Open letter to Lansley from Wycombe Labour Party

Wycombe Labour Party writes to Lansley to give real examples where his shambolic reorganisation is wasting money and harming patients.

Newtons Farmhouse, Primrose Hill, Widmer End, Bucks HP15 6NU

16 May 2012

Dear Mr Lansley

Concerns about the future of the NHS

We are writing you an open letter setting out the concerns of Wycombe Labour Party about the NHS in Buckinghamshire as the Government starts to implement the Health and Social Care Act (H&SCA).    We are writing to you because these concerns are not about the actions of any one organisation in Bucks but about the health outcomes arising from a number of organisations working together, or more accurately not working together, in Buckinghamshire.  The failures of the new healthcare system are causing serious problems for patients in Buckinghamshire and we believe things will get worse.

No one organisation is responsible or accountable for these outcomes in Bucks but you must be responsible and accountable as Secretary of State for Health.   We would like to know how you propose to remedy the failings of the new system and improve health outcomes in Bucks.

We are going to tell you how the Labour Party in Wycombe has been trying to understand how the H&SCA will impact locally – and what it has found.  We make no apology if our findings are inaccurate as information from the organisations concerned has been slow in coming and difficult to obtain.  Wycombe Labour Party will be making a number of complaints to the Office of the Information Commissioner about this failure to provide information.    Our concerns are as much about members of the public finding out what is happening as about the outcomes themselves.

July 2011

In July last year, Buckinghamshire Primary Care Trust (the PCT) selected an organisation called Care UK to provide an intermediate triage service for Buckinghamshire residents with musculoskeletal problems.   The commissioning process was run and managed by Aylesbury Vale Clinical Commissioning Group,  with involvement and oversight by the PCT.

Aylesbury Vale Clinical Commissioning Group  represents 21 GP practices in Bucks and is currently a not-for-profit limited liability partnership.  Chiltern Clinical Commissioning Group (CCCG) represents another 33 GP practices in Bucks and is a company limited by shares.  Neither of these organisations appears to be registered with the Charities Commission under these names.  The Practice represents the remaining 5 GP practices in Bucks and is a large, national limited company.

It is not clear why Aylesbury Vale Clinical Commissioning Group  was given the responsibility to commission this service instead of, or as well as, CCCG and The Practice. Nor is it clear what, if any, input the CCCG or the Practice had in the commissioning process.

The contract for the service is worth about £2 million a year.  The service was intended to save the NHS £1.3 million a year by reducing the number of patients referred to hospitals for operations; the new service was intended to provide quicker and better diagnosis, better pain relief and more focussed treatments such as physiotherapy.

Care UK is a large multi-national company in the private sector.   A report in the Sunday Observer said that Care UK had set up a corporate structure that allows the avoidance of tax on millions of pounds worth of profit; it has a reduced tax bill by taking out loans through the Channel Islands stock exchange and coming to an agreement with HMRC.

Care UK won the contract on both price and quality grounds. Staff, including physiotherapists, from the NHS were transferred to Care UK when it won the contract.

October 2011

By October last year, performance on waiting times for Buckinghamshire patients had deteriorated from 92.4% of patients starting treatment within 18 weeks in October 2010 to 84.4% i.e. a doubling of the number of people who had to wait more than 18 weeks.  Performance for waiting times for trauma and orthopaedics, which make up 17% of the total, had crashed to 69.1%.  Performance in Bucks on both counts was much worse than the national averages.

Performance for patients going to Bucks Healthcare NHS Trust (BHT) was much worse, deteriorating to 80.6% for all patients and to 54.4% for trauma and orthopaedic patients.   The private sector consistently achieved 100%.

January 2012

In January this year, when the October figures emerged, we wrote to the Chief Executives of the PCT and Buckinghamshire Healthcare trust (BHT) to ask for an explanation of the drop in performance.

The PCT did not reply.

The Chief Executive of BHT wrote to say that the drop in their performance was due to the failure of Care UK to reduce the number of referrals.  This had led to the backlog of trauma and orthopaedic cases.  BHT had reduced its capacity for trauma and orthopaedic operations in anticipation of a reduction in referrals and had then had to restore that capacity when the reduction did not happen – and that had taken time.

We asked how much this had cost BHT.  We had to write twice for an answer and BHT eventually responded to say that “it had had to use its resources differently to manage demand when the reduction did not materialise”.  However, “it was not possible to extrapolate the direct costs related to these specific changes.”   So resources, perhaps millions of pounds, that would have been used for other patients had to be re-directed back to trauma and orthopaedics cases.  The healthcare of other patients therefore suffered because of the failure of the Care UK contract.

February 2012

In February, we asked the PCT for information about possible cherry-picking by the private sector; we understood that the private sector takes low risk cases which have a relatively quick throughput and make a healthy return, leaving BHT to take high risk cases which take longer and cost more.  This might account for the disproportionately poor performance on waiting lists of BHT as compared to the private sector.

We also asked the PCT if it had received any funds specifically to reduce waiting lists, and if so how much.

And we also asked the PCT about our concerns that patients were being taken off the waiting list for treatment before they reached 18 weeks in preference to those who had already reached the 18 weeks.  This would have improved the apparent performance of the PCT in hitting its 18-week target.  We asked for a personal assurance from the Chief Executive that patients would continue to be treated according to clinical need and strictly in line with the length of time they had spent on the waiting list. We understand that the Royal College of Surgeons is undertaking research on this issue as it is concerned that this practice is common amongst NHS Trusts with pressure on them to reach the 18-week target and reduced funding to undertake the work.

We have received no response to these concerns.

February 2012

Also in February, we asked the PCT about the performance of Care UK.  We asked for its monthly performance reports against its targets, the costs arising from any failure to deliver those targets, what financial penalties had been imposed on Care UK as a result of these failures and what reductions had been made to the payments for the Care UK services if the throughput was less.

We have not received a full response to our request from the PCT but understand that:

–          GPs are continuing to send many of their trauma and orthopaedic patients direct to consultants in hospitals and failing to use Care UK as an intermediate triage service.  We have not been told what percentage of patients are still being referred direct and how this compares with the forecasts when the contract was awarded to Care UK.

–          The PCT has no power to direct GPs to use Care UK.

–          AVCCG, who were instrumental in commissioning the service, has no power to direct GPs to use Care UK.  We have not been told what efforts the CCG is making to persuade its members to use Care UK, nor have we been told what efforts it is making to persuade GPs represented by the other two CCGs in Bucks.

–          Care UK will not receive its bonuses for reducing referrals and is making efforts to persuade GPs to use its services.

–          Care UK continues to receive flat rate payments for providing services even if throughput is lower than forecast.

–          The PCT continues to pay for patients referred direct even if those referrals should have gone to Care UK.

Finally, we understand that BHT has failed to gain foundation status primarily because it has missed its financial and waiting time targets.  This puts the continued operation of BHT at risk.

So if we look at the outcomes in this one limited part of NHS healthcare in Bucks:

Costs and savings

–          The NHS has not made savings on the contract.

–          In fact, the NHS has incurred costs.  BHT has incurred the costs of reducing its capacity and then re-instating it.   The PCT is paying twice for the same patients as it pays Care UK anyway and also the hospital service if patients go direct.

–          This means money has had to be re-directed from elsewhere in BHT and the PCT.  Healthcare which would have been provided to other patients has not been provided.  Other patients have suffered.

–          Care UK has probably made a profit on the contract, not least because it gets paid for a service which has a lower throughput than forecast.  It can therefore cut back on its variable costs like staffing and still get paid.

–          Care UK will presumably continue to avoid paying tax on that profit.

–          The CCGs will make no savings nor incur costs on the deal.  Although AVCCG commissioned services from Care UK and spent NHS money, there is no financial incentive for it or the other CCGs to use the service and therefore save the NHS money.

Other consequences

–          Waiting lists have lengthened, dramatically so for trauma and orthopaedics last year.  This has caused suffering to many patients.

–          Many staff have transferred from the NHS to the private sector, causing at least uncertainty and at worse a lowering of morale; employees have moved from the NHS whose principles of public service many endorse to an employer whose duty is to make money for its shareholders.

–          BHT has failed to gain foundation status.  Care UK’s failure to reduce referrals must have had a significant impact on BHT’s waiting time targets and probably on its financial targets.  This failure has therefore contributed to BHT failing to gain foundation status.

Responsibilities and accountabilities

–          Each of the organisations has acted, as far as we can tell, in line with its own responsibilities and accountabilities.

–          The PCT manages a substantial budget which it is required to hand over to the CCGs on a shadow basis this year.  It is required to tender for services through a transparent and open process. It is responsible and accountable for this work to you as Secretary of State.   You will close the PCT down next year.   We understand half the staff might be made redundant by Christmas.

–          The CCGs are currently private sector companies responsible to their trustees or shareholders. They are waiting authorisation to become statutory bodies next year.   They will then be responsible and accountable to one of four regional commissioning boards yet to be established and hence to the National Commissioning Board and yourself as secretary of State.

–          BHT is required to provide a service to the public, up to now largely from public funding.  In order to continue in business it has to achieve foundation status and is trying to do this.  It is currently responsible and accountable to you as Secretary of State.  When it achieves foundation status it will be accountable to Monitor.

–          Care UK is a private sector company responsible and accountable to its shareholders for making a profit.  We do not know who the shareholders are.


In looking at this relatively limited area of NHS work, we would point out how extremely difficult it has been to obtain full, accurate and timely answers to the questions we have asked.  This has made it difficult for Wycombe Labour Party to understand what is going on and scrutinise the operations of the NHS.   Part of the problem lies with the increasing fragmentary structure of the healthcare system.

It will become even harder once the H&SCA is passed.   We would therefore like to know how members of the public will be able to ensure in future that taxpayers money is being spent effectively and with propriety by the various responsible bodies providing healthcare services.

It is absolutely clear to us that the system is not working, and the situation will get worse.   The system is wasting money, it is causing waiting lists to lengthen, it is diverting money from healthcare services and patients are suffering.  The only organisations doing well are private sector companies making a profit from the fragmentation of the NHS.  The system is threatening the continuation of the Bucks Healthcare Trust.

And no organisation has, or will have, the power to improve matters and the responsibility to account for its actions to the public.

In short, the system is a complete shambles.

We would like to know what you propose to do to resolve these problems.

Copies of this letter go to the Chief Executives of the PCT and BHT, to Aylesbury Vale and Chiltern Clinical Commissioning Groups and The Practice, Care UK and the Shadow Health Secretary.

Yours sincerely

Linda Derrick, Health & Social Care Policy Lead

Mark Ferris,  Secretary Wycombe Labour