"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?


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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7 problems with the Snooper’s Charter, according to the experts

In short: it was written by people who "do not know how the internet works".

A group of representatives from the UK Internet Service Provider’s Association (ISPA) headed to the Home Office on Tuesday to point out a long list of problems they had with the proposed Investigatory Powers Bill (that’s Snooper’s Charter to you and me). Below are simplified summaries of their main points, taken from the written evidence submitted by Adrian Kennard, of Andrews and Arnold, a small ISP, to the department after the meeting. 

The crucial thing to note is that these people know what they're talking about - the run the providers which would need to completely change their practices to comply with the bill if it passed into law. And their objections aren't based on cost or fiddliness - they're about how unworkable many of the bill's stipulations actually are. 

1. The types of records the government wants collected aren’t that useful

The IP Bill places a lot of emphasis on “Internet Connection Records”; i.e. a list of domains you’ve visited, but not the specific pages visited or messages sent.

But in an age of apps and social media, where we view vast amounts of information through single domains like Twitter or Facebook, this information might not even help investigators much, as connections can last for days, or even months. Kennard gives the example of a missing girl, used as a hypothetical case by the security services to argue for greater powers:

 "If the mobile provider was even able to tell that she had used twitter at all (which is not as easy as it sounds), it would show that the phone had been connected to twitter 24 hours a day, and probably Facebook as well… this emotive example is seriously flawed”

And these connection records are only going to get less relevant over time - an increasing number of websites including Facebook and Google encrypt their website under "https", which would make finding the name of the website visited far more difficult.

2. …but they’re still a massive invasion of privacy

Even though these records may be useless when someone needs to be found or monitored, the retention of Internet Connection Records (IRCs) is still very invasive – and can actually yield more information than call records, which Theresa May has repeatedly claimed are the non-digital equivalent of ICRs. 

Kennard notes: “[These records] can be used to profile them and identify preferences, political views, sexual orientation, spending habits and much more. It is useful to criminals as it would easily confirm the bank used, and the time people leave the house, and so on”. 

This information might not help find a missing girl, but could build a profile of her which could be used by criminals, or for over-invasive state surveillance. 

3. "Internet Connection Records" aren’t actually a thing

The concept of a list of domain names visited by a user referred to in the bill is actually a new term, derived from “Call Data Record”. Compiling them is possible, but won't be an easy or automatic process.

Again, this strongly implies that those writing the bill are using their knowledge of telecommunications surveillance, not internet era-appropriate information. Kennard calls for the term to be removed, or at least its “vague and nondescript nature” made clear in the bill.

4. The surveillance won’t be consistent and could be easy to dodge

In its meeting with the ISPA, the Home Office implied that smaller Internet service providers won't be forced to collect these ICR records, as it would use up a lot of their resources. But this means those seeking to avoid surveillance could simply move over to a smaller provider.

5. Conservative spin is dictating the way we view the bill 

May and the Home Office are keen for us to see the surveillance in the bill as passive: internet service providers must simply log the domains we visit, which will be looked at in the event that we are the subject of an investigation. But as Kennard notes, “I am quite sure the same argument would not work if, for example, the law required a camera in every room in your house”. This is a vast new power the government is asking for – we shouldn’t allow it to play it down.

6. The bill would allow our devices to be bugged

Or, in the jargon, used in the draft bill, subjected to “equipment interference”. This could include surveillance of everything on a phone or laptop, or even turning on its camera or webcam to watch someone. The bill actually calls for “bulk equipment interference” – when surely, as Kennard notes, “this power…should only be targeted at the most serious of criminal suspects" at most.

7. The ability to bug devices would make them less secure

Devices can only be subject to “equipment interference” if they have existing vulnerabilities, which could also be exploited by criminals and hackers. If security services know about these vulnerabilities, they should tell the manufacturer about them. As Kennard writes, allowing equipment interference "encourages the intelligence services to keep vulnerabilities secret” so they don't lose surveillance methods. Meanwhile, though, they're laying the population open to hacks from cyber criminals. 


So there you have it  – a compelling soup of misused and made up terms, and ethically concerning new powers. Great stuff. 

Barbara Speed is a technology and digital culture writer at the New Statesman and a staff writer at CityMetric.