"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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Lord Empey: Northern Ireland likely to be without government for a year

The former UUP leader says Gerry Adams is now in "complete control" of Sinn Fein and no longer wants to be "trapped" by the Good Friday Agreement

The death of Martin McGuinness has made a devolution settlement in Northern Ireland even more unlikely and has left Gerry Adams in "complete control" of Sinn Fein, the former Ulster Unionist leader Reg Empey has said.

In a wide-ranging interview with the New Statesman on the day of McGuinness’ death, the UUP peer claimed his absence would leave a vacuum that would allow Adams, the Sinn Fein president, to consolidate his hold over the party and dictate the trajectory of the crucial negotiations to come. Sinn Fein have since pulled out of power-sharing talks, leaving Northern Ireland facing the prospect of direct rule from Westminster or a third election in the space of a year. 

Empey, who led the UUP between and 2005 and 2010 and was briefly acting first minister in 2001, went on to suggest that, “as things stand”, Northern Ireland is unlikely to see a return to fully devolved government before the inquiry into the Renewable Heat Incentive scheme is complete -  a process which could take up to a year to complete.

“Adams is now in complete control of Sinn Fein,” he said, adding that it remained unclear whether McGuinness’ successor Michelle O’Neill would be “allowed to plough an independent furrow”. “He has no equal within the organisation. He is in total command of Sinn Fein, and that is the way it is. I think he’s even more powerful today than he was before Martin died – by virtue of there just being nobody there.”

Asked what impact the passing of McGuinness, the former deputy first minister and leader of Sinn Fein in the north, would have on the chances of a devolution settlement, Empey, a member of the UUP’s Good Friday Agreement negotiating delegation, said: “I don’t think it’ll be positive – because, for all his faults, Martin was committed to making the institutions work. I don’t think Gerry Adams is as committed.

Empey added that he believed Adams did not want to work within the constitutional framework of the Good Friday Agreement. In a rebuke to nationalist claims that neither Northern Ireland secretary James Brokenshire nor Theresa May can act as honest or neutral brokers in power-sharing negotiations given their reliance on the DUP’s eight MPs, he said: “They’re not neutral. And they’re not supposed to be neutral.

“I don’t expect a prime minister or a secretary of state to be neutral. Brokenshire isn’t sitting wearing a hat with ostrich feathers – he’s not a governor, he’s a party politician who believes in the union. The language Sinn Fein uses makes it sound like they’re running a UN mandate... Gerry can go and shout at the British government all he likes. He doesn’t want to be trapped in the constitutional framework of the Belfast Agreement. He wants to move the debate outside those parameters, and he sees Brexit as a chance to mobilise opinion in the republic, and to be seen standing up for Irish interests.”

Empey went on to suggest that Adams, who he suggested exerted a “disruptive” influence on power-sharing talks, “might very well say” Sinn Fein were “’[taking a hard line] for Martin’s memory’” and added that he had been “hypocritical” in his approach.

“He’ll use all of that,” he said. “Republicans have always used people’s deaths to move the cause forward. The hunger strikers are the obvious example. They were effectively sacrificed to build up the base and energise people. But he still has to come to terms with the rest of us.”

Empey’s frank assessment of Sinn Fein’s likely approach to negotiations will cast yet more doubt on the prospect that devolved government might be salvaged before Monday’s deadline. Though he admitted Adams had demanded nothing unionists “should die in a ditch for”, he suggested neither party was likely to cede ground. “If Sinn Fein were to back down they would get hammered,” he said. “If Foster backs down the DUP would get hammered. So I think we’ve got ourselves a catch 22: they’ve both painted themselves into their respective corners.”

In addition, Empey accused DUP leader Arlene Foster of squandering the “dream scenario” unionist parties won at last year’s assembly election with a “disastrous” campaign, but added he did not believe she would resign despite repeated Sinn Fein demands for her to do so.

 “It’s very difficult to see how she’s turned that from being at the top of Mount Everest to being under five miles of water – because that’s where she is,” he said. “She no longer controls the institutions. Martin McGuinness effectively wrote her resignation letter for her. And it’s very difficult to see a way forward. The idea that she could stand down as first minister candidate and stay on as party leader is one option. But she could’ve done that for a few weeks before Christmas and we wouldn’t be here! She’s basically taken unionism from the top to the bottom – in less than a year”.

Though Foster has expressed regret over the tone of the DUP’s much-criticised election campaign and has been widely praised for her decision to attend Martin McGuinness’ funeral yesterday, she remains unlikely to step down, despite coded invitations for her to do so from several members of her own party.

The historically poor result for unionism she oversaw has led to calls from leading loyalists for the DUP and UUP – who lost 10 and eight seats respectively – to pursue a merger or electoral alliance, which Empey dismissed outright.

“The idea that you can weld all unionists together into a solid mass under a single leadership – I would struggle to see how that would actually work in practice. Can you cooperate at a certain level? I don’t doubt that that’s possible, especially with seats here. Trying to amalgamate everybody? I remain to be convinced that that should be the case.”

Accusing the DUP of having “led unionism into a valley”, and of “lashing out”, he added: “They’ll never absorb all of our votes. They can try as hard as they like, but they’d end up with fewer than they have now.”

Patrick Maguire writes about politics and is the 2016 winner of the Anthony Howard Award.