Flawed data? Why NHS spending on the independent sector may actually be much more than 7%

The presentation of data on NHS expenditure is flawed, writes David Rowland, which prevents policymakers from having a clear understanding of where money within the system is going. He estimates that in 2018/19, the amount spent by NHS England on the independent sector was around 26% of total expenditure, not 7% as widely reported. 

Claims regarding the extent of NHS ‘privatisation’ ought to be easily settled by referring to the official data contained within the Department of Health and Social Care’s (DHSC) annual report and accounts. These accounts, which set out how much is spent by the NHS in England in the independent sector have nonetheless been inconsistent and difficult to interpret. Following a comprehensive review of six years of these accounts our view is that the presentation of this data is seriously flawed and requires revision.

The 7% figure

The settled view in the media is that around 7% of NHS expenditure is spent by the NHS in the independent sector to purchase healthcare for patients. The source of the 7% figure is a table which has been included in the Department’s annual report and accounts each year since 2014-15, which details all expenditure on healthcare provided by ‘non-NHS bodies’. A combined version of all the entries contained within these tables is set out in Table 1 below.

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In total, between 2013/14 and 2018/2019 an additional £5.6 billion of NHS England’s budget went on the independent sector – an increase of 23%. In the main, this overall increase in expenditure on the independent sector is due to the increase in the amount that local Clinical Commissioning Groups (£4.3bn) have purchased from the independent sector.  Most other areas of expenditure on the independent sector – for example Primary Care Services – have not increased substantially. The reported increase in the voluntary sector spend is due to a change in how the DHSC accounts classified this type of expenditure rather than their being any significant actual increase in this area of spend.

Conclusion

It is important to have a reliable estimate of annual expenditure by the NHS in the independent sector so that policymakers can those businesses and organisations which provide publicly funded healthcare to account. Our earlier research estimated that there were around 53,000 individual contracts which underpin flow of money between the NHS and the independent sector. We now estimate that these 53,000 contracts are worth £29 billion each year.

A correct presentation of expenditure also allows the media and parliamentarians to have a clear understanding of where money within the NHS system is going and the trends that are taking place. If these facts are hidden within the accounts, it limits a broader understanding of the nature of healthcare provision in England. Healthcare in England is now very much less directly provided by the NHS than most people think.

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MPs must block the government’s NHS Integrated Care Bill

Announcements that the Government and NHS England have proposals for NHS legislation that will “rein in” privatisation are misleading and beside the point.

The proposed NHS Integrated Care Bill is to enable the fragmentation of the NHS into Accountable Care Organisations – which the government has rebranded as Integrated Care Providers.

It will not save the NHS from big business – rather, it props the door wide open for it.

The undersigned NHS campaigns demand that Parliament:

  • blocks the government’s US accountable care legislation
  • doesn’t enable it by trying to amend it, as the Libdems did with the Health and Social Care Act
  • passes an updated version of the NHS Reinstatement Bill, that clearly abandons  the current neo-liberal, neo-conservative model of integrated health and social care, and extends to social care the NHS core principle of comprehensive health care that is free at the point of access for all, on the basis of clinical need as agreed between patient and clinician – in the changed context of today’s society

If the government’s proposed legislation comes to the table, all opposition MPs – as well as those Conservatives who respect the majority public view that the NHS should be nationalised and run by the public sector – should be under no doubt that they need to block it.

DEREGULATING MARKETS IN THE NHS

The NHS Integrated Care Bill proposals to scrap the Lansley Health and Social Care Act’s Section 75 requirement for competitive procurement of local NHS services and to remove NHS commissioning from the remit of the Public Contracts Regulations 2015, don’t begin to scratch the surface of the problem of NHS marketisation and privatisation.

The proposed legislation leaves intact contracts and their procurement, which we do not think should be the basis of providing NHS services.

Tellingly, Andrew Taylor, former director of the NHS Cooperation and Competition Panel, is on record as saying that the government’s proposals are about deregulating markets in the NHS, that they in no way remove them, and that

“no one has realistically talked about removing the private sector. ”

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Health bosses deny Banbury Guardian info on Oxford PET-CT scanner privatisation

NHS England intends to pass the Thames Valley contract for the PET-CT scanner service to a private company, InHealth

The Banbury Guardian’s attempts to reveal the truth on the privatisation of Oxford’s NHS cancer scanners are being frustrated.

Campaigners trying to keep the contract for advanced scanning in Oxfordshire’s NHS have expressed disgust that Freedom of Information (FOI) requests have still not been answered.

The Banbury Guardian has been fighting for documents explaining how the decision was made to privatise the contract for the PET-CT scanners – against the wishes of everyone – except NHS England (NHSE).

In a comment piece, Banbury Guardian reporter Roseanne Edwards tells the story behind her ongoing battle.

We have been trying to get to the bottom of this matter, in which first the clinicians, Oxford University Hospitals NHS Trust (OUH) and campaigners have tried to keep this vital specialist service within OUH. But we have been thwarted at every turn.

We first asked OUH to give us correspondence between it and NHSE (which has made InHealth its preferred bidder in place of OUH) in mid-March.

The trust had 20 working days to deliver but delayed for months. We pressed them.

When it finally released the correspondence it was incomplete, missing out ten critical weeks of correspondence which we believe would explain why OUH management moved from fierce opposition to a contract handover and refusal to work with InHealth, to a supposed ‘partnership’ that gives InHealth the whole contract for the Thames Valley for operating two mobile scanners at Milton Keynes and Swindon.

The OUH will be a subcontractor to a company that is doing a minute fraction of the work. OUH’s experts, who will be doing the vast majority of the sophisticated work, are said to be furious.

After all that, when we finally got the ‘missing papers’ it was clear there were still crucial emails that had been left out.

We want to know what NHS England said to OUH to compel it to change its mind and go along with the privatisation. We think the public has a right to know.

In a bid to discover what was going on and why the FOI requests were being thwarted, the Banbury Guardian put in another FOI request in early July asking for all correspondence, internally and externally, connected with our original FOI request.

The OUH has failed to release that too and has still not met its obligation under the FOI law. Repeated reminders have been ignored.

The Banbury Guardian also sent a FOI to NHS England requesting evaluation documents on its decision but NHSE has refused, using a commonly employed exemption that releasing the information might prejudice commercial interests and that it failed the ‘public interest’ test since it may prejudice negotiations.

The Banbury Guardian has asked for an Internal Review.

Keep Our NHS Public Oxfordshire believes the PET-CT scanner deal amounts to ‘political horse-trading’.

Liz Peretz said: “This prevarication and delay is disgusting. We believe answers to the FOI requests will reveal unacceptable shenanigans around the comparison of the two original bids, which unjustly favoured the private company over our NHS. This shows problems at the heart of marketisation of our NHS. It shows why we need the NHS Reinstatement Bill to be enacted.”

Oxford East MP, Anneliese Dodds (Labour), said: “The FOI system was created so citizens could hold public bodies to account. Here we have health care bodies which have not been open and accountable about how decisions on services will be made – including whether or not they will be privatised. This is not acceptable.”

SWKONP Freedom of Information Request to Warwickshire County Council concerning School Nurses contract (reply August 15th 2019)

Below: my original questions to Warwickshire County Council (sent July 31st 2019) and WCC reply (August 15th, replies in italics).

As you will see, there are no direct replies to my questions as to scoring and why Compass was awarded the contract, and not South Warwickshire Foundation Trust. I am referred to 4 documents, none of which answer my questions.

Ms Anna Pollert

South Warwickshire Keep our NHS Public

Information Management

Shire Hall

Warwick

CV34 4RL

 

Telephone 01926 418633

Email jonathansheward@warwickshire.gov.uk

Please ask for Jonathan Sheward

Our ref: 4750552 Your ref: Date: 15 August 2019

 

Dear Ms Pollert,

Freedom of Information Act 2000

Your request for information has been considered by Warwickshire County Council under the Freedom of Information Act 2000.

 

You asked us:

I would like to make a Freedom of Information Request to Public Health,

Warwickshire County Council, regarding the tendering of the Warwickshire

School Health Service, and the awarding of the contract to Compass.

Please could you provide information on:

 

  1. The scoring for:

a) Digital capability and how this is measured

b) Access to nursing services by children

c) Integration of school nursing services with other services, e.g. health visitors and social services.

d) Health outcomes of services

e) Competence (and how this is assessed)

Please see answer to q3 below.

  1. Please could you provide me with information on the weighting of the score

criteria.

Please see answer to q3 below.

  1. Please could you provide me with information on how the scoring criteria were

combined. 

In answer to questions 1,2 and 3, please see the following documents attached to our covering e-mail: 

i) Invitation to tender

ii) Service specification

iii) Heath Needs Assessment of School Aged Children in Warwickshire and School

Health & Wellbeing Service Review (Update 2018)

iv) 2017/18 Compass Annual Report

4.Please could you provide me with the performance targets provided to Compass in its contract, whether these were achieved, and the score (% or whatever method WCC Public Health assessment was used).

A detailed service evaluation and audit against the Healthy Child Programme was undertaken as part of the Needs Assessment provided in response to Q1. Appendices 1 and 2 demonstrate the overall performance, including the associated targets. 

  1. Please could you provide me with information on the length of the contract to Compass.

The Initial contract term is 3 years with further options to extend for periods up to 3 years (up to 31st October 2025) and further option to extend for up to 3 years (up to 31st October 2028) being the maximum available extension periods at the discretion of the Council based on the contract performance of the successful applicant.

  1. Please could you provide me with the value of the contract in £s.

Total contract value is £20,721,645 over 9 years.

  1. Please could you explain why the evaluation team was not keen to integrate school nursing services with SWFT’s wider hospital and community pediatric service portfolio, especially health visiting. This question is based on SWFT’s CE’S report, which states, from formal feedback, that ‘Our bid focussed quite heavily on the potential to closer integrate the service with our existing Health Visiting service across the County as well as our wider hospital and community paediatric service portfolio. But it became clear that this approach reduced the attractiveness of our bid as the evaluation team were keen not to integrate this service, particularly with health visiting’.

This is not an accurate reflection of the feedback provided following the contract award, therefore we are unable to respond to this question. 

  1. Please could you explain whether SWFT’s contract for school nursing in Coventry and Solihull was considered in its bid to WCC, and if so, whether its performance was assessed and how.

Bidders were invited to use examples from existing contracts within their tender

response (see the Invitation to Tender). Please contact SWFT if you wish to request

further information from their response. 

If you are dissatisfied with the handling of your request, you have the right to ask for an internal review. Internal review requests should be submitted within 40 days of the date of receipt of the response to your original letter and should be addressed to:

Information Management

Shire Hall

Warwick

CV34 4RL

inforights@warwickshire.gov.uk

Integrated Care Provider Contract – 20/8/2019 from Health Service Journal

The Integrator  Rebecca Thomas

Health Service Journal, 20.8.2019

Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by mental health correspondent Rebecca Thomas. 

This month we had the return of the integrated care provider contract.

In theory, this should be a big deal for NHS policy, but with just one area likely to be using the contract in the near future, the relevance of it is somewhat hypothetical.

Regardless, there are a few things worthy of note in the most recent iteration.

First is the omission of a previous rule that prevented an integrated care provider from holding more than one ICP contract at a time. This omission means, in theory, that a provider could hold an ICP contract across two sustainability and transformation partnerships, if it had GP partners in both areas.

In reality, this is unlikely to happen now the contract cannot be handed to a private provider.

The integration specific requirements for fledgling ICPs are also interesting.

Any provider, for example, will have to have information systems and data sharing agreements that allow it to understand and analyse the health needs of its population, and identify, for instance, which members of its population are at risk of developing certain diseases. The providers must also “use all reasonable endeavours” to offer patients alternatives to face-to-face contact, creating opportunities for the likes of Babylon.

Some areas are already on their way to achieving both these requirements, but having it within a contract would be an additional push.

 

Purchaser/provider split

The big question on everyone’s lips when NHS England first revealed its ambitions for this contract was whether it would end the purchaser/provider split.

The answer appears to be ‘not really’, as there’s nothing within the final version of the contract which suggests commissioners will be able to completely transfer their statutory roles.

For example, before subcontracting a service, an ICP would still need to gain commissioner permission.

Although the contract will give providers a greater say in commissioning decisions and budgeting, those hoping the final version would spell the undoing of the Lansley reforms will be disappointed.

Financial risk

If they do get off the ground, ICPs will be handed big budget multiyear contracts.

The contract size will vary depending on how many GP practices agree to include their contracts and the extent to which social care is involved.

The details around how the non-core GP elements of the contract should be costed are vague and non-prescriptive. The baseline calculations are a mixture of historical activity, demographic modelling, benchmarking activity trends etc, but will need to allow for future flexibility.

Those thinking about either commissioning or providing will want to weigh up where the financial risk sits.

Clinical commissioning groups will bear the risk of changes in population size and demographic, although this is, in theory, addressed by their yearly allocations.

The ICP, on the other hand, will bear the risk of:

  • activity changing – patients using services more or less frequently;
  • variation in patient usage patterns;
  • efficiency savings not realised; and
  • changes which impact the quality of care.

Is this contract required?

The likelihood of this contract becoming a mainstream vehicle for integrated care systems in the near future is low. While some areas are now starting to look into its use – Barking, for example – Dudley CCG is the only commissioner to have started a procurement process to use this contract.

As a reminder, these plans would effectively split the Dudley Group FT in two, with a new trust being formed around its community division. This new legal entity would then hold the ICP contract, allowing GPs to sit on the board.

However, the CCG’s chosen vehicle is still mired in regulatory haze, while providers are still working through the budget details, so it’s not clear when the ICP will come to fruition.

You could also question whether the new contract is needed.

Some would argue the ends of the ICP contract can be met through other means, such as the primary care network contracts, for example.

There are several areas where the ICP contract mirrors what PCNs are designed for, such as incorporating multidisciplinary primary and community care services and social prescribing.

Would a partially integrated ICP, in which GP practices still hold their own contracts, be any different to an NHS trust alongside a group of PCNs?

Since both PCN and ICP contracts are untested, we’re unable to answer this question with any certainty

 

 

Primary CareNetworks will fail to deliver any of five core goals set by NHS England, GPs warn

GPOnline By Luke Haynes on the 5 August 2019

Two thirds of GP partners believe primary care networks (PCNs) will fail to achieve key targets set by NHS England, which include stabilising the GP partnership model and easing pressure on the workforce, a GPonline survey shows.

A significant 65% of GP partners in England who took part in a GPonline opinion poll said PCNs would not achieve a single one of the five core objectives unveiled by NHS England at its June board meeting.

Meanwhile, over half (55%) of all GPs who responded to the survey – 440 in total – said the networks would be unable to deliver on their core aims, which should be achieved by 2023/24.

Several survey respondents told GPonline they believed PCNs, which came into force in July, would dissuade GPs from becoming partners and create additional workload for GPs rather than reduce it.

Principal targets

The networks, which group neighbouring practices across populations of between 30,000-50,000 people, are intended to strengthen primary care services by encouraging practices to work together and share staff.

In June, NHS England’s national director for strategy and innovation Ian Dodge outlined five key ambitions he hoped PCNs would achieve:

  • stabilise the GP partnership model
  • dissolve the divide between primary and community care
  • help solve the capacity gap and improve skill-mix by growing the wider workforce by over 20,000 wholly additional staff
  • become a proven platform for further local NHS investment, including in premises
  • achieve clear quantified impact for patients and the wider NHS

However, a majority of GP partners in England – and a majority of GPs of all types – said PCNs would fail to achieve these targets, casting doubt over the impact of the latest NHS restructure.

GP partnership

Above all, partners believed PCNs would struggle to stabilise the GP partner model, with only one in 10 saying the new measures would be successful.

A similar view was revealed among all GPs surveyed, with just 13% saying PCNs would help to combat a decline that has seen numbers of GP partners in England fall by nearly 3,000 between September 2015 and December 2018.

One GP partner said PCNs would ‘actively discourage’ young GPs from becoming partners; a sentiment echoed by a fellow partner, who labeled the changes ‘very disappointing’.

‘Initially when this was announced I was excited that it may lead to improved patient care. [But] already I feel that it is a mechanism to destabilise partnerships, increase the risk carried by GP partners and prevent new GPs from wishing to undertake partnerships,’ the partner said.

Skill mix

GPs were also not convinced that PCNs would help to solve the workforce gap and improve skill-mix by growing a wider workforce – another of NHS England’s core aims.

PCNs are intended to increase the primary care workforce by 20,000 staff including physios, social prescribers, pharmacists and others by 2023/24. But just shy of a quarter (23%) of GPs in England said the networks would achieve this target. Partners were less convinced than GPs overall, with just 14% indicating that the networks would help to reduce capacity and skill deficiencies within practices.

Many respondents said the recruitment of additional primary care professionals was merely a ‘sticking plaster’ solution to the wider issue of GP retention.

One GP said: ‘PCNs are not the solution to the GP recruitment and retention crisis. The directed enhanced service is unlikely to be adequately funded and way more resources will be needed to achieve targets.’

BMA GP committee chair Dr Richard Vautrey said it was unsurprising that some GPs were sceptical about future developments following countless NHS organisational changes in the past.

However, he said the speed at which PCNs had been set up across England underlined GPs’ commitment to ‘seize the opportunities’ and make a success of the five-year contract that took effect from April.

‘GPC England has been clear from the outset that the £20bn commitment to the NHS to fund the long-term plan and the £4.5bn contract agreement, which includes the development of PCNs, cannot solve all the problems we face… but they are a step in the right direction.

‘We are very aware that too many people believe PCNs will somehow be able to solve almost every problem the NHS faces but they don’t have the capacity or capability to do that and we must manage expectations, giving these new groups time, space and support to develop.’

School nurse contract goes to private company, Compass

Health chief disappointed to miss out on school nurses contract

Stratford Herald Ben Lugg  

A decision not to award a new contract to provide school nurses in Warwickshire to the South Warwickshire NHS Foundation Trust (SWFT) has been greeted with disappointment by its chief executive.

Earlier this month the chief executive’s report revealed that SWFT had lost out on the contract to an independent provider called Compass.

Giving his reaction to the news, Glen Burley, chief executive at SWFT, said: “We were disappointed that our bid to bring the Warwickshire School Health and Wellbeing Service back into the Trust had been unsuccessful. Following the success of our similar contracts in Coventry and Solihull we feel like this is a real missed opportunity for our local health system.

“Preventing illness is a key element of our strategy so we will seek to work collaboratively with Compass, the independent sector provider of the service, to ensure that there is an increase in health promotion and prevention interventions in this really important part of our community.”

The report explained that SWFT may have lost out because its ‘digital maturity’ needed improvement.

It added that SWFT hoped to bid again for the contract in the future.

Compass is the current provider of the School Health and Wellbeing Service in Warwickshire which delivers preventative and universal public health programmes in schools across the county, as well as in youth centres, children’s centres, homes and elsewhere.

It also provides advice on a wide range of health topics from healthy eating; friendships and bullying; to parenting, fussy eating, anxiety and sleep.

The service is delivered by nurses and healthcare support workers and is freely available to all school-aged children and young people from 5 to 19 years old (up to 25 years old for people with special educational needs) and their families and carers.

Rachel Bundock, Compass chief executive and executive director said: “Compass is delighted to have this opportunity to continue delivering this very important and much valued service. We have established some fantastic partnerships over the last four years which contributed significantly to the service’s success. We are very much looking forward to working with our partners over the coming months to implement the next phase of the service.”

The new contract will run from 1 November 2019 – 31 October 2022, following the end of the current contract on the 31 October 2019.

Warwickshire County Council declined to comment on how much the new contract was worth.