Staffordshire Madness

Staffordshire was the last of the Sustainability and  Transformation Plans to be published perhaps because relationships in this part of the country are rumoured to be poor. Both providers and commissioners in the area are challenged. Despite this the commissioners in Staffordshire are going ahead with a hugely controversial project to outsource some £1.2 bn of NHS services. This is at least in part an outsourcing of commissioning functions.

The Public Accounts Committee considered a similar exercise in Cambridge with some grave concerns. The PAC report into the matter noted:-

We asked the CCG why it had decided to contract out the commissioning of services to a third party, given that the commissioning of services is the role of the CCG itself. The CCG explained it had hoped that by commissioning one organisation for all of the services, that the organisation would find ways of integrating pathways of care to get the best outcomes, which the CCG had failed to do until that point.

The CCG acknowledged that it had tried to outsource the responsibility for transforming care pathways. It accepted now that CCGs should not outsource difficult decisions that they should be taking themselves, and that the commissioner is responsible for the NHS services for their local populations. The CCG confirmed that it believes it is now able to fulfil the commissioning role and is investing in developing the organisation to be fit for purpose to do so.

So why are commissioners in Staffordshire being allowed to do something acknowledged to be unacceptable?

When the Staffordshire fiasco began back in May 2013 a press release announced that – Staffordshire’s Clinical Commissioning Groups (CCGs) are teaming up with Macmillan Cancer Support to transform the way people with cancer or those at the end of their lives are cared for and supported. This sounded like a good idea and this project was awarded Pioneer Status by NHS England.

But the twist came soon after when in March 2014 the Financial Times reported that The NHS is embarking on its biggest and most wide-ranging outsourcing of services so far by inviting companies to bid for £1.2bn in contracts to provide frontline cancer treatment in district hospitals and care for the terminally ill. The deals could see the private sector delivering all cancer and end-of-life treatment for children and adults across Staffordshire and Stoke on Trent.

The CCGs were effectively outsourcing a key part of their role as commissioners. The procurement Notice stated that “In Stage 2 the provider will assume the responsibility for managing the provision of Cancer Care (or End of Life Care)”.

The process rumbled along with Macmillan continuing to play a very active part – leading to some questions about if this was a valid use of donations.

There were some delays with the procurement process and then work was paused after the collapse of a similar huge contracting process in Cambridge. Following the involvement of the National Audit Office and Public Accounts Committee there was an agreement that NHS England would review all major contracting processes. But then in November it was announced in the HSJ that NHS England had carried out a review of the programmes and given the go ahead for them to continue. The review has not been published.

Of great concern must be that the key advisors in Staffordshire were the now discredited Strategic Projects Team (SPT), the same SPT who “advised” in Cambridge. The SPT were actually a part of NHS England so there must be a question over how sensible it was for NHS England to review itself.

The HSJ reacted to the news of the continuation of this project:-

The Staffordshire project predates Simon Stevens’ tenure as NHS England chief executive, and quite a lot has changed since it was launched. “Integration” doesn’t mean quite the same thing in 2016 as it did in 2013. In the past three years we’ve had the Five Year Forward View, new models of care and the vanguards, which all overwhelmingly focus on “population health” rather than single pathway integration.

The Stevens-led NHS does seek to integrate and improve single service pathways too – see the acute care collaboration on orthopaedics, or the cancer taskforce – but does the Staffordshire cancer pathway fit with the work now being done nationally by Cally Palmer? Hopefully someone has checked.

Although national leaders aren’t completely averse to single specialism outcomes based contracts, they are clear that you can’t build a population budget out of a mosaic of single service contracts. They want to avoid a scenario where it becomes impossible to set up a PACS on a capitated budget because there are already lots of individual long term contracts for single pathways. The two Staffordshire contracts would certainly punch two big holes in any future MCP or PACS.

The method being used in Staffordshire feels at odds with the new care models approach. No one involved in the vanguards seriously thinks you can award a massive contract to a new provider and expect services to integrate automatically. Part of the reason new care models are taking so long to be formally established is that people are (sensibly) focusing on the relationships and working practices first, and leaving the contracting until much later in the process.

Another complicating factor: the Staffordshire STP covers six Clinical Commissioning Groups, but only four are involved in this contracting exercise. Assuming this notoriously fractious patch does come up with a viable sustainability and transformation plan (nothing has been published yet), these contracts may make it harder to begin whole system working.

Lots of work has been done in parts of Staffordshire on the cancer and end of life care pathways. National leaders have decided it is better to go ahead than to abandon the tender. Presumably the work done so far is of good quality.

Let’s hope so, because, on the face of it, this exercise is a relic of the pre-forward view era and cuts across the generally sensible approach to new models of care being taken elsewhere.

So the HSJ shares the view that this approach with outsourcing of commissioning is wrong and is also incompatible with the new direction set out in the 5 Year Forward View and the STPs.

The CCGs have decided to go ahead by simply restarting the two paused procurement processes both of which only no include private sector bidders. They will decide in private based on documents nobody has been allowed to see.

If this goes the way of Cambridge who will be held to account?