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Speaking before his appearance at the Health Select Committee, he conceded that urgent care services were “getting closer to the cliff edge,” with A&E admission increasing by 51 per cent over the past 10 years

The letter from the 20 A&E leaders talks of the “institutional exhaustion” of the nursing, medical and even clerical staff who being pushed ever harder by the growing volume of work with little outside support

. It also describes how doctors and nurses are being forced to work in what are verging on dangerous environments

They further warn that overcrowding is likely to lead to more deaths in hospitals and reveal that standards of care are deteriorating as serious clinical incidents and delays are rising.

The letter states: “The aforementioned issues have led to us routinely substituting quality care with merely safe care; while this is not acceptable to us, what is entirely unacceptable is the delivery of unsafe care; but this is now the prospect we find ourselves facing on too frequent a basis

Recent developments such as the introduction of 111 and financial penalties for holding ambulance crews in ED are touted as solutions to the crisis: however we as ED physicians recognise that these measures will actually make the problem worse instead of better, and evidence is already emerging to support our opinions.

Furthermore, we firmly believe and strongly recommend that ED leads should be intimately involved with and consulted on the commissioning of Emergency services in the region, as well as other related emergency care changes-such as 111.

There is toxic ED overcrowding, the likes of which we have never seen before.

Labour MPs are particularly angry because London’s University College Hospital – one of the best NHS brain treatment centres in the country – has been told to stop treating brain cancer patients and send them to HCA.

HCA is already at the centre of a massive row after being accused of overcharging the NHS by millions of pounds in a damning report released last week.

HCA has a chequered history in the US and has been fined more than $1billion for mis-selling healthcare.

A senior hospital source told the Mirror: “The radiotherapy community is very concerned about the way NHS England is handing out contracts for NHS patients.

Patients who were being treated there have been told to move to Barts. NHS England have told UCHL that they won’t pay for any more NHS patients to be treated there because they’ve signed a contract with two private hospitals – one of which is HCA

HCA, along with two other private hospital groups, was at the centre of a scathing report from the Competition Commission last week which showed that between 2009 and 2011 they overcharged by up to £193million

£7 an hour, receives an extra £1 an hour for a night shift and £2 an hour for weekends.

"The NHS encourages you to have these NVQs, all this training, improve your knowledge, and then they [private care companies] come along and it all comes to nothing.

Care UK expects to make a profit "of under 6%" by the end of the three-year contract

£700,000 operating profit in the six months between September last year and March this year,

In 1993 the private sector provided 5% of the state-funded services given to people in their homes, known as domiciliary care. By 2012 this had risen to 89% – largely driven by the local authorities' need for cheaper ways to deliver services and the private sector's assurance that they could provide the answer. More than £2.7bn is spent by the state on this type of care every year. Private providers have targeted wages as a way to slice out profits, de-skilling the sector in the process.

1.4 million care workers in England are unregulated by any professional body and less than 50% have completed a basic NVQ2 level qualification, with 30% apparently not even completing basic induction trainin

Today 8% of care homes are supplied by private equity-owned firms – and the number is growing. The same is true of 10% of services run for those with learning disabilities

William Laing

report on private equity in July 2012

"It makes pots of money.

Those profits – which are made before debt payments and overheads – don't appear on the bottom line of the health firms' company accounts, and because of that corporation tax isn't paid on them.

Some of that was in payments on loans issued in Guernsey, meaning tax could not be charged. Its sister company, Silver Sea, responsible for funding the construction of Care UK care homes, is domiciled in the tax haven of Luxembourg

Bridgepoint

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the private sector expects to win £20 billion of business from the NHS, according to the corporate finance adviser Catalyst

a few gluttonous companies—Virgin Care, Serco, Care UK—have secured dominant positions in the market

The biggest privatisations are taking place in community health services.

Local NHS bodies have already been instructed to outsource 39 types of service. Dubbed the “39 steps to privatisation,” this covers everything from autism care to wheelchair provision.

privatisation favours a few big winners over the co-ops, charities and social enterprises

Many Hospital Trusts are being pushed to the financial brink by the disastrous legacy of the Private Finance Initiative (PFI)

In a first for the private sector, in February 2012 Circle took over an entire general hospital at Hinchingbrooke in Cambridgeshire. The hospital has since fallen 19 places in the patient satisfaction rankings and its finances have worsened, forcing Circle to ask for a bailout after just six months. Despite being prepared to make a potential 20 percent cut to the hospital’s workforce, and while mostly owned by investment funds operating out of tax-havens like the Caymen Islands, Circle nevertheless vaunts its friendly-sounding business model under which doctors and nurses are given part-ownership of the company.

another controversial aspect of the Health and Social Care Act—the ability for NHS hospitals to earn half their income from private patients

revealed a tragic case where a consultant left half way through a dangerous birth to carry out a private caesarean section. The baby later died.

many of the dominant players in the new market are owned by ruthless private equity firms

the collapse of the Southern Cross care-home company

All of this comes before the most high-profile part of the Health and Social Care Act has even been fully implemented—the replacement of PCTs with Clinical Commissioning Groups (CCGs)

largely unaccountable new groups, who will in turn outsource the work to privatised “commissioning support units”

Lansley’s long term links and dialogue with private health care lobbyists and providers was barely mentioned (see Spinwatch

this is a large step towards privatisation. Bupa, currently flooding the UK with advertising, knows this. So do Virgin, Sainsbury’s, United Healthcare, Circle, and Care UK.

£20 billion of ‘efficiency savings’ are really £20 billion of ‘cuts

The first Foundations were set up from the wealthiest, most successful hospitals, and have accumulated surpluses of £2 billion – while NHS hospitals which are not foundations face mounting financial problems. Now ministers want to let them make unlimited money from private medicine, while funding for NHS patients is being sharply reduced.

the damage done to hospital cleaning standards by Margaret Thatcher’s government putting cleaning and other support services out to tender in the 1980s

Two decades later hospitals are still struggling with the rising tide of infections and hygiene problems caused.

100 hospitals have been built since 1997 using the “private finance initiative”

Some early PFI hospitals have already paid back double the cost of the hospitals, but still have 15-20 years to pay. Many PFI hospitals are closing beds and wards in the new hospitals and sacking staff to cut costs: some need rescuing by government.

Now services in the English NHS could be opened up by the new government to competitive bids by “any qualified provider”. But the private sector will only bid for services where it is certain of a profit.

Staff have expressed concern that this might delay an ambulance in a real emergency and that the new system is not sophisticated enough to distinguish between urgent and less serious cases.

The Guardian revealed last year that whistleblowers believed the company was putting patients at risk and falsifying data.

too few staff to operate safely

By 2003, the company owned more than 100 homes and was attracting the attention of investment bankers.

Southern Cross's operating company and property assets were separated

It was blatant financial engineering but it made sense on paper: acquisitions could be financed by spinning off the bricks and mortar into a different company, selling it on to property investors and then using the proceeds to buy more care operators.

The sale-and-leaseback model worked fine when property prices were heading north: property players were happy to invest, and Southern Cross was willing to agree to upwards-only rents as it could borrow at cheap rates.

Even during the best of times, profit margins in the care homes business are thin; as long as occupancy rates remain comfortably over 85%,

a company that leases its homes from landlords can make good profits.

occupancy rates fell

Barclays Capital, for instance, took over Care Principles, a company that looked after patients who had been sectioned under the Mental Health Act

A report in the Observer last month disclosed that nearly 30% of the group's 581 centres in England had been served with improvement orders by CQC inspectors.

Local authorities were trying to care for more elderly and frail people in their own homes, so by the time they arrived at residential centres, their condition had deteriorated to include dementia, immobility and incontinence, which are more expensive to care for

Blackstone left long before the bust. It floated the company for £640m in 2006 and sold its last Southern Cross shares a year later. In total, the private equity firm made a profit of £1.1bn on its original investment. Others were left to pick up the pieces.

But Emily Thornberry, shadow health minister says: "Social care cannot be left to uncontrolled market forces."

But surprisingly, no body in the UK seems to have direct responsibility for ensuring private care companies avoid risky business models of the kind that sank Southern Cross.

Along with the health unions, the doctors' British Medical Association, the Royal College of Nurses and the Royal College of Midwives are now all demanding the bill be scrapped.

Cameron and Lansley insist they don't plan to privatise the NHS, of course. But that's exactly what's happening on the ground even before the bill hits the statute book. The first private company to take over an NHS hospital, the Tory-linked Circle Health, won the contract to run Hinchingbrooke hospital in Cambridgeshire in November, even as it admitted it may not be able to "provide a consistent level of service to its patients".

And the government has been in talks with international health corporations about taking over 20 more, while private companies are already running local doctors' services and preparing to administer the clinical commissioning groups of GPs

Add to that ministers' announcement last month that they would raise the cap on the proportion of income English hospitals can raise from private work from about 2% to 49%

whereas the existing law allows private provision, the coalition bill will require it

it also opens the way for the privatisation of funding, the introduction of charging and top-up payments for services that are currently free, and the cherry-picking of patients by commissioning groups

the Department of Health in the United Kingdom (UK)1 has found that bed occupancy rates exceeding 85% in acute hospitals are associated with problems dealing with both emergency and elective admissions. That county has instituted a target bed occupancy of 82% as one of its hospitals' quality measures.

Borg3 also found a significant correlation between bed occupancy and MRSA infection rates.

The association between nosocomal infection and bed occupancy rate was also highlighted in another UK Department of Health report5 . That report revealed that hospitals with occupancy rates of more than 90% had a 10.3% greater incidence of MRSA infection than those with occupancies below 85%. Furthermore, the UK House of Commons Committee of Public Accounts has "repeatedly noted that high levels of bed occupancy are not consistent with good control of infections" 6 .

This model suggests that there is a discernable risk of a hospital failing to provide sufficient beds, and thereby safe efficient care, when average bed occupancies exceed 85%.

considering the nature of hospital system, "spare (bed) capacity is essential if an emergency admissions service is to operate efficiently and at a level of risk acceptable to patients".

Orendi6 has recently compared the circumstances in the UK with those in the Netherlands where the average hospital bed occupancy rate was 64%, as opposed to 84% in the UK (2005), with the same number of beds per head of population.

The lesser pressure on hospital beds may in part have been the result of the special level of care provided to nursing home patients

Canadian data also show that hospital bed availability has a significant influence on ED length of stay for admitted patients10 (access block) and thus a delay in patients reaching an appropriate inpatient bed. This was most marked when "hospital occupancy exceeded a threshold of 90%", as also found by Sprivulis et al11.

analysis of emergency presentations to an Australian hospital has shown that access block may increase a patient's overall hospital length of stay12

increased in-hospital mortality11,13

increase in the mortality of patients presenting to EDs in Western Australia11 independent age, season, diagnosis or urgency.

there appears to be sufficient evidence to support the contention that bed occupancy rates provide a useful measure of a hospital's ability to provide high quality patient care and that 85% is a reasonable target.

NHS Gloucestershire had not put this work out to tender, nor explored in-house/NHS options which, campaigners say, would have made tendering unnecessary in the first place

only reduced staff terms and conditions upon the service leaving the NHS, would offer a key cost saving

any cost gain would be significantly reduced by the new social enterprise VAT bill

which would not have applied under the internal NHS model

the Lansley edict of July 2011, that £1 billion of NHS services would be opened up to competition.

Lansley’s ‘do it quick never mind the risk’ stick, the underbelly of which we highlighted last week

the Hull example, where aside from the one-off transfer costs, when NHS Hull morphed into a social enterprise, they found the need to build an entire new wing to house the extra administrative staff – those who had been ‘cut loose’ from the NHS – because the new enterprises are required to have their own duplicate back office functions where previously they could draw on NHS central resources.

as long as matters are kept within the NHS there is no contract on which EU procurement law ‘actually bites’,

this result at the High Court also begs the question: now the Bill is passed, exactly how far are our current NHS providers obliged to put existing services out to competitive tender?

The Gloucestershire example seems to demonstrate there are more angles to take than even the government themselves had considered in their own search for profiteering loopholes.

Will it really be possible, as Professor Allyson Pollock advises, to “stop all commercial contracts”, citing the danger of the government continuing to claim commercial confidentiality trumps the public’s right to know about contract decisions.

The PCT is legally obliged to: 1). Involve public; 2). Consider NHS options; 3). Invite ‘expressions of interest’ (in bidding) – crucially, not the same as ‘inviting bids’; before 4). Deciding what to do, which may or may not involve ‘inviting bids’, depending on whether NHS bodies come forward, which would mean they didn’t need to go to stage of open tender, i.e. inviting bids.

The commission recommended that up to 20 private hospitals in 11 UK locations should be sold off to other operators to widen competition.

"When one thinks of what half a billion pounds could have been spent on in the NHS, let alone around the world, one has to be pretty scathing about that decision."

The findings come at the end of a gruelling battle with the drug companies to see the actual data produced during all the trials, rather than the often ghostwritten and always company-funded scientific papers selectively published in medical journals. In a watershed development, they have put all the company data online, to allow anybody to interrogate the source material.

The Department of Health said it looked forward to receiving the report, but insisted that the stockpile was important.

Roche said it fundamentally disagreed with the review and maintained that the drugs were a vital treatment option for flu patients. Cochrane had got it wrong, the company said. "The report's methodology is often unclear and inappropriate, and their conclusions could potentially have serious public-health implications," said UK medical director Dr Daniel Thurley. "We'd absolutely defend [Tamiflu] for treatment and prevention." A recent study of 30,000 patients given Tamiflu in the swine-flu pandemic, published in the Lancet, found it saved lives.