Adult Community Services

Wednesday 26th June 2019 Westminster Hall

[Mike Gapes in the Chair]

16:00

[Karin Smyth (Bristol South) (Lab)]

I beg to move,

That this House has considered re-procurement of adult community services by Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group.

It is a pleasure to serve under your chairmanship, Mr Gapes. I am pleased that this important subject has been selected for debate. Although they cannot be present, my hon. Friends the Members for Bristol West (Thangam Debbonaire), for Bristol East (Kerry McCarthy) and for Bristol North West (Darren Jones) fully support my comments. This is an important issue for the people of Bristol South, and it is a local example of the debate on the legacy of the Health and Social Care Act 2012 and of the invidious position that local managers are being put in to understand the procurement rules.

Hon. Members know that I speak frequently about accountability and the opaque way in which many parts of the NHS operate. We seem to have lost sight of the fact that, however individual bodies are constituted, our health services are public services that are paid for by taxpayers—our constituents. I have also repeatedly said that if we keep asking people to pay more for our health services, they must have a greater say in the way that those services are run, particularly when they are being changed.

I have spoken before of my concern about the attitude of my local clinical commissioning group in Bristol, North Somerset and South Gloucestershire to the openness and transparency of its work, especially on the reprocurement of adult community services. The lengths to which the CCG, supported by NHS Improvement, has gone to hide, cover up and obfuscate are nothing short of a scandal. Most infuriatingly, the whole protracted cloak-and-dagger exercise has been entirely unnecessary, because a far less onerous and costly approach could have been used instead. The reprocurement is the wrong approach at the wrong time to developing community services, and runs counter to the direction of travel being set, in theory, by the new NHS 10-year plan.

Before I review the shortcomings of the reprocurement in greater detail, I will remind hon. Members why it matters. Away from the jargon, acronyms, terse letters and confidentiality agreements, thousands of people across Bristol, North Somerset and South Gloucestershire simply want to know what is happening to their local health services.

My constituent Clive got in touch just over a year ago to tell me about the great work being done at the Healthy Together leg clinic at the Withywood Centre, which provides intervention and treatment for the leg ulcers of patients in south Bristol. It is exactly the sort of joined-up, innovative and integrated community provision that Ministers tell us they want to see—a true partnership between Bristol Community Health, local GP practices and Age UK in Bristol, which come together across different sites to deliver gold-standard patient care that promotes faster and longer-lasting wound healing. The clinic also provides a social setting where patients feel more supported and are encouraged to feel more in control of their condition. There is time for people to care.

The service has transformed countless lives in my constituency and has been nominated for a national award. As I saw first hand when I visited the clinic earlier this month, it is an exemplar of the sort of collaborative provision that the new adult community services contract could and should expand on. Such collaboration takes years to yield results and very much responds to the local needs of the particular community.

The people who are providing the service, however, do not know for how long they will be able to continue, because the CCG will not tell them. The patients do not know for how long they will be able to access that life-changing service, because the CCG will not tell them. As the local MP, I cannot lobby, engage or reassure people, despite asking repeatedly for a peek behind the self-imposed reprocurement iron curtain, because—hon. Members will have guessed it—the CCG will not tell me.

Interestingly, another consequence of the process, which I do not have time to really go into, is the destabilising impact on the voluntary sector. Age UK will have to wait, cap in hand, to see which successful bidder secures the primary contract and how it then decides to sub-contract the provision. The same goes for all voluntary organisations involved in this sort of service provision. It would be bad enough if the Healthy Together clinic were a one-off —the only service caught up in a closed-shop procurement mess—but it is not. In truth, every adult community service is in the same position, which is simply not good enough.

Despite a year of making speeches in this place, asking questions of Ministers, doing time-consuming research and making countless phone calls to offices, neither the CCG locally nor NHS Improvement nationally will engage with me beyond continually asserting that they had no choice but to go down this route. That is a prime example of what the Health and Social Care Committee referred to in its recent report, which said that the

“problems stem not only from the procurement rules themselves, but also from people’s interpretation of these rules and their difficulty in understanding what is permissible within the rules.”

In place of answers, I am forced to restate the litany of my constituents’ questions and concerns that have essentially gone unanswered. First, there is a fundamental lack of clarity surrounding the reprocurement and an abject failure to link it to any broader NHS strategies. I am not the only one who is concerned about the process. I have been spoken to privately by many consultants, nurses, and other staff throughout the healthcare system; I am grateful to them for contacting me.

At no point has the CCG properly defined a needs assessment in the request for proposals. Moreover, at no point has it made the business case for change—the most basic starting point for any such process. Staggeringly, there is no service baseline, so we do not know what services exist. By extension, there are no defined outcomes, so bidders are being asked to make proposals. That is not what commissioning is meant to be about.

Although Ministers continue to trumpet the importance of the sustainability and transformation plans, there is no sense of alignment with those plans, the NHS long-term plan or the emerging integrated care systems. Similarly absent is any indication of integration with local councils on social care or public health, which we all acknowledge are the key issues facing our constituents.

Secondly, there are concerns about the chosen procurement process, because any number of much less onerous and costly approaches were possible. As ever, however, accurately assessing the process is near impossible because of the vice-like secrecy that the CCG has used throughout. What is certain is that we do not know how much it is costing the CCG or the bidders, which include the current not-for-profit community service providers. That means that we do not know how much it is costing us, the taxpayers.

I worked in the national health service for many years, and I have some experience of procurement in the organisation, but I have struggled to understand properly the process through which the procurement has been undertaken. To illustrate, the CCG’s description of the chosen process, in its own words from its own document—bear with me, Mr Gapes, because I did not write it—says:

“The procurement is being undertaken using a process developed by the CCG which has similarities to a competitive process with negotiation. For the avoidance of doubt, the CCG is not running the process strictly in accordance with any specific procedure set out in the Regulations so reserves the right to depart from that form of procedure at any point. This Request for Proposals sets out the procurement process the CCG plans to use for this particular Contract. The inclusion of particular stages, the use of terminology and any other indication shall not be taken to mean that the CCG intends to hold itself bound by the full scope of the Regulations.”

What does that mean? I think it means that the process is as clear as mud, carried out behind a wall of secrecy, but with a disclaimer that enables the CCG to do what it wants without our knowledge. Although we cannot access the process details, what we know does not bode well.

There are myriad loose ends and errors throughout the process. Taken together, they form a significant body of concerning issues. Of course, I would never have known about them—most people do not—if I had not scoured 300 pages of detail and 100 clarification questions asked by bidders. In fairness, I doubt the CCG was expecting anybody outside the process, including the local MP, to do so, but I read them all because I like detail and I think it is important to know what is going on. A lot of the gaps and oversights concerned me.

There seem to have been incorrect working assessments about bed numbers at South Bristol Community Hospital; gaps relating to workforce numbers and staff who have been TUPE-ed; and a number of misunderstandings and examples of where the CCG lacked knowledge about current contracts, rental payments and void space. There is also missing information about assets, and the bidders were apparently expected to carry out the due diligence. That not only places a huge burden on providers, but runs the risk that the entire process will collapse if it is not carried out correctly, as has happened elsewhere. It is worth highlighting that the National Audit Office investigation into the collapse of the UnitingCare Partnership contract in Cambridgeshire and Peterborough found that bidders

“faced significant difficulties in pricing their bids accurately due to limitations in the available data”.

The evidence I have seen in the documentation suggests that that is now happening.

We should all be very worried about that, because failed procurements in Staffordshire for cancer services and end-of-life care, and in Cambridge and Peterborough, had similar procurement processes to the one chosen by Bristol, North Somerset and South Gloucestershire CCG. In each case, there was a secretive process, a complex procurement methodology and a failure to engage. Together, they cost taxpayers millions, and they all failed. Instead of learning lessons, NHS Improvement and the CCG seem intent on repeating the mistakes.

[Darren Jones (Bristol North West) (Lab)]

I congratulate my hon. Friend on securing this important debate. Does she agree that the complexity of the procurement process and the difficulty that she—an expert in this area—is experiencing means that patients who rely on these services and workers in not-for-profit organisations, who deserve to know what the process means and what the outcomes will be for them, find it impossible to take part as important stakeholders?

[Karin Smyth]

Absolutely—I completely agree. That is why I will continue to speak up on behalf of my constituents; I know I have my hon. Friend’s support.

Predictably, I would like to finish where I began, on the issue of secrecy and a lack of transparency. As I have highlighted, this absurd behind-closed-doors approach has bedevilled the reprocurement from the off. If this is such a great change to community services, why are we not trumpeting it? Reprocurement was first referred to in governing body papers in May 2018, but other than that there has been virtually nothing. There was no official announcement, no media blitz, no news stories or television news clips, no leaflets in local GP surgeries or South Bristol Community Hospital to enable local people to have their say on the plans—nothing. Although there has been talk of consultation, it seems that only 20 people from south Bristol took part. In fairness, there were some nods to engagement, and surveys were completed by 196 people. There was an engagement planning workshop with patients, carers and the voluntary sector, but because it is a contracting process, they were asked to sign a confidentiality agreement.

There is no evidence that even that limited feedback has been listened to or acted on. The workshop was merely an illustration to bidders of what stakeholders might want to identify when community services are planned and delivered. Tellingly, in documents from January, the CCG stipulated:

“Formal public consultation is not required as part of the procurement as no ‘significant variation’ to services is planned at this stage”.

Why is it being done if there is no significant variation to services?

All the documentation—approximately 300 pages in total—is hidden behind a portal, including more confidentiality agreements. The whole process appears so desperate to avoid the merest hint of engagement that it screams, “We’ve got something to hide!” It is utterly self-defeating, and serves no one well—not patients, bidders, the CCG or the community at large.

The CCG says that it is seeking a consistent service across all three areas and both acute trusts. Two of the CCGs and one of the trusts have been in deficit for years, and at various times in the past few years they have been on NHS Improvement’s naughty step. The deficits are now being shared across the whole community. The jam is being spread more thinly and differently from how it was spread before. The process is being embarked on to help spread the already struggling and inadequate level of service more thinly. Those service providers are spending money that should be spent on services on a process that I believe will inevitably reduce community services in Bristol.

I have great respect for the Minister, but I have no confidence that the Government will be able to make any difference to the local position. I hope that she takes note of the variability in how the rules are interpreted locally, as the Health and Social Care Committee noted in its response to the legislative proposals for the NHS long-term plan. Other commentators are saying the same. I hope the Minister will reflect on this local example. Will she explain directly or through her officials why, when I wrote to the Secretary of State about this originally, I got a reply from NHS Improvement? NHS Improvement is the provider regulator; this is a commissioning issue.

I believe that the Government should rapidly respond to the proposals to remove the requirement for competition under the section 75 regulations. There is no reason to wait; they need to get on with it. This saga shows that the lack of investment in NHS services remains a problem. Why not just build capacity rather than go through these expensive tendering processes with providers outside the NHS? I actually support the place-based approach to service provision in the NHS plan, but I object to the fact that this reprocurement goes counter to that plan.

At the very least, on behalf of local people, I would like the Minister to support my calls to see the proposals before contracts are signed for the next 10 years. We need a local plan and collaboration with the local authority that meets our health and social needs. I want a guarantee that people in south Bristol will not be worse off. Currently, no one can give me that.

16:17

[The Minister for Care (Caroline Dinenage)]

It is a great pleasure to serve under your stewardship, Mr Gapes. I thank the hon. Member for Bristol South (Karin Smyth) for securing this debate. She spoke passionately on behalf of her constituents. It is right to bring such concerns to this forum. She asked the questions that any good MP should ask, and she has the right concerns. She spoke strongly about valued local services that no one wants to see lost, such as her Healthier Together service, and said that she fears for their future. I hope that some of the things I shall say will allay her fears, but if I do not cover anything she mentioned, we shall write to her to give her as comprehensive a response as possible.

Community services play a vital role, but we have perhaps not emphasised them as much as we should have done in recent years and decades, so we must put that right. Effective community services mean that patients are treated where they are most comfortable—often their own home—and supported to manage their conditions and live independently. More widely, they are key to improving the patient experience. They provide preventative care and prevent people’s illnesses and ailments from getting worse. Crucially, they prevent reliance on the big acute hospitals.

The NHS long-term plan sets out our vision for community services. It highlights the need to move away from small, narrowly defined and often poorly co-ordinated community services to those which are more joined-up and operate over a larger footprint. It also encourages much longer commissioning times, to enable us to build the relationships that we want to continue to establish. Importantly, it will make it easier for patients to navigate the system without having to repeat their story multiple times, and will ensure that their care is delivered in a smoother, more timely manner. To help to deliver on that vision, as part of the extra investment in the NHS long-term plan, an extra £4.5 billion per year will be spent on primary medical and community health services by 2023-24.

That is why ideas such as this, from local areas such as Bristol, North Somerset and South Gloucestershire, which embed community services as a central component of their plan in a way that mirrors the vision of the NHS long-term plan, appear very attractive. By awarding all its adult community services in a single contract, we can see that the CCG is aiming to promote a cohesive, integrated approach, which will improve consistency and efficiency across its entire geography.

The CCG’s 10-year funding approach also reflects the NHS long-term plan and will enable transformative change, through the kind of long-term relationships we need, based around strong, collaborative partnerships across not only the health and care system, but also the third sector, which the hon. Lady mentioned and which plays such a crucial part in the delivery of some of our most vital community services. We think that the length of the contract will allow the local area to design its services not only for the current need, but to address the future needs of its population, while also giving greater certainty to the workforce.

Additionally, the plans contain key commitments on community services set out in the NHS long-term plan. These include delivering care through multidisciplinary teams, the deployment of rapid response teams and providing services in central hubs located in people’s communities, where they can get the holistic support that will enable them to stay healthy and well.

We think that all those things will ensure that patients receive timely, integrated and holistic care in their community, with a greater focus on treating the whole person rather than merely their condition. This approach will join everything together, so that people no longer slip through the gaps or get pushed from pillar to post or from A to B, and it will provide a one-stop shop where people have a named contact and a real integration of community, mental health and adult social care services and the third sector.

The hon. Lady spoke with great passion and knowledge about the importance of transparency and engagement when deciding service provision, something that of course I entirely agree with. At the same time, it is right that these decisions are made by local areas, such as CCGs, local authorities, sustainability and transformation partnerships or integrated care systems, because those people decide how services should be configured to meet the needs of their local area. When they do so, we have clear expectations of them: they must involve patients, carers and the public in decisions about the services they commission, and be clear and transparent about their decisions.

That could be where we appear to have a difference of opinion between how the hon. Lady feels that her CCG has communicated and the way the CCG feels that it has. I have spoken at length to the director of commissioning and the chief executive, who say that in this particular case they have made considerable efforts to meet those expectations. They report that they engaged with 500 local people, including health and care professionals and representatives from the third sector, and that patients and carers have been supported to engage with the process through a public reference group, which I know she mentioned.

Additionally, the CCG says that it has engaged with a range of organisations and partners from across the local system, including hospital and mental health trusts as well as local authorities, to better inform the contract process. Those organisations have met bidders for the contract to discuss service provision. The CCG says that that collaborative process will help the contract holders to build relationships and allow patients to receive integrated services, which is what we all want.

The CCG also says that it has taken steps to ensure a transparent process, including press releases, letters to stakeholders, engagement events and making key information available online. Additionally, the CCG reports that the procurement is being overseen by a programme board that includes patient and carer representatives.

The hon. Lady made the point that it might be premature to go out for tender while the NHS long-term plan’s proposals for amending procurement requirements are being considered. That is a very good point, but unfortunately considerations around legislative changes do not change the CCG’s duty to comply with current procurement law, nor do they change its duty to use its resources as efficiently and effectively as it can.

The CCG has agreed that if the legislation changes during the procurement process it will review and evaluate that process, but more widely, by law it must ensure that there is no gap in access to services. Its contracts for adult community services will expire in the coming years, and by law cannot be extended. The CCG has informed me that if the procurement was halted, it would create the risk that when the current contracts expired, local people would be left without vital community services, which the hon. Lady knows they rely on. Of course, that simply cannot happen.

The hon. Lady also rightly noted that we must ensure that contracts are given the necessary external support and scrutiny. To that end, NHS England’s and NHS Improvement’s integrated support and assurance process—for which we use another of those attractive acronyms, ISAP—provides a co-ordinated, consistent approach to reviewing complex contracts, which is intended to ensure that complex contracts are cost-effective, robust and in the interests of patients.

On 17 October, NHS England and NHS Improvement held an early engagement meeting with the CCG, where they discussed this contract under ISAP. Following that meeting, NHS England and NHS Improvement were assured of the need to have a single contract that runs for 10 years. A full ISAP process is triggered when a procurement is found to be sufficiently novel and complex. NHS England and NHS Improvement found that in this case these requirements were not met, meaning that the full ISAP process was not required. Instead, NHS England and NHS Improvement regional teams will provide assurance that is informed by ISAP principles, which will include ensuring that the contract provides value for money, that it is centred around patient care and, crucially, that some of the key parts of patient care that the hon. Lady spoke about are not lost. The regional teams must also jointly ensure that the correct processes are followed, and that any chosen provider has the capacity and capability to deliver the services set out in the contract. Importantly, the regional teams must then give further formal, joint approval before the CCG can award a contract.

With that in mind, scrutiny of how we award contracts for delivery of health services is clearly vital. We must be assured that due care is taken so that patient outcomes are absolutely first and foremost, and that services are organised and delivered with prudent financial planning. To that end, NHS England and NHS Improvement will continue to closely monitor this contracting process. I welcome the close attention that the hon. Lady has paid to this contract; I know she has looked at it very thoroughly and I am grateful that she has raised her concerns. We believe that the CCG’s approach in this case is right, but we will continue to engage in every way possible with all parties to help ensure its successful delivery.

Question put and agreed to.