"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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This Ada Lovelace Day, let’s celebrate women in tech while confronting its sexist culture

In an industry where men hold most of the jobs and write most of the code, celebrating women's contributions on one day a year isn't enough. 

Ada Lovelace wrote the world’s first computer program. In the 1840s Charles Babbage, now known as the “father of the computer”, designed (though never built) the “Analytical Engine”, a machine which could accurately and reproducibly calculate the answers to maths problems. While translating an article by an Italian mathematician about the machine, Lovelace included a written algorithm for which would allow the engine to calculate a sequence of Bernoulli numbers.

Around 170 years later, Whitney Wolfe, one of the founders of dating app Tinder, was allegedly forced to resign from the company. According to a lawsuit she later filed against the app and its parent company, she had her co-founder title removed because, the male founders argued, it would look “slutty”, and because “Facebook and Snapchat don’t have girl founders. It just makes it look like Tinder was some accident". (They settled out of court.)

Today, 13 October, is Ada Lovelace day – an international celebration of inspirational women in science, technology, engineering and mathematics (STEM). It’s lucky we have this day of remembrance, because, as Wolfe’s story demonstrates, we also spend a lot of time forgetting and sidelining women in tech. In the wash of pale male founders of the tech giants that rule the industry,we don't often think about the women that shaped its foundations: Judith Estrin, one of the designers of TCP/IP, for example, or Radia Perlman, inventor of the spanning-tree protocol. Both inventions sound complicated, and they are – they’re some of the vital building blocks that allow the internet to function. 

And yet David Streitfield, a Pulitzer-prize winning journalist, someow felt it accurate to write in 2012: “Men invented the internet. And not just any men. Men with pocket protectors. Men who idolised Mr Spock and cried when Steve Jobs died.”

Perhaps we forget about tech's founding women because the needle has swung so far into the other direction. A huge proportion – perhaps even 90 per cent - of the world’s code is written by men. At Google, women fill 17 per cent of technical roles. At Facebook, 15 per cent. Over 90 per cent of the code respositories on Github, an online service used throughout the industry, are owned by men. Yet it's also hard to believe that this erasure of women's role in tech is completely accidental. As Elissa Shevinsky writes in the introduction to a collection of essays on gender in tech, Lean Out: “This myth of the nerdy male founder has been perpetuated by men who found this story favourable."

Does it matter? It’s hard to believe that it doesn’t. Our society is increasingly defined and delineated by code and the things it builds. Small slip-ups, like the lack of a period tracker on the original Apple Watch, or fitness trackers too big for some women’s wrists, gesture to the fact that these technologies are built by male-dominated teams, for a male audience.

In Lean Out, one essay written by a Twitter-based “start-up dinosaur” (don’t ask) explains how dangerous it is to allow one small segment of society to built the future for the rest of us:

If you let someone else build tomorrow, tomorrow will belong to someone else. They will build a better tomorrow for everyone like them… For tomorrow to be for everyone, everyone needs to be the one [sic] that build it.

So where did all the women go? How did we get from a rash of female inventors to a situation where the major female presence at an Apple iPhone launch is a model’s face projected onto a screen and photoshopped into a smile by a male demonstrator? 

Photo: Apple.

The toxic culture of many tech workplaces could be a cause or an effect of the lack of women in the industry, but it certainly can’t make make it easy to stay. Behaviours range from the ignorant - Martha Lane-Fox, founder of, often asked “what happens if you get pregnant?” at investors' meetings - to the much more sinister. An essay in Lean Out by Katy Levinson details her experiences of sexual harassment while working in tech: 

I have had interviewers attempt to solicit sexual favors from me mid-interview and discuss in significant detail precisely what they would like to do. All of these things have happened either in Silicon Valley working in tech, in an educational institution to get me there, or in a technical internship.

Others featured in the book joined in with the low-level sexism and racism  of their male colleagues in order to "fit in" and deflect negative attention. Erica Joy writes that while working in IT at the University of Alaska as the only woman (and only black person) on her team, she laughed at colleagues' "terribly racist and sexist jokes" and "co-opted their negative attitudes”. 

The casual culture and allegedly meritocratic hierarchies of tech companies may actually be encouraging this discriminatory atmosphere. HR and the strict reporting procedures of large corporates at least give those suffering from discrimination a place to go. A casual office environment can discourage reporting or calling out prejudiced humour or remarks. Brook Shelley, a woman who transitioned while working in tech, notes: "No one wants to be the office mother". So instead, you join in and hope for the best. 

And, of course, there's no reason why people working in tech would have fewer issues with discrimination than those in other industries. A childhood spent as a "nerd" can also spawn its own brand of misogyny - Katherine Cross writes in Lean Out that “to many of these men [working in these fields] is all too easy to subconciously confound women who say ‘this is sexist’ with the young girls who said… ‘You’re gross and a creep and I’ll never date you'". During GamerGate, Anita Sarkeesian was often called a "prom queen" by trolls. 

When I spoke to Alexa Clay, entrepreneur and co-author of the Misfit Economy, she confirmed that there's a strange, low-lurking sexism in the start-up economy: “They have all very open and free, but underneath it there's still something really patriarchal.” Start-ups, after all, are a culture which celebrates risk-taking, something which women are societally discouraged from doing. As Clay says, 

“Men are allowed to fail in tech. You have these young guys who these old guys adopt and mentor. If his app doesn’t work, the mentor just shrugs it off. I would not be able ot get away with that, and I think women and minorities aren't allowed to take the same amount of risks, particularly in these communities. If you fail, no one's saying that's fine.

The conclusion of Lean Out, and of women in tech I have spoken to, isn’t that more women, over time, will enter these industries and seamlessly integrate – it’s that tech culture needs to change, or its lack of diversity will become even more severe. Shevinsky writes:

The reason why we don't have more women in tech is not because of a lack of STEM education. It's because too many high profile and influential individuals and subcultures within the tech industry have ignored or outright mistreated women applicants and employees. To be succinct—the problem isn't women, it's tech culture.

Software engineer Kate Heddleston has a wonderful and chilling metaphor about the way we treat women in STEM. Women are, she writes, the “canary in the coal mine”. If one dies, surely you should take that as a sign that the mine is uninhabitable – that there’s something toxic in the air. “Instead, the industry is looking at the canary, wondering why it can’t breathe, saying ‘Lean in, canary, lean in!’. When one canary dies they get a new one because getting more canaries is how you fix the lack of canaries, right? Except the problem is that there isn't enough oxygen in the coal mine, not that there are too few canaries.” We need more women in STEM, and, I’d argue, in tech in particular, but we need to make sure the air is breatheable first. 

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