Oxfordshire Keep Our NHS Public report

The number of private companies that run parts of the NHS in Oxfordshire is growing. In each contract, a provider agrees to deliver, for a certain number of years, a particular service within a “performance framework”.

Some of these contracts are with the local Clinical Commissioning Group, some with NHS England, some with NHS hospital trusts (Oxford University Hospitals, and mental and community health).

These contracts are by their nature rather inflexible. And, since they are held by private companies, they are not easy to change during the lifetime of the contract.

Contracts are awarded on the basis that they fulfil certain targets. But in the contracts with private companies that we have looked at, a number of targets were not met. We’ve also found that problems highlighted in patient testaments are not covered by the performance framework. So, complaints, in these cases, are ineffective.

Health services must be flexible – episodes and epidemics are not predictable. They need staff, wards, A&E, operating theatres that can work as professionally and compassionately as possible, where problems and hold-ups can be quickly addressed. This requires services run by professionals confident in their staff, their back-up, their buildings and equipment.

This report, based on performance during 2018-19 of some of the main private contractors, shows that contracts with the private sector hinder rather than help this to happen. For instance, the NHS main website awards one of them, HealthShare, just 1.5 stars out of 5. InHealth (which provides diagnostics) was only awarded 2 stars out of 5.

Where is the evidence on the local private sector in Oxfordshire?

I. Background

In Oxfordshire, the Clinical Commissioning Group has a number of contracts with private providers. These include:

  • HealthShare (physiotherapy and all things musculoskeletal)
  • InHealth (endoscopy, colonoscopy, echocardiogram)
  • Physiological Measurements Ltd (diagnostic services)
  • Boehringer–Ingelheim (a pilot joint specialist community team for those with respiratory problems). The funding is joint. BI say they have no clinical input.
  • Specsavers, Scrivens and The Outside Clinic (audiology services)
  • Other smaller contracts and grants related to other areas outside of planned care.  

This includes:

  • provision of diagnostic services for autism,
  • work with the third sector to deliver falls-prevention programmes,
  • several services delivered by individual GP practices such as skin cancer monitoring and minor surgery,
  • a company called Ingeus to deliver a diabetes prevention programme locally,
  • and Oxon GP Federation provision of access hubs for primary care, Hospital at Home services, out of hours, and some specialist clinics.

In addition to private companies commissioned by the CCG, there are some commissioned by NHS England. These include:

  • Healthcare@Home (follow-on cancer care at home)
  • Alliance Medical (diagnostics)

All this adds up to a very complex environment for GPs, hospital consultants, and the general public. There are likely to be problems in the following areas:

  • Access. Will the clinic be easy to find? Properly indicated? Pleasant to use? Not far from home?
  • Communication. Will the private provider send information back to the GP quickly? Will the GP be able to ask follow-up questions?
  • Getting changes to service. If the reports from patients are bad and the service is not good, how easy is it to get changes? What kind of complaints procedure or monitoring opportunities are there?

II. Problems with the contracts

The second area of difficulty is the contract. How is it monitored? What are the criteria for measuring success or failure? What happens if things go wrong? Can a contract be ended?

III. How successful are these contracts in Oxfordshire?

We have two main sources of evidence: the performance monitoring framework and testimony from patients or their GP or consultant.  We have been able to obtain monitoring reports for only three of the providers. But they do contain some interesting information.

InHealth (endoscopy, colonoscopy, echocardiogram)

According to the targets in the contract:

  • Referrals within 6 weeks, agreed threshold 95%. Result: average 80.35%, lowest in one month 45%.
  • Referrals within 2 weeks for suspected heart failure, agreed threshold 95%. Result: average 92.7%; in 2 months only 50%.
  • Seen within 30 minutes of the time given for appointment, agreed threshold 90%. Result: 100%
  • Patients offered appointment within 5 days, agreed threshold 98%. Result: 100%.
  • Urgent findings processed on day of scan, agreed threshold 100%. Result: 99%; in 2 months only 93%.

The agreed threshold, therefore, allows for a failure rate of around 5% routinely on most measures. This in itself is not acceptable to the public. The actual reported performance shows some frankly unacceptable deviations from even this agreed threshold.

If these services were in house, problems could be dealt with quickly. As it is, these private contractor problems interfere with the patient journey, causing holdups. They also interfere with NHS performance data and thus contribute to headline failure ratings for CCGs and NHS trusts.

Endoscopy, urgent cancer referral: performance indicators

  • “2 week wait” patients (referred urgently by their GP or clinician). Target: 98%, result: 67.6% (April 2018 to March 2019)
  • “1-day referral” (“booked within one day”): target: 98%, result: 43.9%

The indicator for how quickly people are booked in for cancer diagnosis in urgent referral cases is clearly crucial. It appears in InHealth’s performance framework as “%  2-week wait patients booked within 5 days of referral”.

From April 2018 to March 2019 the success rate was 67.6%. This cannot be seen as acceptable. Yet because this is a service in the private sector, the patient, the GP, and the consultant are powerless to act.  They can complain, get the service investigated, and report to the CCG that the target of 98% has not been met this year – but that is all.

There is another slightly mysterious indicator in the framework for “non e-referrals”. One could surmise that this was a route for the very urgent cases, where the GP rings up InHealth saying please fit this one in asap because the target – still 98% – is “booked within one day”.  But here the report contains the even more disturbing news – only 43.9% of referrals were actually booked within the one-day slot.

Healthshare

Healthshare, which took over all Oxfordshire’s muscular-skeletal services a couple of years ago, has been subject to continuous scrutiny after a poor report reached Oxfordshire’s Joint Health Overview and Scrutiny Committee last year.

The performance framework HealthShare agreed with the CCG shows no target for the length of time from referral to treatment. It simply said that patients should be offered “first or second choice of MATT (musculoskeletal assessment, triage, and treatment) within 10 working days”. Within 10 working days of what?

The target HealthShare had agreed to, which may have helped win them the contract, was 95% and was apparently exceeded – 100%. In fact their indicator targets were mostly exceeded, except for the “patient discharge letter to GP within 3 working days”: target 95%, actual 92%. Not bad.

However one patient, months after filing a complaint, finally received a letter from Healthshare suggesting the problem was not their end – they had completed paperwork correctly but:

Unfortunately, onward referral has to be a two-part process as the patient administration system and the onward referral system are separate, however we are investigating the use of software that will allow the two systems to integrate.”

In other words, one of the results of signing away one part of the NHS patient journey to a private provider is that the connections don’t work (incompatible IT systems). And patients fall through the cracks.

These are extracts from a full report by Oxfordshire Keep Our NHS Public, which also includes first-hand reports and case studies.

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