Warning over primary care trusts in commissioning health services

Primary care trusts, which commission services for patients from the public, private and voluntary sectors, are at risk of breaching NHS competition rules in a "significant" number of cases. 

The warning comes from the panel set up to advise health ministers on the application of competition in the NHS.

It is the latest twist in a deepening row over whether the government is seeking to squeeze out non-NHS providers - including the not-for-profit sector - in the battle to win contracts for providing publicly-funded healthcare.

In September Andy Burnham, health secretary, appeared to overturn existing policy when he said the NHS should henceforth be regarded as the "preferred provider" of healthcare.

However, almost four months after Mr Burnham pledged the rules governing the bidding process would be rewritten to reflect the new approach, nothing has emerged. 

The Department of Health recently said that they would be published "in the coming weeks" - leading to speculation that they might not emerge before the election, or before the panel issues its initial judgment in March.

That means the panel must make its judgment based on the competition rules currently in force - prompting the warning from Andrew Taylor, the competition panel's chief executive, that PCTs may be making decisions that reflect Mr Burnham's rhetoric but flout current rules.

Mr Taylor said problems it had observed included "excluding potential bidders on grounds unrelated to their ability to deliver the services tendered, and failing to select the bestperforming service provider as the preferred bidder".

However, in a sign of the growing tension between the panel - set up by Alan Johnson, when health secretary - and current health ministers, the health department has publicly rejected that view.

A spokesman said it appeared to be based "on anecdote". The Co-operation and Competition Panel had presented "no evidence" from its casework in a report on its first year's work "to suggest poor procurement practice by commissioners", he said.

The spat comes as the panel is investigating a crucial test case in which Great Yarmouth and Waveney PCT said it could take bids only from NHS organisations to run its provider arm.

From:

http://www.ft.com/cms/s/0/efe144aa-1a99-11df-bef7-00144feab49a.html?nclick_check=1

Hospitals must cut services to stay afloat, watchdog quango warns

Hospitals will have to reduce services, sell off buildings and move into smaller premises to cope with financial pressures in the next few years, the head of the foundation trusts’ regulatory body has warned.

Accident and emergency departments treating only a few serious cases may be downgraded to minor injury units

William Moyes, who steps down from his role as executive chairman of Monitor after six years told The Times that too many hospitals were not grasping the economic challenges ahead.

While political parties have promised to protect NHS funding and avoid service cuts, Mr Moyes said it was inevitable that some hospitals would have to reduce services and sell off assets to keep afloat.

Any hospital department that was treating too few patients to cover its costs risked compromising the quality of care, he said. Some maternity and paediatric units, which are very costly to run, might be merged or relocated, while A&E departments could be downgraded to minor injury units if they had a small number of serious cases that could be sent elsewhere.

“People need to know where they are making money or losing money. If you find a service where the income can’t cover the cost, you may eventually have to question whether the income is ever going to be sufficient, and whether this is in fact the wrong activity for the hospital.

“In quite a lot of places the number of births is too small to support the cost of giving a high-quality service. You have three choices: increase the flow of patients, move the service elsewhere or stay as you are and risk compromising the care.”

Mr Moyes, who oversees the regulation of finances and governance of England’s 125 flagship foundation trusts, said that as well as focusing on core departments, trusts would need to consider stripping out “uneconomic” facilities such as pathology laboratories and scanning units in some hospitals that were being used for very small numbers of patients.

“There may be surplus assets — buildings, land, equipment, stuff they think they might need in years to come under their development plans — and in some cases working in a much smaller physical space and disposing of all the hospital penumbra that can be brought into the main building.”

Mr Moyes said he had requested that foundation trust chief executives resubmit a “downside assessment” — stripping back their budgets — to get a more realistic grasp of the funding pressures they faced. He said that he was disappointed when, on being asked to revise their financial predictions in September, a number of trusts had resubmitted even more rosetinted forecasts of growth.

“You can’t assume everything will go well and if a problem arises the Department of Health will bail you out,” he said.

His warnings were echoed yesterday by Sir David Nicholson, the chief executive of the NHS, who described the coming years as “extremely challenging”. Giving evidence to the Commons Health Select Committee, Sir David warned of pay cuts and service reorganisation. “It is going to be very tough,” he said, adding that tighter budgets would mean the 1 per cent pay cap demanded by the Treasury would be treated by NHS managers as a maximum rise, not an entitlement. His comments came a day after inflation hit 2.9 per cent when unions are already angry over a pay freeze on council workers.

“There is essentially a trade-off between pay and numbers of jobs,” he told the committee. “In a cash-limited system, that is the big unknown for us. We need to talk through with the trade unions and staff associations about what that trade-off is.”

Sir David has previously warned that the NHS would have to find productivity and efficiency savings of between £15 billion and £20 billion over the three years 2011-12 to 2013-14.

The head of the Audit Commission added to the debate, saying that political pledges to safeguard spending on health and education were “insane”.

Steve Bundred told the Commons public administration committee that billions would have to be saved. “It seems to me absurd to imagine that the only services where no efficiencies can be found are those that have been the most generously funded for ten years,” he said.

Mr Moyes said he thought that an “unintended benefit” of future economic turbulence would be to heighten hospitals’ understanding that they had to operate with a robust business model.

“A lot of hospitals, even the very good ones, are at the stage of learning how to think long-term,” he said. “We are good at strong visions, big pictures, but we need to learn to be very good at pessimism and what will happen if things are not going to turn out well.”

From:

http://www.timesonline.co.uk/tol/life_and_style/health/article6997644.ece

NHS governance 'reduced to paper chase' - Audit Commission

Many NHS trust board members cannot be sure whether or not their hospital is operating within the law, the Audit Commission has found.

Formal processes to ensure boards can be certain legal and regulatory standards are met have been reduced to a “paper chase”, risking a repetition of the major failures at Maidstone and Tunbridge Wells and Mid Staffordshire foundation trust, it says.

Audit Commission chief executive Steve Bundred told HSJ the commission’s study, Taking it on Trust, was undertaken in the wake of concerns aired by the foundation trust regulator Monitor about the way boards were working at some applicant trusts, the high profile failures at a handful of NHS hospitals, and discrepancies between what trusts tell regulators about their performance and what inspectors find.

The commission studied governance structures and processes at 15 NHS trusts. It found an abundance of formal controls and processes designed to ensure non-executive board members could hold the trust to account on its performance.

But many of these had been reduced to a “paper chase rather than critical examination,” and had become “disassociated” from the day to day running of the trusts.

“The controls are in place. Everywhere we looked they were there,” Mr Bundred said. “But they are not always being operated as rigorously as they should. If boards don’t get this issue right then patients can be at risk.”

“We are not saying things are going wrong, but that things could be much better,” he added. “Mid Staffordshire and Birmingham [Children’s Hospital foundation trust] are examples where things did go wrong. Because they happened, it’s incumbent on all boards to ensure they are working effectively.”

“In some instances boards might not know where the weaknesses are because the controls they have in place to give them assurance are not working as they should.”

From:
http://www.hsj.co.uk/5000855.article

New Care Quality Commission watchdog quango pleads for patience

The new watchdog for health and social care called on politicians to put an end to a decade of regulatory turmoil in hospitals and social work.

The Care Quality Commission, which opened last week, is the third new quality regulator for health, and the fourth for social care, in only nine years.

"To lose one regulator is unfortunate, to lose two is downright careless - and to lose three would be pretty criminal in my view," said Lady Young, its chairman, in an interview with the Financial Times.

The new CQC opens its doors only weeks after Mid-Staffordshire hospital was granted flagship foundation trust status by one regulator, during an inquiry by another that revealed "appalling" standards of emergency care. The Baby P case last year, in which a young London child died after dreadful neglect, raised serious concerns about the regulation of social care.

Lady Young, a former National Health Service manager who came to the CQC from the Environment Agency, which regulates everything from car scrap dealers to nuclear power stations, said the new, combined watchdog needed time to prove itself.

"Good regulators develop a track record," she said. "We need a bit of time, 10 good years at least - preferably longer. Not for me but for the organisation", she said.

"Look at the Audit Commission . . . They have tackled a whole range of new jobs, they have been flexible, they have been adaptive and they have done a good job generally. They know how to do it. They develop a track record."

The new commission will be different, she said, not least because it will embrace both health and social care, along with the supervision of detained mental patients, in one organisation. Given the risks that more members of an ageing population will fall through the cracks between health and social care services, that had to be right, she said.

But, after the regulatory failure at Mid-Staffordshire NHS Foundation Trust, there will be other changes too, she said.

Mid-Staffordshire was granted foundation trust status by one regulator, Monitor, in the middle of the inquiry by another, the Healthcare Commission, one of CQC's predecessors, that found "appalling" standards of emergency care from which, the commission said, patients died.

As well as the two bodies failing to communicate, the hospital's services were rated "fair" - barely adequate but not dangerous - for two years during which, concluded the commission, patients had suffered and died.

A fresh data analysis technique to examine high death rates that will continue to be developed by CQC, eventually picked up the problem.

But as in the case of Baby P, where Ofsted rated Haringey's social services as "good" at the time the child died, "that does raise questions about the balance between clever use of data and inspection," Lady Young said.

"We need to get the balance right between data and inspection - and we will be out there sniffing the breeze, being on the ground and eyeballing staff and patients."

A good regulator is there "to nip problems in the bud," she said. A host of fresh data about the quality of care is on its way, which the commission will share, and which ought to make that easier.

But Lady Young warned against the current trend - "which is: when things go wrong, blame the regulator".

"We do need to highlight where responsibility lies for the provision of quality care," she said. First with doctors, nurses and care workers on the ground. Then with boards of organisations. And then with those who commission care and performance - manage the systems. The commission will provide independent oversight, information that will help address quality, and assurance, she said.

But "it will be a failure of the service if the management [does] not get to quality issues before we do".

From:
http://www.ft.com/cms/s/0/8f51dc0a-1e53-11de-830b-00144feabdc0.html?nclick_check=1

Only 14 pc of NHS Trusts give value for money

The National Health Service has tightened its grip on its finances, the Audit Commission said and is beginning to extract better value for money from its funding, but still has a long way to go.

Two years after the NHS in England recorded a £547m deficit, with local auditors highly critical of the level of financial control in many trusts, half of NHS organisations are performing well in their use of resources, the commission said.

But a mere 14 of the 300 NHS bodies surveyed achieved top scores in every category for the use of NHS money and some 20 - a significant minority of them in London - failed to reach minimum financial standards.

Improvements in the way the money is managed over the past year have been "impressive", Michael O'Higgins, the Audit Commission chair, said. "However, pockets of real concern remain. Poor financial management can put services for patients at risk," he added.

"The challenge . . . is to raise standards to those of the highest-performing organisations," the commission said.

The analysis covers hospitals, primary care and ambulance trusts but excludes NHS Foundation Trusts, which tend to include better-performing organisations and whose finances are overseen by their regulator, Monitor.

From:
http://www.ft.com/cms/s/0/cac9a900-901b-11dd-9890-0000779fd18c.html?nclick_check=1

Health Minister defensive over Cerner NPfIT NHS progress

When advisers to ministers write replies to Parliamentary questions they have no legal duty to be candid. Within reason they can say what they like. So for them answering written Parliamentary questions may be no more challenging than playing tennis with the net down.

Indeed, when asked about the NHS's National Programme for IT [NPfIT], ministerial advisers can use Parliamentary replies to make light of the concerns of clinicians and others. And this is what happened when Worthing MP Peter Bottomley put a question about Cerner sites to Ben Bradshaw, who's the latest in a series of ministers to be put in charge of the NPfIT.

Cerner's "Millennium" software will be used to help NHS staff administer hospitals and keep records on the care and treatment of patients. It's due to be installed at hospitals across London and the South of England as part of the NPfIT.

Bottomley asked Bradshaw what representations he'd received from clinicians in hospitals about Cerner Millennium go-lives. Bradshaw's reply in January 2008 suggested that clinicians are concerned only about things such as the number of keystrokes to carry out certain functions.

Bradshaw said in response to a question from Worthing MP Peter Bottomley:

"While Ministers have not received any direct representations, we are aware that users in the early deployments expressed some concerns about the system's management and statutory reporting functionality, and some of its usability features, for example the number of key strokes required for certain functions. Action has been taken to address these concerns and to enhance these areas. This is making a positive impact. Many users who have become familiar with Millennium over time have expressed satisfaction with the system."

There have been some successes with Cerner go-lives. Barnet and Chase Farm Hospitals NHS Trust, for example, now has near a real-time overview of when beds are vacant and where. The reality, also, is that at some hospitals where Millennium has been installed there have been protracted difficulties, not necessarily through any fault of NHS trusts or Cerner, or the local service providers, Fujitsu and BT.

The Audit Commision, in the latest annual audit report on Weston Area Health NHS Trust, referred to the implementation of what it called the Cerner National Care Records System. The Commission said that remedial work continued for months. It said:

"Significant problems with the implementation of the Cerner system have resulted in poor data quality and a lack of robust information...Weston Area Health NHS Trust was included within the first deployment of the Cerner National Care Records Service (NCRS) and implemented the NCRS system in October 2006.

However, it was soon recognised that the system was not providing the services required by the Trust and that significant remedial work would be required.Over the last nine months the Trust has been working with the suppliers and the SHA to resolve these issues..."

Bradshaw's reply gave no hint that an independent organisation such as the Audit Commission had deemed as "significant" problems arising from a Cerner implementation.

Bradshaw's answer did include statistics from Cerner sites including Weston. The system at Weston had 1,700 total users, 1,400 at peak times and an average of 450. Queen Mary's Sidcup NHS Trust had 2,050 total users, 170 at peak time and [only] an average of 50. Buckinghamshire Hospitals NHS Trust had a total of 880 users, 700 at peak time and an average of 450. But do statistics mean anything?

Buckinghamshire Hospitals NHS Trust went live with the Cerner Care Records System on 25 September 2006. More than a year later, in November 2007, the trust's board was told of some of the day to day difficulties. On the matter of keeping track of patients with MRSA and C Difficile, the Care Records System was "not working consistently" although Fujitsu, the supplier of Cerner's Millennium system in the South of England, was working on a fix.

The trust board was told:

"CRS - which is not working consistently Fujitsu are working on a fix for this. In the meantime a ‘belt and braces’ approach is being taken by the Infection Control team to ensure patients are not missed. There is currently no functionality in CRS for flagging patients with C. difficile. "

Last month Buckinghamshire Hospitals NHS Trust categorised the risk of the Cerner Care Records Service causing disruption to clinics, targets and workforce as "likely" to materialise, and it categorised the potential severity of the consequences as "major".

Avon, Somerset and Wiltshire NHS Cancer Services has said that "Current opinion regarding Cerner is that it will not support cancer data collection and reporting requirements for at least 5 years, possibly nearer 10 years."

And NHS South Central reported in November 2007 that "Deployment problems at those sites that have implemented the [Cerner] system has created concern amongst those organisations in the deployment pipeline. Regular communication is now taking place to rebuild confidence and keep organisations up-to-date with progress on the contract reset."

Health Direct Comment:

It has been said before but if ministers and officials continue to play down the problems of NPfIT implementations they'll carry on alienating clinicians and other NHS staff whose support they need to make a success of the programme. Ministers and NHS Connecting for Health, which runs part of the NPfIT, do not need to put the programme in a zoo enclosure marked "Say kind things only - this enclosure is for the worried and nervous".

This is the question asked by Peter Bottomley MP and Ben Bradshaw's answer:

Bottomley:

"To ask the Secretary of State for Health which hospital trusts have installed Cerner's Millennium system; on what date it was installed; which hospital trusts are expected to install the system and when; what the name is of the senior clinician on each hospital IT board; which Minister is responsible for the system roll out; what representations he has received from clinicians in hospitals using the system on their experience of using it; if he will ask a chief medical officer to consult clinicians using the system in (a) Kent, (b) Sussex, (c) Cheshire and (d) Buckinghamshire; and if he will update the figures provided previously in the answer of 23 July 2007."

Reply by Ben Bradshaw, Minister of State, Department of Health:

"Nine health communities have to date gone live with the Cerner Millennium system provided through the national programme ... In addition two London NHS hospital trusts, the Homerton University Hospital NHS Foundation Trust, and Newham University Hospital Trust, had initiated procurements of the Millennium system before the national programme. To date, some 2.7 million patient records have been entered in the systems currently in use.

"Four further trusts are currently expected to go live with the existing release (release 0) of the Millennium system by the early part of 2008. These are Taunton and Somerset NHS Trust in 2007, and the Royal United Hospital Bath NHS Trust, the Royal West Sussex Hospital Trust, and Barts and the London NHS Trust in 2008. Thereafter, release 1 of the system will form the basis for other implementations across both Local Service Provider areas in 2008-09 and beyond..."

"Details of clinical representation on bodies responsible for overseeing local implementation of NPfIT systems are not held centrally.

"While Ministers have not received any direct representations, we are aware that users in the early deployments expressed some concerns about the system's management and statutory reporting functionality, and some of its usability features, for example the number of key strokes required for certain functions. Action has been taken to address these concerns and to enhance these areas. This is making a positive impact. Many users who have become familiar with Millennium over time have expressed satisfaction with the system.

"From the inception of the IT programme relevant and experienced clinicians have contributed to the effective identification of requirements, design and testing of all systems wherever across the NHS these are being delivered. This continues to be the case. NHS Connecting for Health has appointed a chief clinical officer to lead the clinical engagement and clinical contribution to the programme."

From:
http://www.computerweekly.com/blogs/tony_collins/2008/02/minister-defensive-over-cerner.html

NHS deficits leading to quality divide for patients as red tape costs soar

A deepening divide is emerging between NHS organisations that are managing their finances well and the nearly one third that remain in poor financial health, the Audit Commission has warned.

A minority of about 27 organisations – including hospital and primary care trusts – are in such difficulty that according to Steve Bundred, the commission’s chief executive, “there appears little hope that they can get out of trouble by themselves”.

The commission’s report also provides the first firm figures on the cost of redundancies from the government’s decision to slash the number of strategic health authorities and primary care trusts – revealing that the average payout has exceeded £300,000.

The finding that the best performers in the NHS are opening up an ever-wider gap with those at the bottom mirrors the conclusion of last week’s “state of the nation” report from the Healthcare Commission on the NHS.

“There is a worrying gap between the top performers and those still failing to meet their duty to balance their books,” Mr Bundred said, in spite of the NHS’s surplus of £515m last year and forecast surplus of £983m this year. Foundation trusts are also sitting on cash balances of more than £1.3bn.

Its measures of quality showed high performance at the top end, a disappointing number of NHS organisations providing a merely adequate service, and big problems at the bottom end.

The worst performers on service quality were in general also the worst performers financially.

Mr Bundred said the NHS “needs to focus urgently on the management of this small group of NHS bodies that are failing across the board”.

Alan Johnson, the health secretary, has said the poorest performing hospitals faced being taken over by organisations that performed better. This has happened in Birmingham, where the Heart of England foundation trust took over the Good Hope hospital.

Meanwhile, the Commission reported that the bill for redundancies arising from health service reorganisation had so far amounted to £192m, with much more to come in this year’s accounts.

The average payout stands at more than £308,000. Some payments to individuals had been “significant”, the commission said, with some costing more than £500,000.

Savings from reducing the number of organisations amounted to only £90m of the £250m that the government had said the changes would generate, the commission said. It would be monitoring closely whether the savings were made, it added.

The health department has said the cost of job losses will amount to at least £320m. The Audit Commission noted that someone made redundant might be re- employed by the NHS after only four weeks. But it said it had not been possible to find out in how many cases this had occurred.

From:
http://www.ft.com/cms/s/0/b36e7de8-80f5-11dc-9f14-0000779fd2ac.html

Health Direct suggest that the Audit Commission is behind the curve in their calculations. On July 20, 2007 Health Direct posted: NHS manager's payout is nearly £1m

An NHS manager has been given a redundancy package worth almost £1 million in what was described as "a lottery win rather than a payout". David Johnson, the former head of a regional strategic health authority, was one of about 70 staff who left the organisation when it was abolished as part of a restructuring programme.

The 50-year-old received a package worth £899,810 including salary and pension arrangements. The reorganisation was supposed to save £250 million a year in administration costs. However, the NHS is thought to have spent at least £320 million on redundancy packages to those who have lost their jobs.