Failed contracts reveal cracks in the NHS market model
Health care is understood by most people to be a social good rather than a source of profit. Various changes resulting from a series of health bills (eg 1989/ 2012) have led to healthcare being treated as a commodity - something to be bought and sold ('purchased' and 'provided'). The Health and Social Care Act passed in 2012 has resulted in thousands of NHS contracts being put out to tender. Hundreds of contracts are now advertised and awarded each year. Our research has found that over 60% are won by non-NHS bodies.
The cost of this healthcare market is difficult to calculate and estimates vary widely at between £10 billion and £4.5 billion per year. Part of this expense results from a growing list of contracts that have collapsed, or have been terminated prematurely.
The growing list of contract failures spans all areas of healthcare from acute hospital care, through community care and the ambulance service to primary care and back-office functions of the NHS. And the list of failures is growing as more and more companies realise that the chronic underfunding of the NHS means that little or no profit can be made out of these contracts.
In primary care, the government's enthusiasm for private company involvement led to encouraging groups of GPs to band together to set up their own private limited companies to run large groups of surgeries all in the name of efficiency. 2016 saw two of these federations collapse and go bankrupt - Danum Medical Services in Doncaster and surrounds and Horizon Health Choices Ltd in Bedfordshire. The common thread to the failure of these enterprises was not enough money is available to fund high quality services. In other cases, such as The Practice and Greenbrook Healthcare, private companies have abandoned contracts finding it impossible to make a profit.
Here is a round-up of some of the most high profile contract failures in the last few years.
Thames ambulance to be stripped of its North Lincolnshire contract.
Thames Ambulance Service Ltd (TASL) started its contract with North Lincolnshire in 2016 for non-urgent patient transport. Problems in the service soon surfaced, but despite working with the CCG and recommendations from the Care Quality Commision (CQC), the company failed to improve. As a result, in March 2018 the CCG served notice on the company.
An inspection by the CQC in October 2017, led to a damning report in February 2018, which can be found on the CQC website. The CQC uncovered a range of failings including one day when 13 patients were left waiting at hospital for transport. Patients were also left waiting in the cold for transport and missing appointments because the service couldn’t be provided adequately enough to get patients there on time.
One of TASL staff members described their employer as “inept” and “disorganised”. The state of the service's vehicles was also highlighted by the CQC inspectors, with one vehicle 5,000 miles past its service due date and no hot water being available to clean them properly, inspectors found.
Coperforma and the Sussex non-emergency transport contract
One of the most controversial contract failures in recent times has been the Coperforma contract in Sussex for non-emergency patient transport. This four year contract worth £63.5 million was awarded in 2015 by seven CCGs, led by the High Weald Lewes Havens CCG. Coperforma replaced the NHS’s South East Coast ambulance service (SECamb) on 1 April 2016; it was then just a matter of days, before problems with the contract hit the headlines. By mid-April local and national press were reporting on a service in chaos, with crews not turning up to pick up patients leading to missed appointments and patients languishing for hours in hospitals awaiting transport home. Patients included those with kidney failure with appointments for dialysis and cancer patients attending chemotherapy sessions. The GMB union representing the ambulance crews said it was an “absolute shambles”. There then began calls to strip Coperforma of its contract.
In mid-April the CCGs that awarded the contract launched an investigation. In June, these Sussex CCGs produced a report criticising Coperforma for “unacceptable levels of performance”, noting patients having problems contacting the service and being collected late or not at all.
Despite this report and continued complaints, Coperforma’s service failed to improve and cracks started to show in the way the contract work was organised through sub-contractors.
Under the contract, Coperforma acted as an intermediary sub-contracting out the ambulance work to private ambulance companies. Many of the staff working for the sub-contractors had transferred from SECamb after this organisation lost the contract. However, by August it was evident that there were issues of payment to sub-contractors. VM Langfords was the first sub-contractor to go bust in June 2016, followed in September 2016 by Docklands Medical Services.
In September 2016, an email leaked to BBC South East from four of the sub-contractors claimed the problems had reached "critical levels". The email was highly critical of Coperforma's management, its staff, its operating system, and warned that the company was struggling financially. The email said Coperforma was withholding and refusing to pay invoices, with the three main providers owed more than £1.2 million. The email warned NHS managers "to act now before the service collapses."
In October a third sub-contractor, Thames Ambulance, reported financial difficulties. The sub-contractors all blamed Coperforma, saying they are owed millions in unpaid invoices by the company. The lack of payment to sub-contractors meant that many of the ambulance crew members had not been paid and were owed thousands in back pay.
Finally in October 2016, Coperforma were forced to give up the contract. Despite promising to transfer money to pay the ambulance crews, High Weald Lewes Havens CCG had to step in and provide the money for the back pay. In November 2016 the CCGs announced a managed transition to the NHS’s South Central Ambulance Foundation Trust beginning immediately and with a final takeover in April 2017.
In December 2016, a report by Brighton & Hove’s Healthwatch based on the experience of dialysis patients listed a litany of failures by Coperforma, including anxiety and stress due to failures of the service, transport failing to turn up and drivers who did not know the area and were inappropriately trained and equipped. In early November it was revealed that the Care Quality Commission had served six improvement notices on the company.
The CQC report showed significant concerns about Coperforma’s oversight of its subcontractors. Areas needing improvement included the timeliness of services, registering a manager with the CQC, and vehicles and equipment being appropriate for safe transport of patients, including those in wheelchairs.
Private Ambulance Service - Bedfordshire and Hertfordshire
In late September 2017, the private ambulance company, Private Ambulance Service contracted to run non-emergency patient transport from hospitals in Bedfordshire and Hertfordshire went into administration, with trading ceasing 9 October 2017. The business, which 126 vehicles and employed 300 people, took over the contract in April 2017. Problems had been reported with the service, including a report in the Herts Advertiser in July 2017 about Herts Valleys CCG issuing an apology after ongoing problems with the performance of the company, including leaving vulnerable patients stuck in their homes or in hospital for hours waiting for transport.
Arriva and North West Ambulances
In September 2015 the transport company Arriva was found to have wrongly claimed £1.5 million in bonuses on the contract to run non-emergency transport for NHS patients in Manchester. Arriva wrongly reported its performance in order to gain the bonus payments. Arriva was awarded the contract in 2013 after saying it could run the contract cheaper than the North West Ambulance service. In 2014 Arriva received 600 complaints about the service with 80% partially or wholly upheld. Arriva has paid back the bonuses and apologised.
Capita and the Primary Care Support Services contract
Capita took over the coordination of primary care support services in September 2015. The contract with NHS England was designed to save £40 million per year by bringing together a previously fragmented service to a single national provider for Primary Care Support England (PCSE). Capita's bid hinged on making a £21 million per year saving. The contract is worth £330 million over seven years. Capita immediately began centralising support services to three national hubs and implementing a single online ‘portal’ for practices to order supplies and ‘track’ the movement of patient records.
However, since the contract began there has been an never-ending series of problems - ranging from things as mundane as surgeries running out of prescription pads and syringes to far more serious problems with the secure transfer of patient notes around the country, with notes going missing or delivered to the wrong surgery, and women being dropped from the cervical cancer screening programme. The problems encompassed GPs, dentists, opticians and pharmacists.
A campaign by the GPC (General Practice Council) has been ongoing since early 2016; in May 2016 chair of the GPC Dr Chaand Nagpaul wrote to NHS England demanding practices be compensated for extra workload due to the ‘systematic failure’ of PCSE, and indemnified against any claims as a result of support service issues.
In September 2016, NHS England had to intervene, serving default notices on Capita and increasing the numbers of staff.
In November 2016 the GPC reported that the support services remain a 'chaotic mess' despite nearly a year since the services were outsourced to Capita.
Finally, in May 2018 the National Audit Office (NAO) produced a report on the contract noting that patients had been “put at serious risk of harm” due to Capita's failures. The report noted how both parties grossly underestimated the size and complexity of the task and the risks involved. The NAO report was particularly critical of NHS England and its inability to control Capita’s “aggressive” programme of office closures and redundancies, even when it became clear “it was having a harmful impact on service delivery”. In response NHS England highlighted the £60 million the contract had saved; the NAO report noted that the extent of harm to patients will not be known for some time to come.
In an excellent analysis of the contract by Richard Vize in The Guardian, he notes that the contract was "a textbook example of how to set up an outsourcing contract to fail. Pretty much everything that could have gone wrong went wrong."
Under the contract Capita was expected to make massive losses in the first two years in return for later riches. Vize notes that "With a big upfront loss, Capita had a massive incentive to cut costs quickly, so by the end of 2016 it had shut virtually all the local offices it had inherited and halved the staff. Vital local knowledge was lost."
Furthermore, as things went wrong, Vize notes how everyone argued rather than focusing on fixing the problem. Capita is reported to have lost £125m in the first two years – double the target and Capita and NHS England are still arguing over the contract. The NAO notes: "two and a half years into the contract basic principles are still not agreed, which limits NHS England’s ability to hold Capita to account. NHS England and Capita have still not agreed how to calculate 11 performance measures, and how these data should be used to calculate payments owed to Capita for delivering the services."
One of the ways patients could potentially have been put at risk was the problems with the “performers list” of GPs, dentists and opticians practising in the NHS, including whether they are suitably qualified and have passed other relevant checks. According to the NAO report, problems with the list also led to around 1,000 GPs, dentists and opticians being unable to work, 200 of whom have sought money for lost earnings.
Another part of the contract was pensions administration for GPs. Delays have been reported to the payment of pensions as well as confusion surrounding many of the administration processes for the pensions. Despite Capita being in charge since 2015, in April 2018 there were still many ongoing issues.
Capita have had long standing issues with payroll and pensions nationally, in 2016 they were a year late submitting Barnet Council’s pension scheme to the Pensions Regulator, resulting in a fine.
Problems are still ongoing with the contract, the NAO notes that "users continue to experience poor delivery with seven severe service failures in February 2018."
Dr Richard Vautrey, chair of the BMA’s GP committee, said his members want elements of the service to be taken back in-house. “With this as an option, we are now asking NHS England how it plans to resolve the shambles that is Capita’s running of Primary Care Support England,” he said. The NAO also recommends that NHS England should determine whether all current services within the contract are best delivered through that contract or be should taken in-house by NHS England.
GP surgery closures
There were a record number of GP surgery closures and mergers in the year from April 2016 to April 2017, according to an investigation by Pulse. The investigation found that more than a quarter of a million patients in England were forced to move GP surgery last year, a 150% increase on 2014 figures, and a 15% increase on 2015. Then NHS Digital figures for the year to June 2017 show that 202 practices in England closed or merged: 64 in the north of England, 54 in the south of England, 46 in the Midlands and east of England and 38 in London.
Of these closures, many were due to GPs handing back contracts due to retirement, but others were due to private companies pulling out of contracts due to financial pressures.
The Practice Group
In Brighton and Hove, The Practice Group announced in January 2016 that it will terminate its contract for five GP surgeries in the city at the end of June, leaving 11,500 patients looking for a new GP. After NHS England intervened, The Practice Group continued to operate the surgeries until September 2016, to allow more time for the local CCG to put new services in place.
The Practice Group gave several reasons for giving up the contract, including the need to relocate two surgeries due to redevelopment projects, rising demand for services, and a difficulty in recruiting and retaining GPs, however a major reason is a reduction in central funding for the surgeries. Local MP Caroline Lucas said: “Once again it looks like patients may end up paying the price for the privatisation of our health service. These surgeries are at risk because a profit-making company couldn’t balance the books, not because they’re not needed.”
In October 2016, Greenbrook Healthcare announced its intention to hand back an APMS contract for five GP surgeries in west London nine months before the end of the contract. This puts around 27,000 patients at risk of losing their GP. Greenbrook Healthcare has been in discussions with NHS England since early 2016, however no additional funding has been offered. The company stated that due to rising demand and problems with GP retention the contracts have become “unfit for purpose”.
Danum Medical Services
The private limited company Danum Medical Services Ltd was set up in Doncaster by 23 local practices and had 63 individual shareholding GPs’. The company held APMS contracts for six practices in the Midlands and Yorkshire. In March 2016 DMSL went into administration leaving individual GP surgeries in debt, with one surgery reported to be facing losses of £20,000.
The company reported that it provided a high quality service but as one GP involved said: "The reason they have failed is they have tried to provide high quality care on a budget where it is impossible to do so."
Horizon Health Choices Ltd
Horizon Health Choices Ltd was a private company set up by 54 GP surgeries in Bedford and the surrounding area. In November 2016 the decision was announced to liquidate the company due to problems with recruiting GPs and internal management issues. The liquidation of the company will lead to the closure of one GP surgery and the loss of thousands of pounds by the surgeries that had invested in the company.
Horizon was launched in response to Government encouragement for GPs to work at a large scale. NHS England has made such working at scale a national priority with the GP Forward View and the new Multispeciality Community Provider contract for groups of practices with at least 30,000 patients.
Out of hours services
Central Nottinghamshire Clinical Services
In May 2016 Central Nottinghamshire Clinical Services, the private company in charge of out of hours services across the East Midlands, announced it was filing for administration. It stopped its services in Leicester, Leicestershire, Rutland and north Nottinghamshire and they were transferred to another provider. The company also ran care home support services and these were transferred to Nottinghamshire Healthcare Trust.
Primecare in Kent
In September 2017, Primecare, which was awarded one of the first integrated NHS 111 and GP out of hours services contracts, announced that it is to hand back the contract to the NHS mid-way through the three year contract in July 2018.
The contract began in January 2017, but after only seven months, Primecare was placed in special measures after its services in East Kent were rated inadequate by the Care Quality Commission. Failings included not assessing risks to patients’ health and not having enough staff to meet patient needs. The CCG has said that a review of the procurement process will also take place.
There were issues at the start of the contract; the 111 service in East Kent was originally meant to transfer to Primecare in September 2016 together with the out-of-hours service. However, the South East Coast Ambulance Service was asked to continue to provide the 111 service first until October 2016 and then until November 2016 with a phased handover to 10 January 2017. The second request for a delay to November was made with just 12 days’ notice. The delay was while the out of hours services, previously run by IC24, transferred to Primecare. The ambulance trust had no option but to continue to provide the 111 service despite it causing a strain on its service across the region.
Serco in Cornwall
In December 2013 Serco announced that its contract to provide out-of-hours care in Cornwall for Kernow CCG would end 18 months early in May 2015. The contract has been dogged with controversy – Serco had to admit that some of its staff had falsified data to make the company’s performance appear better than it was and whistleblowers had raised concerns about poor staffing levels. In 2013 Serco unsuccessfully tried to sub-contract the work to Devon Doctors, the GP consortium that had failed to win the original bid; Serco had won the bid as it was cheaper.
Cambridgeshire and Peterborough Older Peoples Services Contract
This was an extremely high profile contract due to its high value – worth £700 to £800 million over five years – for the provision of older peoples services for Cambridgeshire and Peterborough CCG. The contract was also one of the first outcome-based contracts under which an element of payment was dependent on achieving agreed clinical outcomes. Outcome-based targets would have to be achieved for the provider to receive 15% of its income.
The process for procuring a provider began in 2013 and was time-consuming and costly according to many reports. A number of private companies were initially interested in the contract, including Circle, Virgin Care and Capita, however they withdrew during the process reportedly due to the steep financial efficiencies required by the contract. By August 2014, the CCG had spent around £1.1 million on the process and had had the contract start date delayed twice. Eventually in November 2014 UnitingCare Partnership, a consortium of NHS organisations, was awarded the contract. The contract began in April 2015 a year after its original start date, but just eight months later in December 2015 UnitingCare announced that it was handing back the contract as it was not financially viable.
In November 2016 the Public Accounts Committee published a damning report on the contract. The PAC describes the handling of the contract as a "catalogue of failures."
The termination of the contract after just 8 months meant around £16 million in unfunded costs for UnitingCare Partnership. These costs had to be shared between its two trust partners—Cambridge University Hospitals NHS Foundation Trust and Cambridgeshire and Peterborough NHS Foundation Trust—as well as the CCG. As a result this reduced the amount of money available for patient services in the area.
Meg Hillier MP, Chair of the PAC, said:
"It beggars belief that a contract of such vital importance to patients should be handled with such incompetence."
Hillier also stated:
"The deal went ahead without parties agreeing on what would be provided and at what price—a failure of business acumen that would embarrass a child in a sweet shop, and one with far more serious consequences."
Circle and Hinchingbrooke Hospital
In January 2015, Circle the private company running Hinchingbrooke hospital pulled out of the contract after just two years of a ten year contract. The company announcement came just before the publication of a damning report on the hospital from the Care Quality Commission (CQC): the CQC raised serious concerns about care quality, management and culture at the hospital. The CQC found a catalogue of serious failings at the hospital that put patients in danger and delayed pain relief. The hospital was put in to special measures, the first time the CQC has had to do this. Circle cited financial reasons for pulling out: under the contract the company was allowed to withdraw if it had to invest more than £5 million of its own money in the hospital and it looked extremely likely that it was going to have to invest much more than £5 million.
Serco and Braintree Hospital
In December 2013 Serco announced that it would be pulling out of its contract for running Braintree hospital in Essex before the end of the contract. In March 2014 the contract was handed by to the Mid Essex Hospital Trust nearly a year early. The company’s other major contract with the NHS for community care in Suffolk has not reaped the profits the company was hoping for and by August 2014, the company announced that it was withdrawing from the NHS clinical services market altogether. In September 2015, when Serco handed over the community care contract in Suffolk to new providers, the company noted that the £140 million the company was paid for the contract was "not adequate" for the work. Serco estimates that it had made an £18 million loss on its three NHS contracts.
The marketisation of the NHS has a high cost even if the contract does not go ahead. The process of tendering a contract can be abandoned at many points; obviously the longer it carries on the more money is effectively wasted by the CCG or trust. The Cambridgeshire and Peterborough contract that was abandoned soon after its start, cost the CCGs millions (see above), but the process of tendering can cost hundreds of thousands even if the contract tender is then stopped - money that could have been spent elsewhere by cash-strapped CCGs.
In April 2017, CCGs in Staffordshire finally abandoned the procurement of a ten year contract for cancer and end-of-life services worth £687 million. The whole process began in 2013 and has cost the four CCGs over £840,000. The tender process was paused in 2015 following the collapse of the UnitingCare Partnership contract in Cambridge and Peterborough. However, after restarting several months later in November 2016, a single final bidder emerged. This was a consortium of Interserve and two hospital trusts. Speaking on behalf of the CCGs, Andy Donald, chief officer at Stafford and Cannock Chase CCGs, said: “The remaining bidder couldn’t convince us they could deliver with the resources available.”
The contract allowed a single prime provider to commission services and the services would be measured against outcomes agreed by commissioners, including full recovery, longer life expectancy or pain free dignified deaths.
Another high profile contract abandonment was the West Sussex MSK contract. This £235 million contract for provision of musculoskeletal services in West Sussex with Coastal West Sussex CCG was awarded but never begun once it was determined just how much damage the contract would do to other NHS services in the region.
In September 2014 Coastal West Sussex CCG awarded the contract to BUPA and social enterprise CSH Surrey. However, pressure from the public and Western Sussex Hospitals Trust, forced the CCG to employ an auditor to assess the effect the contract would have on other NHS services in the area. The auditors concluded that the cumulative impact of loss of MSK services would result in the trust falling into deficit over the next five years. Western Sussex Hospitals had also warned that the loss of the contract could destabilise its trauma services. BUPA and CH Surrey withdrew from the process in January 2015 prior to signing the final contract.