Cambridgeshire CCG and UnitingCare Partnership
Motion made, and Question proposed,
That this House do now adjourn.—(Charlie Elphicke.)
10.1 pm
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 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 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 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.
10.15 pm
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 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, 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.
10.30 pm
House adjourned.
