"The tail’s wagging the dog": How outsourcing is eroding NHS services

The battle over outsourcing for Suffolk’s community health services in Sudbury is a warning for the rest of the country - the future of the NHS is going to be fragmented.

 

The market town of Sudbury, Suffolk (population: 12,080) is not what you’d call a hotbed of political activism. It’s a pretty little place: fringed by the river Stour, the rolling countryside to its south is the setting for some of Gainsborough’s most famous works. But it’s been the epicenter for a battle that’s been quietly raging for several months. It’s a battle which tells us some rather disturbing things about modern government, the health service, and the challenges both will face in the years to come.

Have no doubt - the issue of outsourced medical services will be the only discussion point for years to come. Only this month, Sir Bruce Keogh, the Government's medical director, admitted that some of his colleagues have been using the NHS to further their personal interests. This came after a survey by the British Medical Journal found around a third of doctors in charge of the new clinical commissioning groups have interests in private medical companies.

Our story starts in March 2012, when Serco was awarded a contract, due to begin on 1 October that year, to deliver all of Suffolk’s community health services. For this, it was to be paid £140m for three years’ service. Sudbury WATCH, a local campaign group, understands that it bid £10m less than its rivals. Suffolk Primary Care Trust denied the contract had been awarded purely on cost: the contract stipulated that the original standard of service had to be maintained.

Four weeks after the contract had been awarded. Serco began a consultation, which was issued to its new staff. It was not sent to the county council’s Health Scrutiny Committee, nor to the Local Involvement Network (now Healthwatch). It proposed to cut staff numbers from 790 by 137, but without making any compulsory redundancies among clinical staff.

After receiving disturbing reports from whistleblowers, campaigners began to believe the company was trying to get rid of higher band nurses and therapists. It would leave less experienced therapists doing complex work. They wrote to the Chief Executive of NHS Suffolk in November, and said:

“[It is not] any consolation that job losses will take place through “mutually agreed resignation” or MARS – just another clever way of getting rid of people at minimal cost [...] we are told that staff who refuse to agree to MARS are likely to be given jobs which will require them to drive all over the county as and when required, as well as work to new shift patterns into the evening – an impossibility for staff with young families. This is nothing short of; blackmail’.”

The campaign group received an anonymous letter suggesting that after the contract was awarded to Serco in March 2012, it was subsequently renegotiated over the next few months, in a manner favourable to Serco in breach of procurement rules, and that a substantial sum of money had been paid in September 2012, before the contract started to run in October.

The letter also noted that the company registered with CQC to run Suffolk health services (not Serco but a sub-company called Integrated Clinical Services) was set up a month before the contract was awarded. And that Serco had no track record in running community health services, so NHS Suffolk should have scrutinised the bid more carefully. It claimed the decision was politically driven by the Strategic Health Authority.

In December, Sudbury WATCH took action. It instructed solicitors to issue legal proceedings if NHS Suffolk did not halt the consultation. It argued that, as it involved patient care, the consultation should involve the public. Peter Clifford, the group’s head, told the Suffolk Free Press that he was “not prepared to see Sudbury’s health services wrecked again”. He added: “Combined with the cuts to occupational therapist numbers, community nurses, specialist and district nurses, general health workers and physiotherapists, the end result will inevitably be a serious reduction in the quality of rehabilitation and general care of the elderly.”

Serco claims that the 137 positions has been reduced to 95. However, a spokesman for Sudbury WATCH says: “The number is a red herring. This is about getting rid of experienced professionals. One thing that is for sure is that staff are demoralised. In fact, we understand that at present the company has received too many applications for voluntary redundancy.”

The Acting Chief Executive for NHS Suffolk responded to Sudbury WATCH at the end of last year in a bid to allay concerns. He said: “The CCGs will have the same priority for ensuring good patient care and value for money. Local scrutiny and public input will continue through the usual channels, through the emerging Healthwatch, the Health Scrutiny Committee and the Health and Wellbeing Board. In addition, Serco, like all providers, will be required to carry out regular patient experience surveys to help improve and shape services.”

It did not work. Today the WATCH spokesman tells me: “The legal action against NHS Suffolk and Serco has run into the sand at present because we are up against so much secrecy, fudge and obfuscation. Plus a lack of accountability: NHS Suffolk telling us to ask Serco, Serco telling us to ask NHS Suffolk.”

And all of this is deeply relevant at a national level. First there is a question of how “efficiency” is measured. Serco has already been caught out once this year after the National Audit Office reported it had fiddled its data when reporting to the NHS on targets it failed to meet with its out-of-hours GP service in Cornwall.

Time and again I have blogged on how the target-driven culture of outsourcing contracts doesn’t take into account the human element. In Suffolk Serco claims efficiency savings will be generated through hand-held computers. Sudbury WATCH claims that while there’ll be increased assessments they’ll be carried out by less experienced staff, and so the quality of interaction will diminish. The group says that the company is ultimately relying on crude activity analysis of dubious and unreliable statistics gathered in Suffolk in the past couple of years.

And for the umpteenth time we see a clear issue over the lack of transparency surrounding the outsourcing process. Sudbury WATCH’s spokesman says: “Our biggest problem has been securing information. Before the work was outsourced, the PCT’s job was to consult publicly. They could be challenged, but now commercial confidentiality laws mean It’s been very hard for our lawyers to pin them down over their decision making. There’s a real sense you’re dealing with a private company, not the NHS. Freedom of Information requests are met with commercial confidentiality defense, and Serco isn’t even subject to the act. The tail’s wagging the dog.”

And those who have heard about the Government’s stated aims of increasing integration would be right to wonder at how it’ll work in practice. At present a patient might be welcomed to one of Suffolk’s acute hospitals, then be sent to a non acute bed commissioned by the Clinical Commissioning Group (which has replaced the PCT), which is situated in a care home run by The Partnership in Care (another private business), and then be visited by nurses now working for Serco. Is this the fragmented future of public health?

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In response to the claims put forward in the anonymous letter received by Sudbury WATCH, a spokesman for NHS Suffolk told the New Statesman:

“The process to find a new home for community health services in Suffolk was led by a project board. This board consisted of members of the NHS Suffolk board, local GPs, Suffolk Community Healthcare staff, members of patient representative groups, a staff union representative and an NHS Strategic Projects Team.

“Serco was named as the preferred bidder in March 2012 and was chosen as being the organisation that would deliver the best level of healthcare for patients, good opportunities for staff and value for money for the taxpayer.

“The procurement process was run in an entirely proper, appropriate and normal fashion. This process adhered to the guidelines set out by the Cooperation and Competition Panel, which include a formal complaints and appeals procedure. No formal complaints or appeals have been received.

“After being named as the preferred bidder, Serco and NHS Suffolk went through the standard procedure of due diligence and contract finalisation with a schedule of contract payments being agreed. Payments began at the end of September 2012 and have been running regularly ever since.

“Integrated Clinical Services is a company that was established by Serco with the agreement of NHS Suffolk, NHS Pensions and Suffolk Community Healthcare staff as the appropriate vehicle for employing staff and ensuring they retained their proper NHS pension rights.

“Community health services are still being provided by the NHS, delivered free to patients and are subject to the same high standards of patient care and excellence.”

The celebration of the NHS during Danny Boyle's Olympics Opening Ceremony last year. Photograph: Getty Images

Alan White's work has appeared in the Observer, Times, Private Eye, The National and the TLS. As John Heale, he is the author of One Blood: Inside Britain's Gang Culture.

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Love a good box set? Then you should watch the Snooker World Championships

The game relies on a steady arm, which relies on a steady nerve. The result is a slow creeping tension needs time and space to be properly enjoyed and endured. 

People are lazy and people are impatient. This has always been so – just ask Moses or his rock – but as illustrated by kindly old Yahweh, in those days they could not simply answer those impulses and stroll on.

Nowadays, that is no longer so. Twitter, YouTube and listicles reflect a desire for complex and involved issues, expansive and nuanced sports – what we might term quality – to be condensed into easily digestible morsels for effort-free enjoyment.

There is, though, one notable exception to this trend: the box set. Pursuing a novelistic, literary sensibility, it credits its audience with the power of sentience and tells riveting stories slowly, unfolding things in whichever manner that it is best for them to unfold.

In the first episode of the first series of The Sopranos, we hear Tony demean his wife Carmela's irritation with him via the phrase “always with the drama”; in the seventh episode of the first series we see his mother do likewise to his father; and in the 21st and final episode of the sixth and final series, his son uses it on Carmela. It is precisely this richness and this care that makes The Sopranos not only the finest TV show ever made, but the finest artefact that contemporary society has to offer. It forces us to think, try and feel.

We have two principal methods of consuming art of this ilk - weekly episode, or week-long binge. The former allows for anticipation and contemplation, worthy pursuits both, but of an entirely different order to the immersion and obsession offered by the latter. Who, when watching the Wire, didn’t find themselves agreeing that trudat, it's time to reup the dishwasher salt, but we’ve run out, ain’t no thing. Losing yourself in another world is rare, likewise excitement at where your mind is going next.

In a sporting context, this can only be achieved via World Championship snooker. Because snooker is a simple, repetitive game, it is absorbing very quickly, its run of play faithfully reflected by the score.

But the Worlds are special. The first round is played over ten frames – as many as the final in the next most prestigious competition – and rather than the usual week, it lasts for 17 magical days, from morning until night. This bestows upon us the opportunity to, figuratively at least, put away our lives and concentrate. Of course, work and family still exist, but only in the context of the snooker and without anything like the same intensity. There is no joy on earth like watching the BBC’s shot of the championship compilation to discover that not only did you see most of them live, but that you have successfully predicted the shortlist.

It is true that people competing at anything provides compelling drama, emotion, pathos and bathos - the Olympics proves this every four years. But there is something uniquely nourishing about longform snooker, which is why it has sustained for decades without significant alteration.

The game relies on a steady arm, which relies on a steady nerve. The result is a slow creeping tension needs time and space to be properly enjoyed and endured. Most frequently, snooker is grouped with darts as a non-athletic sport, instead testing fine motor skills and the ability to calculate angles, velocity and forthcoming shots. However, its tempo and depth is more similar to Test cricket – except snooker trusts so much in its magnificence that it refuses to compromise the values which underpin it.

Alfred Hitchcock once explained that if two people are talking and a bomb explodes without warning, it constitutes surprise; but if two people are talking and all the while a ticking bomb is visible under the table, it constitutes suspense. “In these conditions,” he said, “The same innocuous conversation becomes fascinating because the public is participating in the scene. The audience is longing to warn the characters on the screen: ‘You shouldn't be talking about such trivial matters. There is a bomb beneath you and it is about to explode!’”

Such is snooker. In more or less every break, there will at some point be at least one difficult shot, loss of position or bad contact – and there will always be pressure. Add to that the broken flow of things – time spent waiting for the balls to stop, time spent prowling around the table, time spent sizing up the table, time spent cleaning the white, time spent waiting for a turn – and the ability for things to go wrong is constantly in contemplation.

All the more so in Sheffield’s Crucible Theatre. This venue, in its 40th year of hosting the competition, is elemental to its success. Place is crucial to storytelling, and even the word “Crucible” – whether “a ceramic or metal container in which metals or other substances may be melted or subjected to very high temperatures,” “a situation of severe trial”, or Arthur Miller’s searing play – conjures images of destruction, injustice and nakedness. And the actual Crucible is perhaps the most atmospheric arena in sport - intimate, quiet, and home to a legendarily knowledgeable audience, able to calculate when a player has secured a frame simply by listening to commentary through an earpiece and applauding as soon as the information is communicated to them.

To temper the stress, snooker is also something incredibly comforting. This is partly rooted in its scheduling. Working day and late-night sport is illicit and conspiratorial, while its presence in revision season has entire cohorts committing to “just one more quick frame”, and “just one more quick spliff”. But most powerfully of all, world championship snooker triggers memory and nostalgia, a rare example of something that hasn’t changed, as captivating now as it was in childhood.

This wistfulness is complemented by sensory pleasure of the lushest order. The colours of both baize and balls are the brightest, most engaging iterations imaginable, while the click of cue on ball, the clunk of ball on ball and the clack of ball on pocket is deep and musical; omnipresent and predictable, they combine for a soundtrack that one might play to a baby in the womb, instead of whale music or Megadeth.

Repeating rhythms are also set by the commentators, former players of many years standing. As is natural with extended coverage of repetitive-action games, there are numerous phrases that recur:

“We all love these tactical frames, but the players are so good nowadays that one mistake and your opponent’s in, so here he is, looking to win the frame at one visit ... and it’s there, right in the heart of the pocket for frame and match! But where’s the cue ball going! it really is amazing what can happen in the game of snooker, especially when we’re down to this one-table situation.”

But as omniscient narrators, the same men also provide actual insight, alerting us to options and eventualities of which we would otherwise be ignorant. Snooker is a simple game but geometry and physics are complicated, so an expert eye is required to explain them intelligibly; it is done with a winning combination of levity and sincerity.

The only essential way in which snooker is different is the standard of play. The first round of this year’s draw featured eight past winners, only two of whom have made it to the last four, and there were three second-round games that were plausible finals.

And just as literary fiction is as much about character as plot, so too is snooker. Nothing makes you feel you know someone like studying them over years at moments of elation and desolation, pressure and release, punctuated by TV confessions of guilty pleasures, such as foot massages, and bucket list contents, such as naked bungee jumping.

It is probably true that there are not as many “characters” in the game as once there were, but there are just as many characters, all of whom are part of that tradition. And because players play throughout their adult life, able to establish their personalities, in unforgiving close-up, over a number of years, they need not be bombastic to tell compelling stories, growing and undergoing change in the same way as Dorothea Brooke or Paulie Gualtieri.

Of no one is this more evident that Ding Junhui, runner-up last year and current semi-finalist this; though he is only 30, we have been watching him almost half his life. In 2007, he reached the final of the Masters tournament, in which he faced Ronnie O’Sullivan, the most naturally talented player ever to pick up a cue – TMNTPETPUAC for short. The crowd were, to be charitable, being boisterous, and to be honest, being pricks, and at the same time, O’Sullivan was playing monumentally well. So at the mid-session interval, Ding left the arena in tears and O’Sullivan took his arm in consolation; then when Ding beat O’Sullivan in this year’s quarter-final, he rested his head on O’Sullivan’s shoulder and exchanged words of encouragement for words of respect. It was beautiful, it was particular, and it was snooker.

Currently, Ding trails Mark Selby, the “Jester from Leicester” – a lucky escape, considering other rhyming nouns - in their best of 33 encounter. Given a champion poised to move from defending to dominant, the likelihood is that Ding will remain the best player never to win the game’s biggest prize for another year.

Meanwhile, the other semi-final pits Barry Hawkins, a finalist in 2013, against John Higgins, an undisputed great and three-time champion. Higgins looks likely to progress, and though whoever wins through will be an outsider, both are eminently capable of taking the title. Which is to say that, this weekend, Planet Earth has no entertainment more thrilling, challenging and enriching than events at the Crucible Theatre, Sheffield.

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