"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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Does the UK care enough about climate change to admit it is part of the problem?

The government’s energy policies make can make it hard to decipher its commitment to emissions reduction.

“People tell me it’s ridiculous to be flying for a climate change project but you have to get real with it, I mean I can’t cycle across the Southern ocean,” says Daniel Price, an environmental scientist from London. As founder of Pole-to-Paris, Price is about to complete a 17,000km bike ride from the Antarctic to the Arc de Triomphe.

Price came up with the idea in an effort to raise public awareness of COP21, the UN Climate Change Conference taking place in Paris next week. During the trip he’s faced a succession of set-backs: from the discovery that boats were prohibitively expensive, to diplomatic tensions scuppering his Russian visa plans. Yet the darkest moments were when he became overwhelmed by the magnitude of his own mission. “There were difficult times when I just thought, ‘What is the point of this’?” he says. “Cycling round the world is nowhere near enough to engage people.” 

As world leaders descend on Paris, many questions remain unanswered. Not least how much support developing nations will receive in tackling the effects of climate change. New research commissioned by Oxfam claims that such costs could rise to £1.7tn a year by 2050. But with cuts kicking in at home, the need to deliver “climate justice” abroad feels like a bigger ask than ever.

So does Britain really care enough about climate change to accept its full part in this burden? The government’s energy policies make can make it hard to decipher its commitment to emissions reduction. In September, however, it did pledge £5.8bn from the foreign aid fund to helping poorer nations combat climate change (twice that promised by China and the United States). And there’s evidence to suggest that we, as a public, may also care more than we think.

In America attitudes are much darker; in the dismissive words of Donald Trump “It’s called the weather”. Not least since, as a recent study proves, over the last twenty years corporations have systematically spread scepticism about the science. “The contrarian efforts have been so effective," says the author Justin Farrell, a Yale sociologist, "that they have made it difficult for ordinary Americans to even know who to trust.” 

And what about in China, the earth's biggest polluter? Single-party rule and the resulting lack of public discussion would seem to be favouring action on the environment. The government has recently promised to reach "peak" emissions by 2030, to quadruple solar installations, and to commit $3.1bn to help low-income countries adapt to the changing world. Christiana Figueres, the UN’s chief climate official, has even lauded the country for taking “undisputed leadership” on climate change mitigation.

Yet this surge of policy could mask the most troubling reality of all: that, when it comes to climate change, the Chinese are the least concerned citizenship in the world. Only 18 per cent of Chinese see the issue as a very serious problem, down 23 percentage points from five years ago, and 36 points behind the global median.

A new study by political economist Dr Alex Lo has concluded that the country’s reduced political debate could be to blame for the lack of concern. “In China popular environmentalism is biased towards immediate environmental threats”, such as desertification and pollution, Lo writes, “giving little impetus to a morally driven climate change movement”.

For the international community, all is well and good as long as the Chinese government continues along its current trajectory. But without an engaged public to hold it to account there’s always a chance its promises may fade into thin air.

So perhaps the UK’s tendency to moan about how hard it is to care about the (seemingly) remote impacts of climate change isn’t all bad. At least we know it is something worth moaning about. And perhaps we care more than we let on to each other.

Statistics published this summer by the Department of Energy and Climate Change reveal that three quarters of the British public support subsidies for renewable energy, despite only 10 per cent thinking that the figure is that high. “Even if the public think the consensus is not there, there are encouraging signs that it is,” says Liz Callegari, Head of Campaigns at WWF. “Concern for climate change is growing.”

As Price puts it, “You can think of climate change as this kind of marathon effort that we have to address and in Paris we just have to get people walking across the start line together”. Maybe then we will all be ready to run.

India Bourke is the New Statesman's editorial assistant.