Cambridgeshire CCG and UnitingCare Partnership
Motion made, and Question proposed, That this House do now adjourn.—(Charlie Elphicke.)
I thank you, Mr Speaker, for allowing the House the opportunity to consider the extraordinary collapse, after just eight months, of one of the biggest tendering exercises conducted in the NHS: the £800 million contract between UnitingCare Partnership and Cambridgeshire and Peterborough clinical commissioning group.
Two weeks ago, I spent a morning out with an ambulance crew working from the ambulance station on the Addenbrooke’s site outside
I saw the NHS at its best: top-quality care, provided quickly; people in pain
and discomfort treated with dignity and respect; a swift, seamless transfer
into hospital; and fantastic, caring, committed staff, on ambulances and in
hospital. It was our NHS at its best and we should be proud of it. Cambridge
When health leaders in Cambridgeshire said they wanted to create an integrated service for older people that would focus on prevention, it was a worthy aim, albeit polluted by the need for a competitive tender, insisted upon by the Health and Social Care Act 2012. When the contract was finally signed with NHS providers, it should have been the start of a new way to provide care, so what went wrong? That is what I want to quiz the Minister on tonight, because the failure of this contract matters way beyond Cambridgeshire, and it has rightly attracted national attention. A recent editorial from the Health Service Journal said:
“When a five year contract of this size and this importance to some of the most vulnerable people in society fails, it is not enough to shrug and walk away. As NHS England develops capitated, outcomes based contracts for national rollout, it is important to understand and explain what has gone wrong in Cambridgeshire so the lessons can benefit the health service as a whole.”
It is right.
This is a long and complicated story, which some of us have followed closely over many years. You will be glad to hear, Mr Speaker, that I will give an abbreviated account, but I must pay tribute to some of the campaigners who spent many, many months at meetings across Cambridgeshire questioning and challenging: my friend and colleague, Huw Jones; Steve Sweeney, then of the GMB; Jo Rust; Tracey Lambert and Martin Booth from Unison; and many, many others. We always knew something was not right and, sadly, we were proved to be correct.
I believe the story really begins back in 2012, when the future of Cambridgeshire Community Services NHS Trust, which had itself only a few years earlier been separated from the predecessor to the CCG, was thrown into doubt when it failed in its bid to become a foundation trust. Under Government guidance at the time, through the Trust Development Authority, trusts that were not foundation trusts faced being wound up. That was a foolish policy and, as so often, it was later rescinded, but given that this was happening when the infamous 2012 Act was under massive discussion, the real possibility was raised that many care staff would be transferred to private providers. That did not happen, because Cambridgeshire County Council, which many staff had originally worked for, took many of them back, but the consequence was a disintegration of services—the very opposite of what was needed. Integrated teams were ripped apart—an act of vandalism that set care back. The Trust Development Authority, the body overseeing this early-stage debacle, remains the line of accountability for NHS trusts. Those trusts are now being merged, in their regulatory function if not statutorily, into Monitor, which is yet another executive non-departmental public body of the Department of Health.
It is worth noting in passing that, since the time it was denied foundation trust status, causing the disintegration of care, Cambridgeshire Community Services has gone on to be named as the best community trust to work for by the Health Service Journal, and is now doing very well, albeit by working mainly with others outside Cambridgeshire.
Against that backdrop, and because of the 2012 Act taken through Parliament by the then local MP and Secretary of State for Health, the Cambridgeshire and Peterborough clinical commissioning group, in wanting to move to a new model of outcomes-based care, was forced in 2013 to put health services for older people out to tender. The process attracted national attention and was very controversial locally, mainly because of its focus on trying to attract private providers. Shrouded in commercial confidentiality, rumours abounded. Many organisations expressed interest including Virgin Care, Care
Circle, Capita and UnitedHealth and more. UK
Over many months, campaigners and I sat through numerous CCG board meetings and what were described as public consultation meetings where we were assured that all was well and that the many concerns we raised were unjustified. It was announced that the three final bidders for the contract to lead the services were Care for Life, UnitingCare Partnership and Virgin Care. Eventually, in October 2014, it was announced that the five-year outsourcing contract to run older people’s healthcare and adult community care was to be awarded to the UnitingCare Partnership, which was not a private bidder but an NHS consortium of Cambridgeshire and Peterborough NHS Foundation Trust and Cambridge University Hospitals NHS Foundation Trust. The five-year contract was worth £800 million and covered: urgent care for adults aged 65 and over, including in-patient and A&E services; mental health services for people aged 65 and over; adult community services for people aged 18 and over, including district nursing and rehabilitation services; and health services to support the care of people aged 65 and over. It is one of the biggest contracts the NHS has ever tendered.
The partnership started delivering services last April, and regular updates were issued outlining how the new services would work. We now know that, behind the scenes, much wrangling over costs was going on, but that was withheld from public gaze. Then came the bombshell. After eight months, and just one month of the new system operating fully, a joint statement was issued by Cambridgeshire and Peterborough CCG and UnitingCare. Not much detail was given, other than an assurance that services would continue, that patients should be reassured but also that the provider and the commissioner had agreed that
“the current arrangement is no longer financially sustainable.”
The contracts that had been established were to be honoured by the CCG, and patients and carers were promised that services would go on as usual and would not be disrupted. It was also said that it would try to retain the new model of integrated service delivery.
Let us briefly review some of the damage. We still do not really know how much the procurement process cost, but on the public side it was certainly millions, and probably at least as much again for private providers working up failed bids—doubtless to be recouped from somewhere else in the NHS later.
Let me turn now to the impact on staff. Back when Cambridgeshire Community Services failed in its bid for foundation status, a transition steering group was established to oversee the future of thousands of its staff. Teams were ripped apart and, with the new contract, more than 2,000 staff were transferred to Cambridgeshire and Peterborough Foundation Trust and Cambridgeshire County Council.
That was a massive task for the Cambridgeshire Community Services Trust, distracting it from other work. There was huge uncertainty and stress for staff over the future of their jobs. Throughout the entire process, across the NHS in Cambridgeshire, senior managers and local health service leaders were spending large amounts of time on all of this. Was it really time well spent, when last year we saw so many major hospitals repeatedly in crisis?
I have said nothing so far about the strategic projects team. What was its role? Many would ask, “Who are they?” To many who follow these things, the STP is, in effect, the pro-privatisation arm of NHS England, and it played a key role throughout this process. Its website tells us that the team specialises in competitive procurement, the re-design of patient pathways via an integrated care model, change management, service reconfiguration and integration, trust development and culture change.
The STP is part of NHS England. We are told by Lord Prior of
the Minister responsible for NHS productivity, that in its investigation into
the collapse of the contract, NHS England will examine the strategic projects
team’s role, and will also consider how similar contracts will be managed and
assured in future. So it is NHS England that will investigate its own strategic
projects team—a hopeless conflict of interest. That is not good enough. We need
a genuinely independent and transparent review. Brampton
People are right to ask questions about the strategic projects team. Its list of interventions reads like a roll-call of recent NHS disasters: not just this project, but the private hospital saga at Hinchingbrooke in Cambridgeshire, and the failed tendering process for the George Eliot hospital in Warwickshire, among others. Its website leaves one in no doubt about its leading role in the Cambridgeshire older people’s tendering process. It says:
“SPT delivered an open procurement process on behalf of the CCG”.
It delivered—no room for doubt there. On 8 October 2014, when UnitingCare was announced as the preferred bidder, the SPT was again trumpeting its key role. On 12 November, when it was announced that UnitingCare would operate as a limited liability company, the SPT was there again, and it is worth quoting from the press release still on its website to get a sense of just how central it was:
“Andrew Macpherson, Managing Director of the Strategic Projects Team that managed the procurement on behalf of the CCG said: ‘The Strategic Projects Team are once again proud to have supported courageous leadership in the NHS.’”
The SPT may call it courageous; others might describe it rather differently.
Let us be clear—it is the SPT, very much part of NHS England, that has been calling the shots. On the decision to set up UnitingCare as a limited liability company, it was approved by Monitor, the strategic projects team and NHS England at the time, yet all knew that that meant that there would be no room for flexibility, and no room for losses in years 1 and 2, when the model explicitly expected extra cost at the beginning, in expectation of savings later. Looked at from the outside, it is hard to see how that could ever have worked, so why did Monitor, the special projects team and NHS England give the go-ahead? Did none of them spot the potential VAT problems introduced by a limited liability partnership?
Having given a brief outline, let me come to the further questions that I hope the Minister will be able to help us with. First, on the flurry of investigations being announced, although it is right that individual organisations will want to look at their role, there is a danger not only of duplication but of exactly the kind of fragmentation that has caused such problems already. Given the conflict of interest within NHS England that I have already described, would it not be better to have a genuinely independent review carried out by the National Audit Office—a review in which we could all have confidence?
The Minister should surely be able to tell us about the role played by his Department and by Ministers, at two key moments in particular. When it was clear in October/November 2014 that there was insufficient information on costs to agree a final contract, why was the process not delayed until that had been sorted out? Did Ministers know? What exactly was the rush to achieve implementation for April 2015, coincidentally perhaps just weeks ahead of the general election? And what role did Ministers play in the final decision to end the contract in December 2015? There were clearly detailed discussions going on with NHS England and Monitor about how much was needed to keep the contract running. The figure seems to have been about £10 million, a lot of money, but given that killing the contract may well have cost more, it was certainly worth considering. What was the ministerial involvement at that point? Were Ministers consulted? Who made the decision to let the contract collapse?
Looking forward, which is what matters most, patients have been assured that services will be maintained. That may well be true in the short term, but what next? Will the outcomes model be pursued, just with UnitingCare taken out of the equation? Does the CCG have the capacity, and if it does why did we go through that ludicrous tendering process? This has been a sorry saga. It seems that everyone agrees that our NHS and our care services need to be integrated, but years of fragmentation make it extremely hard to achieve.
This was a well intentioned attempt to deal with the perverse incentives that shackle our health and care services, and we need to find out what went wrong. We have dedicated, hard-working staff who want to provide the best care possible to our citizens. We need to find a way of making it possible for them to do that. In my view that means an end to contractualised market models, and a move to a genuinely integrated public system, an NHS solution based not on competition but on collaboration; an NHS solution that patients desperately need, and that staff, I am sure, would cheer.
I congratulate the hon. Member for Cambridge (Daniel Zeichner) on securing the debate and thank the Members who are present, including my hon. and learned Friend the Member for North East Hertfordshire (Sir Oliver Heald)—I know that he has an interest in the matter—for attending. I also pay tribute to all those working on the frontline in the NHS in
particularly at this time of year, when pressures are at their greatest. East Anglia
As the hon. Gentleman has described, the contract between Cambridgeshire and Peterborough CCG and UnitingCare Partnership has very recently been terminated. I need to say right away that NHS England has launched an investigation into the circumstances surrounding the contract. Its terms of reference are to establish, from a commissioner perspective, the key facts and root causes behind the collapse of the contract in order to draw out any recommendations and lessons to be learned. I understand that the CCG is also undertaking a review, as is right and proper.
We should let the NHS complete that process. I hope that nothing I say today can be taken as an assumption that Ministers have in any way prejudged the outcome of that process. Clearly there are different views about what has happened, and I want to wait for the reports of the reviews before deciding what, if anything, needs to be done, either by the NHS or by the Government. Once the reports are published, Ministers will be briefed on their conclusions. I am happy to invite the hon. Gentleman to that meeting, although I cannot say today exactly when it will take place. I know that he is in regular contact with his local NHS, and I encourage him to keep that up.
The core scope of services in the contract with UnitingCare was acute unplanned hospital care for older people—those 65 and over—older people’s mental health services, older people and adult community services and a range of supporting voluntary sector services. The underlying principle was to create an integrated care pathway between all these services. The UnitingCare service model was designed by local clinicians during the procurement process and had a high degree of local health and social care support. Its detail and assumptions were subsequently ratified by two independent auditors. It was designed to: join up services around the patient and reduce service fragmentation; to focus on better outcomes for patients and carers, rather than activity levels; to invest in out-of-hospital services in order to better address the needs of a rapidly ageing and growing population; and to deliver £170 million of savings to the local health economy by 2020 by reducing inappropriate emergency admissions to hospital and inappropriate A&E attendances.
UnitingCare began introducing those new services with an investment of £5.4 million over the first six months of the financial year. They included a number of important local improvements, such as: care based around neighbourhoods, with 17 neighbourhood teams working closely with GPs; access to specialist services, with neighbourhood teams and the support of four integrated care teams to offer more specialist care; a 24/7 helpline, called OneCall; urgent care and support, with joint emergency teams to assess and treat people most at risk of admission to hospital; health and wellbeing, with voluntary organisations working together; a single view of the patient record, called OneView, providing professionals with a summary of all information about a person’s health; and a health analytics service to target interventions at those most at risk of admission.
To achieve those improvements, a contract was needed between the provider and the CCG. The main components of the contract were: a new framework for improving outcomes; a new contracting approach to align incentives in a better way; a five-year contract term; and a new lead provider, UnitingCare. It was therefore a high-value contract; it had a total value of around £800 million. Having taken legal advice, the CCG went to open procurement, using a standard three-stage process—pre-qualification, an invitation to submit outline solutions, and an invitation to submit final solutions. The CCG prospectus set out the CCG budget and the evaluation criteria. It was a contract entered into in good faith. This included submitting bids within the CCG budget. The CCG budget incorporated forecast population growth, an acuity factor, and QIPP—quality, innovation, productivity and prevention—savings for each year.
In 2014, there was in some quarters, as the hon. Gentleman said, concern that the process was “stealth privatisation”. Clearly no one, on any objective criteria, would agree that that was the case; it was merely, as he said, a service reconfiguration placed with a not-for-profit company set up by local health providers. The boards of Cambridge University Hospitals NHS Foundation Trust and Cambridgeshire and Peterborough NHS Foundation Trust held the firm belief that only by introducing radical change led by the NHS would the local health economy under the CCG become viable for patients, staff and the respective trusts across the region. For that reason, they decided to submit a joint bid and, following commercial and legal advice, opted to create a limited liability partnership to fulfil the role of prime vendor, as required by the CCG.
The CUHFT and CPFT consortium was appointed as preferred bidder at the end of September 2014. In October, it formed UnitingCare LLP to hold the contract. The strategic projects team was appointed as procurement adviser to the CCG through a competitive process and its role was to manage the procurement process. The strategic projects team is a specialist unit hosted by the Arden and Greater East Midlands commissioning support unit, which has substantial experience in managing complex procurements. The CCG also appointed legal advisers, Wragge Lawrence Graham, and financial advisers, Deloitte, to support the procurement process.
Much information about the costs of the current services, staffing details and timescales could not be provided by the CCG to UnitingCare until it was at preferred bidder stage. As a result, UnitingCare’s bid was heavily caveated and based on assumptions. To illustrate this point, at the time of preferred bidder award status, there were 71 outstanding clarification questions from the procurement process. The contract signed between the CCG and UnitingCare also included several protection clauses to be utilised in the event of the financial distress of either party. Subsequent to contract signature, additional clauses were agreed that allowed for the rapid exit of the contract in the event of the financial destabilisation of either party. With these protections in place, trust boards, the CCG and Monitor allowed the contract to be signed in November 2014 and for the necessary mobilisation activities to facilitate service commencement on 1 April 2015.
There were clear improvements in patient care. For example, in November 2015 emergency admissions for over-65s reduced by just short of 8% compared with the previous year and by 9% when taking into account population growth; admissions of more than two days’ duration for people over the age of 65 reduced by 14%; and A&E attendance reduced by 3.2% when taking into account population growth. However, in December the contract was terminated by mutual agreement—
As my hon. Friend says, there were advantages to this project and it produced good outcomes. If it is a good concept, will the Department of Health support the services that so need to be provided?
My hon. and learned Friend makes an excellent point. The service is currently being continued, albeit by the CCG rather than through the company that was created for the purpose. As she says, the reforms that were put in place were the right reforms. Indeed, they were led by local clinicians and designed with that in mind.
In Royston we have the Royston NHS and social care hub, which will include beds as well as other services. Does my hon. Friend agree that there is no reason at this stage for people to become anxious that the difficulty with the contract will lead to any change in the quality of services that are planned for the future?
That is right. As both questions have highlighted, the change in the care pathway is being pursued by the CCG and there is no reason for patients—the users of the system—to fear any dramatic change to the service. The remaining issue is the residual issue of how the contract came to be put in place. The dispute between the parties is about their different conceptions of the financial and contractual situation. I do not want to prejudge the investigations, but the service reforms will continue.
The final decision to terminate was taken after extensive discussions between the CCG, UnitingCare, Cambridge University Hospitals NHS Foundation Trust,
and Peterborough NHS Foundation
Trust, NHS England and Monitor. Prior to escalation to NHS England and Monitor,
the CCG, CUH and CPFT worked hard to try to reach a resolution locally. Cambridge
Could the Minister enlighten me on the role played by Ministers in that final decision? Did they know it was happening? Who ultimately terminated the contract?
As I will come on to say, due process was followed in the correct way. One of the reasons for listing all these acronyms is so that the hon. Gentleman can be reassured that the right bodies carried out their due diligence. I do not believe that there was any reason for Ministers to be concerned at any point until the dispute between the parties became clear. Indeed, the reforms had been generated locally by clinicians and an accountable CCG led by clinicians. As the questions I have been asked have illustrated, the reforms were and remain very sensible. This is a better care pathway, with improved outcomes.
The issue is contractual and relates to a dispute between the parties about liabilities in the contract. As I have said, I do not want to prejudge the ongoing investigations, the point of which is to work out what should have been done differently. I can absolutely reassure the hon. Gentleman and the House that we are hungry to learn any lessons from that commissioning experience. We need novel commissioning. We need commissioners around the country to look into different ways of commissioning the reforms to our integration of health and care, and lessons need to be learned when it goes wrong. I emphasise that this was a contract between the parties. As I have said, the Department is looking forward to the reviews and wants to hear the lessons that others can learn.
The CCG has now taken over all relevant contracts with providers that were previously held by UnitingCare, to ensure that there is no service disruption to patients and carers. In addition, the CCG and CPFT, which employ the majority of the affected staff, have worked closely together to ensure that frontline staff are clear that, while the contractual model has now changed, the service model remains in place.
Of course, I agree with hon. Members that it is a matter of extreme concern that the new arrangements lasted barely six months. That is not ideal. We need to work out how the parties got it wrong and what mistakes were made. There are questions for the reviews to address. For instance, there is the question of why, given full procurement and assurance of the process, the result fell so far short in practice, along with other associated questions.
To describe modern commissioning as back-door privatisation is wilfully to misrepresent what is going on. These are clinician-led improvements to the care pathways, and I do not believe that most service users would consider it privatisation. We are talking about two public sector organisations coming together to form a company for the purposes of jointly commissioning care pathway innovation put together by clinicians in the local CCG. If Labour considers that privatisation, it has a serious problem, because most people would consider it enlightened commissioning for modern care pathways. This is a contract issue. The parties to the contract did not get it right, and we are keen to understand why and what can be done to make sure it does not happen again. I want those answers as much as the hon. Gentleman, and I repeat my invitation, to him and other hon. Members with an interest, to meet in due course to learn the lessons and make sure that the benefits of commissioning for integration go ahead without the contractual errors that have bedevilled this project.
Question put and agreed to.