Cherry picking refers to the process of selecting the best or most desirable candidates from a group or population. In the context of healthcare, it refers to instances where private healthcare providers choose patients which are at the lowest risk to them, typically those that are generally healthy, and referring less desirable patients back to the NHS, typically those with complex and ongoing medical conditions. With the increased marketisation in many areas of the NHS, cherry picking is likely to increase.
Cherry picking occurs because private health companies will seek to avoid potentially risky patients with complicated health problems, as they will need higher cost treatments, therefore reducing the profit made by these companies.
In the context of the NHS becoming more unfair, cherry picking increases the likelihood that those patients who are most in need of healthcare will be ignored by the private healthcare providers and therefore must rely on the NHS, with its longer waiting times and rationing of certain treatments. This will then contribute to a two-tiered healthcare system, with those who need treatment but cannot pay at the bottom of the pile.
The result of cherry picking for the NHS is that it will have to shoulder the costs for the treatment of complex cases, which as a publicly funded healthcare provider, treats patients based on need rather than profit potential.
In April 2011, David Cameron set a number of reforms to the NHS, including a new clauses aimed at limiting the ability of private firms to ‘cherry-pick’ who most lucrative patients:
Virgin Care in running for £28m Bristol NHS contract (BBC News: 14 August 2015)
Campaigners have raised concerns a private firm could win a £28m contract to provide children's community health services in Bristol.
Virgin Care is one of two bidders in the running to provide NHS services such as school nurses, health visitors and community mental health services.
The firm provides some children's health services in Devon and Surrey.
More than 4,000 people have signed an online petition against the move in Bristol on the 38 Degrees website.
Dr Charlotte Paterson, from campaign group Protect Our NHS, said: "I think it's a shameful thing for the (GP-led clinical commissioning group) possibly to allow Virgin to come in and make a profit out of our most vulnerable people in Bristol, children."
She argued that children's health services needed to be integrated with social care and education.
Critics warn firms will be able to cherry-pick the most profitable services, destabilising the NHS, while private companies say they can improve the health service, bringing innovation and efficiency.
Bupa 'harming NHS' by offering patients “bribes” of £2k to use public services instead of private hospitals (Mirror: 8 April 2014)
Britain's biggest medical insurer has been accused of harming the NHS by offering patients “bribes” of £2,000 to use public services instead of private hospitals.
Bupa is offering the cash handouts to customers who agree to undergo cancer, heart and gynaecological ops on the NHS, we can reveal.
A letter from the private health giant to a male cardiac patient explains: “The cash payment takes the place of private treatment funding.
“If you are admitted to hospital under the NHS as an in-patient for any of the above procedures, we will pay you a fixed sum amount.”
The cash payments have been condemned as “outrageous” and “disgusting” by doctors.
And Labour demanded the Government immediately launch an investigation into the impact of the “bribes” on the NHS .
MP says going private could undermine NHS (This is Cornwall: 18 July 2013)
People are being urged to take operations on the NHS to help bolster the health service. West Cornwall MP Andrew George said that going private could undermine the future of local hospitals, such as at Penzance, St Michael's in Hayle and Royal Cornwall Hospital at Truro. Mr George raised the issue with the Health Secretary at a Health Select Committee. He said: "There is gathering evidence that private health companies are 'cherry picking' some of the potentially more profitable routine diagnostic, surgical and other referrals. Although I understand why many patients will be seduced to attend consultations with private companies, every patient who chooses private over the NHS potentially undermines the future of our NHS services and hospitals."
DH publishes 'cherry picking list' and tariff details (HSJ: 21 December 2012)
The Department of Health has published a list of procedures which are liable to be “cherry picked” by independent providers, and could be paid for at a lower rate. The list is included in details of the proposed payment by results arrangements for 2013-14, published yesterday. They also confirm tariff policy will continue to increase financial pressure on providers next year. Concerns have been raised for several years that non-NHS providers - such as independent sector treatment centres - may be being overpaid by the NHS because they often carry out less complex procedures. It was pointed out these providers could “cherry pick” these cases at the expense of the NHS, and in June last year the NHS Future Forum called for “additional safeguards” to prevent this. The tariff for 2012-13 included provision for the tariff price to be lowered for contracts which said patients were limited to particular, less complex cases, for example “terms which prevent them from treating patients of a certain age or with complications or comorbidities”. It is unclear how much this has been applied. In October the DH said it would not “tackle this issue through changes to tariff structure”.
Block on patient ‘cherry picking’ dropped (Financial Times: 2 October 2012)
Ministers have dropped plans to prevent private hospitals profiteering through “cherry picking” NHS patients by paying providers a reduced rate. The move has prompted concerns the government is backtracking from reassurances over private sector involvement in the NHS made over the course of its controversial health bill, finally passed in the spring after more than a year of political wrangling. The policy against “cherry picking” was announced last November as an explicit response to concerns over expanding private sector involvement. Around half of all NHS-funded hospital care – about £40bn a year – is paid for through a national tariff, where hospitals are paid a set rate for each patient, depending on the treatment given. As private hospitals generally do not treat complex or emergency patients, critics claim private contractors can profit by “cherry picking” easier patients.To appease these concerns, the Department of Health in November announced that hospitals whose costs were lower due to treating “easier” or less complex patients would be paid a reduced rate. The policy was widely assumed to be directed at private providers. But in the annex to a letter sent to NHS chiefs last month, David Flory, the deputy NHS chief executive, revealed the policy would be dropped from April. But a spokesman for the health department insisted the government had not lessened its resolve to clamp down on profiteering. “We are committed to preventing ‘cherry picking’ of patients but there is more than one way to tackle this,” he said.
Analysis: Questions over new cherry picking safeguards for NHS (The Bureau Investigates: 14 June 2011)
‘We will create additional safeguards against ‘cherry picking,’ said the Government today, announcing a set of welcome changes to the Health and Social Care Bill. NHS doctors have long complained about privately-run treatment centres’ practice of cherry-picking, which amounts to selecting the most uncomplicated, low-risk cases while leaving the risky patients to be dealt with in NHS hospitals. For example, surgical treatment centres may not treat patients with diabetes, or those who are obese. The Government announced plans to tackle this using a new pricing system; ‘Services will be covered by a system of prices that accurately reflect clinical complexity, except where this is not practical’, it declared. However there is a greater risk to patients than being turned down by private treatment centres – and that is not being turned down.
Independent sector treatment centres: learning from a Scottish case study (BMJ 2009;338:b1421: 30 April 2009)
Since 2000, the Department of Health has had an explicit policy of using NHS funds to contract out some elective surgery and associated clinical services to the private for profit sector, known in England as the Independent Sector Treatment Centre (ISTC) programme. Under the ISTC programme, the government intends that the private health care industry will provide elective surgery and other clinical services at a projected total cost to the NHS of over £5bn.
ISTCs are explicitly allowed to cherry pick, selecting the low risk patients: this analysis shows that ISTCs are performing the easier procedures within the contract. For example, data from the Information Services Division show that only 6% of referrals contracted for joint replacement and 11% for general surgery resulted in actual treatments, compared with referrals for minor procedures, which have much higher rates of treatment completion of over 80%.
David Cameron retreats on NHS reforms (The Telegraph: 2 April 2011)
David Cameron is to perform a major climb-down on reforms to the National Health Service in an attempt to head off a growing rebellion. The Prime Minister is drawing up key changes to the flagship Health and Social Care Bill which will see his reorganisation of the NHS watered down.
Under the terms of the compromise deal, GPs who do not want to take charge of the health service budget for their area will not now be forced to do so. The Government is also planning amendments to limit the market proposed in health care, with safeguards which will attempt to prevent private firms "cherry-picking" the most profitable services and leaving NHS hospitals at a disadvantage.
Now, ministers are drafting a series of Government amendments in an attempt to address the concerns of medical groups, including the British Medical Association, and staunch opposition from the Liberal Democrats, who voted against the reforms at their Spring conference.
Following Mr Cameron's decision not to force all GPs to take on responsibility for NHS budgets, the coalition is discussing:
* New clauses limiting the ability of private firms to "cherry-pick" the most lucrative work, by ensuring that payments match the complexity of treatment;
* Attempts to redefine the role of the system's regulator, so that value for money replaces promotion of competition as its prime duty;
* Improved public accountability for the GP consortia, which are intended to ultimately take control of around £60 billion of public money each year.
Sources close to the Prime Minister said he wanted to act because it was clear that the reforms were headed for a series of damaging clashes.
Myth 10: Private providers will just cherry-pick the easiest cases, undercutting the NHS (NHS Future blog)
The problem with the ISTC programme is that the provider was paid for referral, not for treatment. The government says that providers will be paid for treatment, but they do not say that once referred the provider must treat the patient, since there is no such provision in the Health Bill it means that once a private hospital receives a more complicated case they may refer the patient back to the NHS. The NHS has a responsibility to treat patients, private providers will never have this responsibility because they know that the NHS is always there for the more difficult cases.
There is extreme difficulty in judging whether ISTCs are cherry picking due to the lack of access to data, due to commercial confidentiality clauses, meaning that contracts, performance and finances cannot be examined. There is nothing in the Health Bill to prevent this, indeed, the Health Bill enables private providers to be even more secretive and apply "commercially confidentiality" clauses to their contracts with the NHS: this means that if the private providers are cherry picking we will not know about it.
Independent sector treatment centres 'cherry pick' patients (Health Service Journal: 16 November 2009)
The government is reportedly scaling back independent sector treatment centres amid claims that they do not provide value for money. York University research suggests the centres are seeing fewer patients from deprived areas, and that those they do see need fewer diagnoses and procedures.
Published in the journal Health Policy, the research says the centres “cherry pick” patients, leaving complex and more expensive cases to the NHS.
It says: “If treatment centres routinely treat patients with less complex needs, they may profit at the expense of NHS hospitals. If so, this would suggest that the payment system is unfair - if these observed differences between hospitals and treatment centres drive costs, then payments should be refined to ensure fair reimbursement.”