The decision by Bath and NE Somerset, Swindon and Wiltshire Integrated Care Board (ICB) to award a contract for the provision of all community care services across the ICB area to a private equity-owned company – HCRG Care Group – is continuing to cause some controversy.
The ICB managed to award the contract without a Full Business Case, and it remains unclear just exactly how a contract valued at over £1bn can be awarded without authorisation by HM Treasury.
This dispute sits alongside a very similar argument going on in Kent and Medway, where a new system-wide contract for children’s and adults’ services community services, now out to tender, will span five years from October 2025, with an option to extend for up to three further years, with an estimated total value of £1.8bn over 8 years.
The complexity of drawing up a bid from Kent Community Health Foundation Trust has been blamed for the cancellation of two Trust board meetings: it last met in October and is not due to meet again until April. And even while the Trust continues its furtive efforts, disclosing details only to Board members and governors, the Trust chair tries to convince the Health Service Journal that “we take openness and transparency with the public very seriously”.
Kent and Medway ICB itself is even more tight-lipped: a request for basic information about their strategy and plans was met by the questionable claim that everything is “commercially sensitive” – that now hackneyed block to the public scrutiny on decisions, even where they will have a big impact for many years to come.
In both cases, there are huge implications for services currently delivered by multiple providers, and it is possible that a private for-profit provider could take them all over.
Yet neither is being regarded as a ‘reconfiguration’ or a ‘substantial change in services’ – either of which would trigger the full NHS service change process, with all that implies about having to set out the case, and to consult and engage with the public.
In Kent/Medway one of the Councils in the area has already challenged this interpretation and hopefully will be able to insist on openness.
Back in Bath no such challenge has been raised, but there is the likelihood of an application to the Secretary of State to recognise that this is reconfiguration and then to call-in the defective process the ICB has used.
There is little doubt that community services require considerable attention. These have always been a Cinderella service, often first in line for cuts. The disaster of New Labour’s policy for Transforming Community Services (which were altered, but for the worse) and the Cameron government’s disastrous 2012 Health and Social Care Act led to services that are fragmented across multiple providers, often with a significant input from the third sector.
That’s why a few surviving Care Trusts, various social enterprises, and other’ not-for-profits’ now sit alongside the for-profit sector, which includes the expanding HCRG (formerly known as Virgin Care). The one attempt to form a truly integrated Care Trust to deliver such services (in Dudley) failed quite comprehensively.
There is a lack of genuine voice, in contrast to the extensive lobbying capabilities of the major acute trusts and foundation trusts.
Because of the fragmentation and the entry of the larger private providers, community health services have almost achieved the dubious status of being driven by compulsory competitive tendering. Although the new Provider Selection Regime sets a different tone and allows some scope for innovation the ICBs have no interest in thinking differently, and even if they did have ideas, they don’t have the management capacity or leadership to translate ideas into better outcomes. (To be fair there are places where community care provision is valued and far better organised, for example in West Yorkshire.)
The two current sagas illustrate a number of important issues.
ICBs should be the bodies to integrate services – but they are not up to the job, so they hand it over to the private sector – but have to pay for it.
ICBs clearly do not have the capacity and capability to manage large programmes, to use the many flexibilities around procurement, or even to write Business Cases: (when they have tried to do so they appear to have read the required web pages, listed the required headings and simply stuck some text underneath each one.)
The prohibition on having people on ICBs with private sector backgrounds has just been ignored. Indeed, the new Partnership Agreement between the NHS and the independent sector explicitly contradicts the prohibition, stating (2.1):
“Independent providers are an important part of NHS systems and should be involved in planning local services. This includes planning services based on knowledge of available local capacity and commissioning services from a range of providers, both NHS and independent, across the whole care pathway.”
The ICBs that should be in the lead over the shift out of hospitals and into primary and community care usually lack ideas but mostly lack competence: they simply do not attract the highest quality of leaders and managers.
The imbalance between the power of the big acute Trusts and everyone else remains; the ICBs have almost no influence over acute care, but acute care gets a voice on the ICBs.
Government policy to halt and reverse outsourcing and prohibit the iniquity of a two-tier workforce is being blatantly ignored. Ministers refuse to intervene to uphold their manifesto commitments. Nor will NHS England intervene to stop poor behaviour or even outright failures to follow guidance and regulations.
The NHS has lost its consistent commitment to engaging with its staff, public, and patients unless forced to. For those seeking answers, it appears that bodies frustrate proper use of the Freedom of Information Act. Absurdly common reasons for non-disclosure, such as “commercial confidentiality,” are used and can’t be challenged. Few NHS bodies make any serious attempt to discuss important matters in public.
In the next financial year, ministers and NHS England have made it clear they are only interested in things that have direct input on reducing the Referral To Treatment queue – everything else is of marginal interest.
The brave councillors and local campaigners who are battling on against privatisation or other unreasonable or unworkable policies and decisions will have to find ways to force the local issues into national headlines if they are to challenge this new status quo.
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