By Mark Cockerton, Advisor on urgent healthcare & GP out-of hours services
I’m assuming that readers will have read the White Paper so I haven’t covered the detail of those proposals. As a very broad summary: A major feature of the 2012 reorganisation was to introduce automatic tendering of NHS healthcare services and bring the commissioning of NHS healthcare services under the jurisdiction of the Competition and Markets Authority.
Both of those are going to be reversed next year. It says it all that the previous ‘reforms’ are being dismantled by the governing Party that introduced them.
9 years too late in my view…
Regular tendering of urgent care services has become commonplace. There is precious little evidence of any VFM or service quality benefits arising from tendering; neither are there any shining examples of that process improving collaborative working in urgent care. Some of you will disagree with that, however my assertion is that it isn’t the competitive tendering process that drives service quality.
Many of us remember the world before competition when our organisations were fully-compliant against all 13 NQRs and there was an immediate action plan drawn up to deal with any non-compliance. The assumption that including a requirement to collaborate in a contract specification would mean that collaboration would follow is a pretty damn naïve one. It often had the opposite effect with services much less inclined to collaborate after being in competition with each other during a tender process.
Had NHS competitive tendering been a success when judged against the huge cost of the organisations (including CCGs and Commissioning Support Units) set up to service the system, we’d have been given examples showing us how well it was all working. I have never seen any VFM comparisons taking into account the cost of commissioning, contracting and tendering.
Given the failure to achieve notable service improvements from competitive tendering there is strong public and NHS staff support for scrapping section 75 of the Health and Social Care Act 2012 and for removing the commissioning of NHS healthcare services from the jurisdiction of the Public Contracts Regulations 2015. That’s something that I also support as the current commissioning arrangements are not fit for purpose.
Collaboration and integration
I believe that different parts of the NHS and other healthcare Providers will work together more easily once they are freed from feeling they need to erect barriers with organisations that could potentially compete with them, whenever the next tender is issued. Fear of future competition from ‘partner’ organisations is something I frequently observe and its a serious barrier to co-operation in the urgent care sector currently.
That’s because the local Acute Trust, Community Trust, Ambulance Service, GP Federation, Primary Care Network and commercial provider can (and do) compete with the Social Enterprise provider to deliver urgent care services; either alone, or in partnership with another organisation. I can’t think of another part of the healthcare system that has such a range of organisations competing to deliver it, or where tendering opportunities have been more plentiful. The replacement of the requirement to regularly tender urgent care contracts and replace that with the expectation that local Providers will collaboratively work together in an Integrated Care System, to provide the best service possible with the available resources, has my support… in principle.
However, there are huge challenges coming for organisations that have followed a policy of remaining ‘independent’ and made little progress towards integration. There are many references in the White Paper to ‘placebased’ services and those organisations operating in areas where they have little geographical relevance as they won their contracts in areas where they had no history of service delivery are particularly threatened.
Where are the threats to Social Enterprise organisations, including UHUK members, providing urgent healthcare and unscheduled primary care?
- Having worked for one of the Pathfinder Integrated Care Organisations I learned first hand how easy it is to push an ‘external’ Provider outside the integrated care system. How would an organisation without longstanding links to a local geographic area and enjoying little emotional ownership from local primary care and patients, be able to ‘win’ against an alliance of Acute Trust/ Ambulance Service/ core local Primary Care organisation and Local Authority?
- Without enjoying strong local emotional ownership, or being fully embedded within local primary care and/or having local ‘political’ support, social enterprise and commercial organisations risk losing their contracts when the term ends. In my view.
- The alternative outcome is that organisations external to the Integrated Care System may be offered a ‘take it or leave it’ financial envelope that will be very unattractive. The expectation is of course that the Integrated Care System delivers value-for-money. Those core organisations inside the System will seek to maintain their income so far as possible by forcing those organisations outside the System to take the brunt of efficiency savings.
- Any commercial and social enterprise organisations that have depended on a strategy of continually securing new ‘out of area’ contracts to replace other ‘out of area’ contracts lost in competitive tendering processes in order to maintain their financial security, are particularly threatened. That’s because their prospect of securing future contracts in areas where they don’t currently have a very well-established presence is going to be minimal.
- Future integrated urgent care contracts are very likely to be secured by collaborative arrangements between local Acute Trusts, Local Authorities, a core local Primary Care Organisation and Ambulance Trusts. Any provider outside the local area and the Integrated Care System is, by definition, going to be unable to define how they will be able to offer integrated care.
- Organisations that have built an integrated management structure and physical infrastructure paid for by a contract portfolio that includes ‘out-of-area’ contracts are likely to have their future financial viability adversely affected. The economy of scale issues that drove their organisational development become financial barriers when the organisation needs to downsize if it loses one or more contracts that it is unable to replace.
- Politically, Acute Trusts/ Ambulance services/Community Trusts/ Mental Health Trusts/ Primary Care Collaboratives and Local Authorities have a size and influence that no Social Enterprise could ever hope to match.
- High-level discussions will already be taking place between NHS Trusts, Local Authorities and Ambulance services to position their organisations in the Integrated Care Systems. Agreement about who from those organisations is going to become the Chief Executive Officer may already have been reached.
- In some areas Primary Care will have been included in those preliminary political discussions. However, only those social enterprise providers that are extremely well-established locally and have some local political clout will be a party to those discussions. That is also something I saw in the Pathfinder Integrated Care Organisation I worked for. By the time Primary Care joined the discussions it was clear that alliances had already been formed between the Acute Trust and Ambulance service and it was catch-up from that point. Securing appropriate influence for the Primary Care organisation against the combined might of the Acute Trust and Ambulance Service, when the CEO of the Acute Trust was the CEO of the Integrated Care Organisation following a deal with the Ambulance Trust ‘was a challenge!’.
- Bear in mind that the Boards of Integrated Care Systems need only to include NHS Trusts, Local Authorities and Primary Care. There is certainly no expectation or requirement that Social Enterprise providers have a seat on the Board and very few will do.’
Plan for action
- There is still nearly a year until the new Integrated Care Systems are expected to be up and running in April 2022. So there is still time to build a ‘political alliance’. The obvious alliance for social enterprise urgent care organisations is with local Primary Care Organisations but building relationships with local Acute Trusts/Ambulance services/ Local Authorities is essential too.
- Social Enterprise urgent care providers tend to have unrivalled access to local GPs and that gives an opportunity to improve relationships and ensure that the organisation is ‘emotionally embedded’ within local primary care.
- Much of the high-level strategy on the establishment of the Integrated Care Systems will be undertaken by senior clinicians. Clinical Directors of the organisation should be outward-looking and seeking to establish effective working relationships and networks with all other local healthcare Providers, including Acute Trusts and Ambulance Trusts. It is not the time for organisations to be inwardly-focussed.
- All other Senior Managers should be given an objective to build effective working relationships with local healthcare providers. The Chief Executive has a vital role in building the most effective working relationships with CCG leadership.
- Dust off the organisations constitution and ensure that it is being followed, particularly with regard to the involvement of patients, staff and GPs in the organisation. At times of change, buy-in and support from local people is often valuable.
- Dust off too the latest tender submission you made and remind yourself about the promises made with regard to integration, seamless care, joint working, patient involvement etc.
- There will almost certainly be a due diligence process before a Social Enterprise provider is included in an Integrated Care System so make sure you are keeping to your Constitution and can demonstrate how you are different to a commercial provider.
- If there is any opportunity to work with the Acute Trust/ Ambulance Trust/ Primary Care – take it.
- Any organisation that is dependent on ‘out-of-area’ contracts to maintain financial viability should be reviewing its exit strategy for those contracts and making plans to limit its financial exposure if those contracts are lost and replacement contracts are not secured. That includes reviewing its management structure so that staff and managers are identified to particular contracts and can be TUPE’d should individual contracts be lost.
The proposed reorganisation is, in my view, the biggest threat to the viability of Social Enterprise providers since the introduction of NHS 111. Leadership of those organisations need to step up and help to secure their future. Those organisations that are still around in 3 years time will be those that have been able to form political alliances and relationships with far larger organisations.
Mark Cockerton has 40 years experience in the NHS and not-for-profit urgent care sector. He is currently Managing Director of Urgent Healthcare Solutions, which provides leadership and support services including tendering, organisational development, interim management, IT and telecoms advice, HR support, mentoring services, patient involvement and financial advice exclusively to the Social Enterprise urgent health sector.