"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Tuesday, 26 February 2013

Come on Tim!

The NHS generates a lot of data: for example, data about the number and cost of procedures carried out, waiting times and the numbers and cost of prescriptions. This blog is not about that data, this blog is about governance: the huge number of documents that NHS organisations produce from their meetings.

Every NHS Trust has to hold its board meetings in public and publish its board papers. Under the previous legislation Foundation Trusts could exclude the public from board meetings, but under the Health and Social Care Act 2012 Foundation Trusts must hold board meetings in public and publish board papers. Trusts hold board meetings monthly, every other month or once every three months. (It is bizarre that Hinchingbrooke has just four board meetings a year, with less information made public in each meeting than most trusts provide in their monthly board meetings.) Every year NHS Trusts and Foundation Trusts have to publish an annual report and a quality report. Foundation Trusts also have to publish an annual forward plan outlining their plans for the following three years.

From April 2013 we will see a huge number of new organisations. These include the statutory NHS Commissioning Board (NCB), Clinical Commissioning Group (CCG) boards and local authority Health and Wellbeing Boards (HWB). Further, there will be non-statutory local Healthwatch, NCB regional arms (former SHA clusters), NCB local area teams (made up of former PCT clusters) and Commissioning Support Units (CSU). It is unclear how many of these sub committees and non-statutory organisations will publish their papers.

There are also organisations like Care Quality Commission and Monitor (as well as committees of these organisations like Healthwatch England and the Competition and Cooperation Panel), that are specific to healthcare and organisations like the Office for fair Trading, the Competition Commission and the National Audit Office that periodically perform investigations of the health economy and publish reports. Finally, local authorities also have Oversight and Scrutiny Committees for health, adult social care and children's services. There are many other organisations that affect how NHS and social care services are delivered, but I am sure by now you have got the point that every month there are many hundreds of board papers made public (or should be made public).

So how do you access these papers? The only central repository is Monitor which holds the Annual Reports and Forward Plans for Foundation Trusts only (strictly speaking these reports are laid before Parliament, where they are also available, but Monitor provides the most accessible location). If you want to get access to board papers for NHS and Foundation Trusts you have to hunt around their website for them (the best place is to look under the About Us menu, if the site has one). Local authorities have to publish their own committee papers, but again, there is no standard for how or where on their websites these are published, so you have to hunt around their website to find them. We have yet to see what CCG policies will be about publishing public board papers, but is likely that each CCG will decide where on their own website they publish them in a similar way to Foundation Trusts: again, no standard.

The NCB is open about their own board papers, but appear to accept no responsibility for the organisations that they host, so to find board papers for the regional arms you have to seek out and search their websites, and if you want board papers for local area teams and CSUs you will be very lucky to find anything at all.

This is a mess. It has been a mess for years and it is an insult to democracy that it is difficult for people to access these board papers. It is also an insult to the public that no one has done anything about this issue. Luckily, we have a national Czar called the "National Director for Patients and Information", Tim Kelsey. Unfortunately, giving people access to board papers is nowhere on Tim Kelsey's list of things to do, so it seems I have to do his job for him. The following is a strategy that the NCB should implement.

Central Website

All board papers must be available from a central website. There should be no exclusions, all NHS providers should provide board papers for this website within a month of the meeting. The NCB should also have a policy about historical documents, I suggest that to be able to make any meaningful comparison between organisations we need five years of information, so the NCB should require that all board papers from 2008 to the present should be available, regardless of whether the organisation have had public board papers during that period. (remember: this is about open data.) Similarly, all commissioners (CCGs, local authorities, former PCTs and SHAs) should provide their public board papers for the site. The website should provide search facilities so that users of the website can perform powerful searches across the documents of all organisations.

Open Governance

The National Czar for open data should insist that the board papers of committees, and organisations hosted by his employer (regional arms, local area teams and CSUs) are made public and are published on the central website. Indeed, any government organisation associated with commissioning or providing NHS and social care should make their board papers available through the central website.

Level Playing Field

In the spirit of open data, the National Czar for open data should also lobby the government to ensure that every provider of NHS and social care must publish board papers relevant to the NHS care they deliver. To prevent a Southern Cross type of scandal affecting NHS patients, the government should ensure that all providers of NHS and social care should publish their complete finance board reports. The reason for this is that in many cases the NHS business of such organisations are often the only profitable part of the company, so publishing finance reports of their NHS business will not give a complete picture about the financial health of the company.

The first two suggestions could be started tomorrow with a deadline to have such a website up and running by the end of the year. There is no reason not to have such a website. Any argument about this being expensive to deliver is specious since the government in the recent SI 257 regulations are mandating such a central website for all the NHS procurement tenders, and this potentially will have far more documents that I am suggesting should be made available about governance. The third suggestion - a real "level playing field" of governance - is more difficult, but I think that anyone who is serious about open data would agree that this suggestion is important.

Over to you, Tim Kelsey.

Saturday, 16 February 2013

Treasury clawbacks

Here are two interesting quotes taken from the opposition day debate on the NHS on 16th January 2012.
The Secretary of State for Health (Mr Andrew Lansley):We delivered £4.3 billion of cost improvement in the NHS in the last financial year. We are aiming to do more this year. We delivered £2.5 billion, according to the deputy chief executive of the NHS, in the first two quarters. Every penny saved by reducing costs in the NHS is available to be reinvested in the NHS.
Andrew Lansley is known for his absolutist language, it is not "most of the savings" it is "every penny saved". Similarly, the then Minister of State Simon Burns uses bullish language, but in this case, he adds some more details to Lansley's claim:
The Minister of State, Department of Health (Mr Simon Burns):Any and all money made by the NHS is returned straight into care, not to the Treasury.
This is equally absolutist ("any and all money"), but is also mentions the villain that scares people: the Treasury.

However, both are wrong. Over the last financial year the NHS underspent by £1.7bn and the Treasury clawed back £1.4bn of that. Indeed, HSJ (paywalled) say that:

The spokesman also confirmed that the DH recorded a £1.9bn underspend in 2010-11 - but made no use in that year of the "budget exchange" scheme which allows government departments to carry over some unspent funds for use in future years. This means at least £2.9bn of DH funding has been clawed back by the Treasury in the past two years. This is despite the NHS facing a funding settlement for 2011-12 to 2014-15 that is likely to mean its “tightest four-year period in the last 50 years”, according to think tanks the Nuffield Trust and the Institute for Fiscal Studies.
So over two years almost £3bn of NHS money has been clawed back by the Treasury for deficit reduction. This is not what Lansley and Burns were suggesting.

Wednesday, 13 February 2013

Fair Playing Field

In 2007 Circle bought Nations Healthcare and with this came the Independent Sector Treatment Centre (ISTC) in Nottingham and the Midlands Centre in Burton and a facility in Bradford. The contract for the Burton facility ended in July 2011, and the contract for the Bradford facility ended in June 2010. The following map (pdf) shows the relationship of the treatment centre (in the top right hand corner) to Nottingham University Hospital. Further, the staff who work in the treatment centre are seconded from the University Hospital under a Staff Services Agreement. It should be very clear that the treatment centre is part of the complex and depends on the NHS hospital.

Nations Healthcare was one of the first companies to be contracted to run an ISTC, the New Labour government's mechanism to privatise some NHS services. The company was created in 2002 and has its origins in the US. Nations Healthcare was contracted to open its ISTC in Nottingham in December 2007, but it missed this deadline and the facility opened in July 2008. By this time Nations Healthcare had been taken over by Circle. Thus, the Nottingham NHS Treatment Centre should be regarded as always being a Circle facility because it was not opened until after Circle took over Nations.

The contract with Circle was extremely generous compared to the NHS hospital a short walk next door. The contract is known as a Minimum Take (MT) contract. Unlike Payment by Results (PbR, the payment system for NHS providers) Circle has a guaranteed income known as the "minimum take" and this means that commissioners pay the treatment centre even if they treat fewer than 95% of the patients they are contracted to treat. Further, the commissioners pay national tariff plus 22% for all activity up to 105% of plan and are paid national tariff for any activity over 105%.

Circle crow about how "efficient" they are at Nottingham, claiming on their website in 2012 that they:
"deliver[ed] average productivity gains of 18% each year since opening,"
That is, they claimed that from 2008 to 2012 they had an "average" productivity gain of 18% every year. Put this another way, a procedure that cost £100 in 2008 would cost £45 in 2012: is this possible? A management consultancy group called IPA produced a case study of Circle (Sept 2011) and in this they say:
"Circle has only been delivering services at the Midlands Centre for three years, Nottingham for two years, and Bath for less than a year, so data on long-term productivity trends is limited. However, evidence gathered by the company shows that in 2009, Nottingham had a 22 per cent productivity gain, and the Midlands centre had a 17 per cent productivity gain. Data is not yet available for Bath. At the Midlands Centre the employees have been engaged in a turnaround operation, after a period of low performance under the previous owner, which has set a clear direction." 
This says that two of the facilities that Circle had purchased from Nations (the Nottingham ISTC and the Midlands Centre in Burton) had poor productivity in 2008 and in 2009 there were similar productivity gains at both. The study lays the blame for the poor productivity of the Midlands Centre on Nations Healthcare, however, 2009 is two years after Circle took over Nations (ie they had been running the facilities for 2008 and 2009) and in the case of the Nottingham ISTC, Nations had never run the facility, so the 22% productivity gain in 2009 was an improvement on the poor running of the centre by Circle in 2008.

The last full Annual Report from Circle is for the year ending 31 Dec 2011 (pdf). This report states that  the Nottingham treatment centre was the only profitable part of the business. In 2011 it treated 87,340 patients generating revenue of £51.2m. The operating profit was £2,4m. Compare this to the much smaller CircleBath which treated 33,174 patients (both private and NHS) generating revenues of £13.2m and an operating loss of (£9,156k). Clearly Circle are not good at delivering private healthcare. In 2011, the total loss of Circle Holdings was £32.9m.

Most of the 87,340 patients of the Nottingham treatment centre will be treated on "minimum take", so the £51.2m is 22% more than an NHS hospital would be paid. Since the profit is just 5% of revenue, one has to question whether Circle could make a profit at the Nottingham treatment centre if it was paid like an NHS hospital.

The contract for the Nottingham Treatment centre has been re-awarded to Circle. The contract is for 5 years and the tender advertisement suggests that the contract is worth between £22m and £42m. The tender was handled by Midlands and East SHA on behalf of Principa CCG. The so-called Clinical Commissioning Group did not do the commissioning, instead, it was done on their behalf by one of the four centralised arms of the National Commissioning Board. Nottingham University Hospital was one of the original bidders for the tender, and considering it provides the staff, does the same work at tariff, and is right next door to the treatment centre, it would appear to be a nobrainer that they would get the contract. Details of the contract are currently not available, so we do not know if Circle will be paid at tariff, or on a minimum take. If the contract is on the former (tariff), then it is difficult to see how the ISTC can make a profit (and difficult for Circle to have a sustainable future). If it is the latter (minimum take) then this will go against government policy of a fair playing field.