The Clarity of Commissioning

The Clarity of Commissioning

Clinical Commissioning Groups Freedom of Information

Data Sharing &

Out-sourcing of Contracts

Dr. Geoffrey A. Walker (2015)

The Clarity of Commissioning Dr. Geoffrey A.Walker 04/02/2015 1

Executive Summary 2 Introduction 3 1. Online Disclosure of Information 3 2. Freedom of Information 3 3. Key Findings and Analysis: Out-sourcing of Contracts 4 4. Summary and Conclusion Recommendations Notes References

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Contents


Executive Summary This report has surveyed the 11 CCGs in the North East of England in terms of online access to information, responding to Freedom of Information requests and out-sourcing of contracts. Online access to information is adequate but in need of some improvement. Responses to FoI requests are good but could reach a very high standard with some adjustments. Finally, the out-sourcing of contracts is an area of concern, however, the involvement of the private sector appears to be low relative to overall levels of expenditure for each CCG. Recommendations:

1. Access should be provided to a disclosure log which archives responses to FoI requests and this should be easily navigated from the homepage. 2. Responses to FoI requests which contain quantitative, financial or a combination of both types of data should be provided in an MS Excel spreadsheet format. 3. Aggregated data of out-sourced contracts should be published on CCG websites and should clearly show the type of contract awarded.


Introduction A previous report, The Transparency of Trusts, examined information sharing in NHS Foundation Trusts. Trust capacity for information sharing, in this report, was found to be quite poor in a number of cases. Information and data sharing in Clinical Commissioning Groups (CCGs), however, examined in this report, is demonstrated to be considerably more appropriate and effective. CCGs are clinically led groups that include all of the GP groups in their geographical area. The aim of this is to give GPs and other clinicians the power to influence commissioning decisions for their patients. They are overseen by NHS England (including its Regional Offices and Area Teams). These structures manage primary care commissioning, including holding the NHS Contracts for GP practices. Each CCG has a constitution and is run by its governing body. Each has to have an accountable officer responsible for the CCGs duties, functions, finance and governance. Most CCGs initially appointed former PCT managers to these posts. Only a quarter of accountable officers were GPs in October 2014, but 80% of CCG Chairs were GPs. However, only half of GP practices said they felt involved in CCG decision-making processes (Health Service Journal 2014). For the purposes of this report, CCGs, in the North East of England, were given a single information request which they responded to in a systematic and timely manner. Follow up queries, on some information were also responded to in a similar way. MS Excel was used to analyse responses and produce the figures used in the report. The report is divided into 4 sections:

1. Online Disclosure of Information: including details of publication schemes and disclosure logs. 2. Freedom of Information: including details of FoI requests, their processing and responses. 3. Key Findings and Analysis: Out-sourcing of Contracts: including details of out-sourced contracts. 4. Summary and Conclusion: including recommendations for improving services.


1. Online Disclosure of Information All 11 CCGs provided access to a publication scheme: a requirement of the FoI Act (2000). However, only 7 provided access to a disclosure log of FoI responses. Disclosure logs did not adhere to a standard format and, in some cases, were not clearly tagged as to what information was disclosed. Responses to FoI requests for organisational information should be accessible in full and this was not the case. The tendency is to make reference to the nature of the request and response and not publish the actual response.

2. Freedom of Information 2.1. Freedom of Information Requests All 11 CCGs, in the North East, were asked the following question, on the 1st of December 2014:

Could you please provide me with a list of all health service contracts allocated in the financial year 2013/14? This list should contain the following details: 1. Specific service provided 2. Name of contractor 3. Date contract commenced 4. Total value of contract awarded

The speed of response was exemplary with all requests replied to within 15 rather than the prescribed 20 days allowed under the Freedom of Information Act (2000).

2.2. Processing of Freedom of Information Requests Freedom of Information requests in the North East and Cumbria are processed by the Information Governance Unit, part of the North East Commissioning Support Unit (NECS). Their headquarters are located in John Snow House, Durham University Science Park, Durham, DH1 3YG. Their website address is: http://www.necsu.nhs.uk/ NECS is one of the largest Commissioning Support Units in the country with annual revenue of 62million. According to their Annual Report for 2013/14, they are:

a new NHS business created in the first instance to help support health and social care organisations across the North East and Cumbria to commission the services they require to best meet the needs of their individual communities.

They claim to possess a sound knowledge of the field that is underpinned by practical delivery of all relevant legislative obligations, NHS Codes of Practice and regulatory requirements that are expected of a high performing information governance function within health care as well as experience of using the Information Governance (IG) toolkit [1].

2.3. Quality of Responses The question was responded to, in full, by all the CCGs. A minority were received in Excel; the majority in PDF format. For purposes of analysis, it was necessary to converts responses received on PDF to Excel. Response times to follow up queries on individual elements of expenditure were rapid and detailed. In some cases, extra detail was provided that was not necessarily requested.


3. Key Findings and Analysis: Out-sourcing of Contracts CCGs offer a range of contracts for out-sourcing services relative to the type of service and the provider [2].

3.1. Number of contracts awarded The total number of out-sourced contracts awarded to the 11 CCGs in the North East during 2013-2014 was 532. Durham Dales awarded the most contracts (106) and Northumberland and South Tees the lowest (26 each). North Durham also has a higher number of contracts than other CCGs: 98.

Figure 1: CCGS by Number of Contracts Awarded

3.2. Value of contracts awarded

The total value of out-sourced contracts, in 2013-14 was in excess of 2 Billion at 2,046,000,000. The highest expenditure was recorded by Sunderland CCG (303,000,000); the lowest in Newcastle East (105,000,000).

Figure 2: CCGS by Value of Contracts Awarded (000,000)

3.3. Expenditure on out-sourced contracts as a percentage of total expenditure

Total expenditure on out-sourced contracts as a percentage of published expenditure, in Annual Accounts for 2013/14, is, on average, 16%. Expenditure ranges from 6% in Northumberland to 26% in Durham Dales.

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Figure 3: Expenditure on out-sourced contracts as a percentage of total expenditure

3.4. Comparison of contracts by number and value

There appears to be no correlation between the number of out-sourced contracts and the total value of these contracts. As expected, CCGs contracts range widely, in terms of value. In Sunderland, for example, contracts awarded range from 1,000 to 171,513,375. The latter figure represents the amount the Trust awards to City Hospitals, Sunderland for acute services in the form of a grant agreement. As such, although, technically out-sourced it cannot be considered as a direct payment to the private sector. This is a similar agreement which is in place for all the CCGs in the North East.

Figures 4: Comparison of Contracts by Number (N) and Value (000,000)

3.5. Contracts with NHS Trusts

Out-sourced contracts with NHS Trusts represent the largest proportion of expenditure on external contracts. Four CCGs recorded expenditure in excess of 200,000,000 (see below) while one recorded expenditure of only 75,000,000 (Newcastle North and East). Expenditure attributed to NHS Trusts is largely for a wide range of acute services and the higher the median range of the age of patients the higher the expenditure. Newcastle North and East shows one of the lowest

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median age ranges of any CCG in England at 31.7 (Office for National Statistics 2013). This may account for the relatively low level of expenditure on acute services.

Figure 5: Contracts with NHS Trusts (000,000)

3.6. Contracts with Spire Healthcare plc, Ramsey Healthcare and Nuffield Tees

Spire Healthcare plc is the second largest provider of private healthcare in the United Kingdom after BMI Healthcare. Spire Healthcare was formed from the sale of Bupa Hospitals to Cinven in 2007, followed by the purchase of Classic Hospitals and Thames Valley Hospital in 2008. It is listed on the London Stock Exchange and is a constituent of the FTSE 250 Index. It is currently engaged in a significant financial relationship with CCGs in the North East to the value of 7, 096,000. Its hospitals are displayed as an option in the choose and book scheme. Under choose and book, patients have the right to choose which hospital provider they are referred to by their GP. This legal right, which was introduced in April 2009, lets patients choose from any hospital provider in England offering a suitable treatment that meets NHS standards and costs. Patients can choose which hospital they are seen in accordance with what matters to them most, whether it is location, waiting times, reputation, clinical performance, visiting policies, parking facilities or other patients' comments. A choice of hospital is available for most patients and in most circumstances. Exceptions include emergency and urgent services, cancer, maternity and mental health services. If you need to be seen urgently by a specialist (for example, if you have severe chest pain), your GP will send you where you'll be seen most quickly. David Gallagher, Chief Officer of Sunderland Clinical Commissioning Group, has said, the provision of surgical services from Spire and other independent sector providers is essential in helping patients achieve their constitutional rights of treatment within eighteen weeks. [N]

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Figure 6: Contracts with Spire (000)

South Tees CCG also made significant payments to the private sector for acute services: Ramsey Healthcare: 3,456,574 Nuffield Tees: 2,149,045 A total payment of 5,605,619 in the financial year 2013/14.

3.7. Contracts with Specsavers Ltd

Six CCGs, in the North East, have contracts with Specsavers, largely for hearing aids. The total value of these contracts is 1,530,000. As part of the NHS package, Specsavers provide a free hearing test with a qualified hearing aid professional. They arrange follow-up appointments, without further visits to your GP, and make sure that the hearing aids are working effectively. All aftercare, including necessary battery replacements, is included in the NHS package. Mathew Gully, director of hearing at Specsavers, said the company is dedicated to understanding, responding and meeting the clinical and commissioning needs of GPs. Doug and Mary Perkins, the co-founders of Specsavers in 1984, are said to have a personal wealth of 1,150,000,000.

Figure 7: Contracts with Specsavers (000)

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4. Summary and Conclusion This report has surveyed the 11 CCGs in the North East of England in terms of online access to information, responding to Freedom of Information requests and out-sourcing of contracts. Online access to information is adequate but in need of some improvement. Responses to FoI requests are good but could reach a very high standard with some adjustments. Finally, the out-sourcing of contracts is an area of concern, however, the involvement of the private sector appears to be low relative to overall levels of expenditure for each CCG.

Recommendations 1. Access should be provided to a disclosure log which archives responses to FoI requests and this

should be easily navigated from the homepage. 2. Responses to FoI requests which contain quantitative, financial or a combination of both types of

data should be provided in an MS Excel spreadsheet format. 3. Aggregated data of out-sourced contracts should be published on CCG websites and should clearly

show the type of contract awarded.


NOTES 1. The IG Toolkit is an online system which allows NHS organisations and partners to assess themselves against Department of Health Information Governance policies and standards. The toolkit is a product of the Information Governance Alliance (IGA) The IGA is a group of national health and care organisations that are working together to provide a joined up and consistent approach to information governance. The core members of the IGA are the Department of Health, NHS England, Public Health England and the Health and Social Care Information Centre. The IGA aims to improve information governance in health and care by: Providing a single authoritative source of information and guidance Providing suport to front line staff, managers and their organisations to help them handle personal information confidently and in the best interests of people who use their services Developing the capacity and capability of the information governance profession by providing expert advice and a knowledge sharing network 2. Types of service contracts: Alternative Provider Medical Services (APMS): APMS provides the opportunity for locally negotiated contracts allowing CCGs to contract with non-NHS bodies. Any Qualified Provider (AQP): is a means of commissioning certain NHS services in England. CCGs determine the services to be commissioned as AQP. The declared intention is to increase patient choice. All providers must meet the qualification criteria set for a particular service and once qualified their service will appear on choose and book for patients to select. NHS Standard Contract (NHSSC): is mandated by NHS England for use by CCGs for all contracts for healthcare services other than primary care. Other types of agreement: Service Level Agreement (SLA): is where a service is formally defined. Particular aspects of the service - scope, quality, responsibilities - are agreed between the service provider and the service user. A common feature of an SLA is a contracted delivery time. Grant-aid: is awarded to the voluntary sector, who, in return expect to operate with a level of independence in service delivery. 3. A view expressed in a personal letter from David Gallagher to Bridget Phillipson MP (23/12/2014).


References Health Service Journal (2014) Online at: http://www.hsj.co.uk/ Information Commissioners Office (2000) What is the Freedom of Information Act Online at: https://ico.org.uk/for-organisations/guide-to-freedom-of-information/what-is-the-foi-act/ Office for National Statistics (2013) Statistical Bulletin Online at: http://ons.gov.uk/ons/publications/index.html

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The Clarity of Commissioning