Musculoskeletal Services: Greenwich

Clive Efford Excerpts

Wednesday 11th January 2017 Westminster Hall

[Clive Efford (Eltham) (Lab)]

I beg to move,

That this House has considered musculoskeletal services in Greenwich.

What a great pleasure it is to serve under your chairmanship for the first time, Mr Hanson.

In 2016, Greenwich clinical commissioning group decided at an inquorate meeting to allocate a £73 million contract for musculoskeletal services to Circle Holdings plc. There were two rival bids at that time: one from Circle and one from a consortium of local providers led by Lewisham and Greenwich NHS Trust and involving local GPs and Oxleas NHS Foundation Trust.

A freedom of information request has exposed the fact that neither NHS England nor Greenwich CCG undertook an impact assessment prior to making requests for tenders or when allocating the contract to Circle. The purpose of an impact assessment is to ensure that no minority or vulnerable group is disadvantaged as a consequence of a decision to let a contract, and it is legally binding. How did Greenwich CCG satisfy itself that no one would be disadvantaged? Responses to the FOI requests to the CCG and NHS England have confirmed that neither party had answers to those questions at that time. As a result of local campaigning, which was led by the local authority, local Members of Parliament and the local community, we now have a review and an impact assessment being carried out subsequent to the contract being let.

The Minister was told by NHS England that it had reviewed the process by which the contract was let, but that is not satisfactory. She may have received assurances that the contract process had been reviewed, but what has not been reviewed is the impact on vital services that had nothing to do with the contract. They may be undermined by the fact that the NHS is so heavily cross-subsidised for providing vital services.

Because members of one of the rival bids were members of the clinical commissioning group, they were required to leave the meeting. That is custom and practice and happens in many fields, but it made the meeting inquorate. In order to allocate a £73 million contract, people who remained in the room were allowed to be double-counted in order to make the meeting quorate. I happen to have a friend who is a lawyer and an expert in health law, and I asked him whether what happened was within the rules. His answer was simple: “No, it is illegal.” At a subsequent health scrutiny panel meeting at Greenwich Borough Council, which was held to investigate the circumstances surrounding the allocation of the contract to a private provider, a representative of NHS England passed the procedure off as common practice. Can the Minister tell me whether it is common practice? Is it acceptable procedure? Is the advice that I have been given—that it is illegal—correct? Does she believe it to be a satisfactory way for such contracts to be allocated? If she is not satisfied, what do the Government intend to do?

The Minister will be aware that it is not permissible to pay anything other than the NHS tariff for services. Circle promised savings of £12 million as part of its successful bid for the contract. We do not know how much Circle intends to take out of the £73 million for its profits, but she will be aware that it is required to be paid the national tariff. If that is the case, will Circle be treating the same volume of patients as are currently being treated under the MSK process? If not, where are the savings and the profit for Circle going to come from?

I asked the Minster some questions to satisfy myself that the Government were happy with the procedure that had been followed. Were NHS England or the Minister informed of how Greenwich CCG achieved its quorum and the fact that the required number of GPs were not present? It was the GPs who were part of the consortium that was bidding who were required to leave the room. When the White Paper was launched by Andrew Lansley, he made it clear that local clinicians should be at the heart of decision making. In this case, we see that local clinicians were anything but at the heart of decision making.

I asked whether the local healthcare trust had been consulted at all in the process, and the Minister told me in an answer that it had been discussed at a meeting in March 2016 and as part of an assurance procurement process in August. That did not happen. Lewisham and Greenwich NHS Trust managers have no recollection of a meeting in August where the matter was discussed. Who told the Minister that the meeting had taken place when it clearly had not? It was not possible for anyone to give that assertion to the Government when the meeting simply had not taken place.

The Minister was also told that Circle was engaging with Lewisham and Greenwich NHS Trust, but the trust says there is no clarity around the clinical model and no commercial offer. That was still the case in November at the council’s scrutiny meeting, with the contract then due to begin on 1 December. The trust had no idea of the money or business that would come its way as a result of the Circle contract.

The Circle contract is a prime contractor model. That means that all patients will be directed to Circle, which will triage them and direct them to whichever services. Lewisham and Greenwich NHS Trust receives something in the region of £10 million for MSK services. It has nothing in its future budget for that service, because it is simply unaware of what it can expect from the contract that will be managed by Circle. How is that acceptable? The trust has to plan ahead for other services, and it is finding that impossible.

The trust has been through a couple of scenarios of what would happen if it was forced to cut its services as a result of losing elements of the MSK contract. It currently has a team of surgeons and some 45% of their surgical workload comes through the MSK contract. Those surgeons are vital to the support of other services, such as A&E. If those surgeons are lost, it will have an impact on other services in the trust. Activity could be reduced in consultant trauma services at Queen Elizabeth hospital which support the A&E. There would be an impact on doctors’ training and rotas; on the quality of training provided to junior doctors and other staff; on related professional services and posts such as nursing and physiotherapy; and, in the longer term, on recruitment at Queen Elizabeth hospital and specifically to its trauma service, including the emergency department, which is a designated trauma unit. It is disgraceful that no impact assessment was carried out to assess these impacts on other services.

The new Eltham community hospital was very much welcomed by my local community. Lots of lobbying has gone on. The local community watched the much loved and admired local building, the Eltham and Mottingham community hospital, being knocked down because they had been told they were going to get a walk-in GP service and a new hospital in the heart of their community, which they could attend for blood transfusions, X-rays and other diagnostics; more importantly, there were to be 40 rehabilitation beds for people leaving hospital and returning to the community. The community were very supportive of that scheme, which started in 2007. I and others in the local community lobbied very hard to make sure that the project stayed on track, and it finally opened in 2014.

Within 18 months of the opening, 20 beds were closed temporarily, to save money during the summer period when there was allegedly a low level of demand, but they were due to open again when winter came along. Now we are told that the beds are not opening. Lewisham and Greenwich NHS Trust is lobbying very hard because it desperately needs the beds back—it is now running at more than 100% occupancy for beds in its hospitals. We are now told that the space available for those 20 beds is part of the MSK project. That is not what my local community signed up for. It is not acceptable that the whole business plan for that hospital and the services to be provided there has been completely changed without any consideration of the local community.

I accept that there is a need for change in the NHS. I do not accept that we need the private sector to do it. If we continue to privatise services like this on the pretext of saving money, we will see a lot of money that should be being spent on patients going out in private profit. It is time to call a halt to the drip, drip of privatisation in our national health service.

If we want to modernise the NHS we need to find ways of doing that, but I wonder how someone could come to the conclusion that Circle is the organisation to take us forward. We know what happened at Hinchingbrooke hospital—Circle walked away the day before the Care Quality Commission was to put the hospital in special measures. At the Nottingham NHS treatment centre, a dermatological national centre of excellence, the consultants walked out. Chris Clough, who was appointed to investigate what was going on there, described it as “an unmitigated disaster”. To keep that service going, Circle brought in locums from overseas costing £300,000 a year. Today, the centre is no longer a centre of excellence.

The Government and NHS England did not learn a single lesson from what happened with the Cambridgeshire and Peterborough social care contract, where the private provider handed the contract back after eight months, saying that it was not viable. They ignored warnings from the National Audit Office about that in July 2016. It seems that the Government are happy to see any process go forward as long as the services are being privatised.

The process is completely and utterly flawed and is completely unsafe. The meeting in June last year was inquorate. It let a £73 million contract without any consideration of the knock-on effects on other vital health services, particularly A&E. The illegality of the process was disregarded and Ministers were given false assurances about the process and the consultation with Lewisham and Greenwich NHS Trust. There was no proper assessment of the suitability of Circle as a health provider. It provides not one clinician in the process—it is purely a management operation and another tier of bureaucracy. We hear endlessly from the Government about the need to cut back bureaucracy, but Circle is simply a signposter in the process, and for the pleasure of doing that it will take private profit out. It contracts with existing private services. In Bedford, there has been a 30% reduction in its contracting with the local Bedford hospital for MSK services and the private services in that area are brimming with profitable elective MSK surgery.

The process for awarding the contract is unsafe and has put patients at risk. Worse still, it has put at risk patients who are not in need of MSK services, due to the knock-on effect on other services. It cannot be that patients will unwittingly attend their local hospital and find that services have been cut because another service in the local health economy has been privatised. It is time to call a halt to this process. I hope that the Minister will step in, stop the process and stop the contract being let to Circle plc, because it is clearly flawed and not in the interests of patients in Greenwich.

[The Parliamentary Under-Secretary of State for Health (Nicola Blackwood)]

It is a great pleasure to serve under your chairmanship, Mr Hanson. I congratulate the hon. Member for Eltham (Clive Efford) on securing this debate. I know that the subject is extremely important to him and his constituents. He has very eloquently raised the different concerns, which is no less than I would expect of him from our shared days on home affairs matters. I would warn him, however, that I doubt whether I will be able to answer every single one of his questions in detail. I will endeavour to get through the best I can and then reply with further detail in writing.

First, I would like to pay tribute to the many staff who work exceptionally hard every day for our NHS and deliver high-quality care for patients. As the daughter of an NHS doctor and nurse, who are now retired, I have seen at first hand how much personal sacrifice that involves from both NHS workers and their families, who often have to spend a lot of time apart from their dedicated NHS family members. It is a sacrifice that I am sure all of us here today would like to honour, especially during this busy time.

It is important to say at the outset—I know the hon. Gentleman is aware of this—that procurement of local health services by means of competitive tendering is a matter for the local NHS. Greenwich clinical commissioning group, which is the deciding body in this case, is a clinically-led independent statutory organisation. We believe it is right that local NHS systems are best placed to understand the health needs of their local populations and to use that knowledge to commission services for local people, to ensure the best clinical outcomes for all patients at the highest quality and best value to the taxpayer.

I know the hon. Gentleman knows that musculoskeletal services are currently provided to about 9,500 Greenwich patients by the four NHS trusts and one private provider, but despite the hard work of local health workers, the latest data show that Greenwich CCG’s referral rate to treatment trauma and orthopaedics performance is only 80.8%, against a target of 92%. It also shows a high number of out-patient appointments—more than 50% higher than the national average—with many seeing a consultant surgeon and then not having surgery. That paints a clear picture of too many patients waiting for too long. Even when they do get an appointment, they do not always see the right health professional, which means another wait for physio or other interventions.

As someone who has a chronic, complex illness and was misdiagnosed for more than a decade, I understand how dispiriting it is to wait in pain only to endure the disappointment of inappropriate or unnecessary appointments or tests and to end up on a new waiting list still in pain, just more frustrated. I know that because I lived it. We have to do better to get the right care to the right patients in the first place.

Taking such steps not only improves patient care and their experience of the NHS, but cuts out wasted appointments and tests, and frees up hugely valuable consultant and technician time, saving money that can be spent on appropriate care instead. That is why the CCG identified the musculoskeletal hub model, which has been successfully implemented using a range of different kinds of providers, private and public—I am agnostic on that point—across the country. It concluded that it would secure better value for money from that more streamlined service model, especially at the point of referral.

Given the hon. Gentleman’s description, I think he knows this, but I will say it anyway: the hub model means identifying one healthcare provider to act as a single point of access for all Greenwich musculoskeletal patients. That healthcare provider then offers patients who need an in-patient operation a choice of where the operation takes place. It is also able to triage patients more effectively into physio and other non-surgical treatments sooner, which means that surgery can often be prevented because it is possible to intervene quicker, which is better for patients.

The hon. Gentleman expressed concern in his parliamentary questions about the procurement process. However, I am sure he welcomes the fact that there was some consultation prior to procurement. He questioned the information that has come to me, and I will double-check it, but I have been told that the draft specification was shared with the CCG patient reference group and the pensioners forum for their comments prior to finalisation. When the musculoskeletal service was put out to tender in April 2016 in an open procurement process, the prospective bidders were required to put forward a programme budget within the range of £14 million to £14.8 million a year.

[Clive Efford]

Lewisham and Greenwich NHS Trust made about 50 requests for information about the scope of the contract it was being asked to bid for during that process, and it received very few responses from Greenwich CCG. It is very difficult to say that there was adequate information or consultation about the impact of the service, because very little information came from the CCG.

[Nicola Blackwood]

I am sure more information could have been made available, but there certainly were attempts to engage with patients to ensure the contract was shaped to meet patient need.

In the end, two bids were received. They were anonymised and evaluated by a panel that included clinicians. According to the information I have received, the CCG had at least four GP members in attendance at the governing body meeting of 29 June, as well as three other voting members. The musculoskeletal specialist was from another area, specifically so that the panel could benefit from his experience without risk of conflict. Following the evaluation section of the meeting, all members with a conflict of interest were asked to leave the room, as the hon. Gentleman said. Those members’ votes were transferred to other governing body members, in line with the CCG’s constitution. I am not sure where the hon. Gentleman’s information about the numbers in the meeting comes from. According to the information I have received—which I will check—the remaining members of the CCG governing body then voted, and the meeting was quorate, in line with the actual numbers in the room. They voted on the still anonymised bids. Following that process, the five-year contract was awarded to Circle Health. The bid was assessed by NHS England to be according to the NHS standard procurement process, which is obviously legal.

As the hon. Gentleman said, under the proposed model, Circle will triage all patients registered with a Greenwich GP who require physiotherapy or planned orthopaedic surgery to ensure they receive the most appropriate medical professional support the first time to avoid inappropriate patient experiences. The aim is to reduce the number of first out-patient appointments, because many have been found clinically unnecessary. Further, if the trust experiences fewer unnecessary out-patient appointments, surgeons will have more time to carry out elective surgery, which will reduce waiting times for those who really need it. Over the lifetime of the contract, the CCG expects the average waiting time at Lewisham and Greenwich NHS Trust to reduce from 7.8 weeks to below 7 weeks.

As I said, regardless of the details of the procurement, which we will check, ensuring that patients are better served with the right care at the right time must be something that colleagues from across the House support. I heard the hon. Gentleman’s concerns about the impact on existing services and his view that the assessment should have been carried out further. At any rate, I am pleased it is being carried out now. As I understand it, Greenwich CCG discussed the procurement with Greenwich Council’s healthier communities and adult social care scrutiny panel—which is very snappily named —at a meeting on 3 November. The panel accepted that the process had been correct, but due to the level of public concern it requested that the CCG and the trust co-commission an independent assessment of the likely impact on orthopaedic activity at Lewisham and Greenwich NHS Trust and also that the outcome of that assessment be shared with the HCASC prior to the CCG’s signing the contract. That is what is happening, and it is clearly the right thing to do.

The main concern raised by the HCASC is that the trust may see a reduction in elective orthopaedic activity, as the hon. Gentleman said, which would affect trauma services. The impact assessment will review the likelihood of a range of impacts—from a minus 40% shift in elective orthopaedic surgery to a plus 40% shift—and the resulting effect on local trauma services, emergency department services and other interdependent services at Queen Elizabeth hospital, as well as the risk to the clinical and financial viability of the trust. It will also consider the potential impact, should there be such a shift in orthopaedic surgery, on sustaining undergraduate and postgraduate training, capacity plans and backlogs, interdependent clinical services, the delivery of the national constitution standards for referral to treatment, and the implications on future recruitment of orthopaedic clinicians and support staff. Those are the parameters that were requested by the trust and others, so I think we can be confident that it will achieve its purpose.

The impact assessment is due to be presented to the Greenwich CCG board on 22 February. The report will be shared with the healthier communities and adult social care scrutiny panel the following day and published on the CCG website. The outcome of the assessment remains to be seen, but I am sure the hon. Gentleman agrees that it is essential that the CCG proceeds with what has clearly become a highly politicised decision with the best interests of patients as its core priority. As I said, the data show that we need to work to improve care for musculoskeletal patients in Greenwich, to ensure that all patients are getting the right care at the right time.

Question put and agreed to.