commercial providers
4. Define the range of services to be provided and the limits of patient entitlements under the NHS
5. Charge for some elements that are currently NHS services, as well as for health services they determine are no longer covered by the NHS
6. Generate and distribute surpluses to shareholders, investors, and employees by underspending the patient care budget
7. Use competition law to challenge public policies that impair their profitability and freedom to operate
8. Contract out all NHS services to a range of private providers
9. Select patients and services