Essential insight into England’s biggest health economy, by Ben Clover

Stop reporting, bring down huge backlog?

No one really wants to talk about competition at the moment, but it’s not gone anywhere.

NHS Improvement this month released some documents London Eye had asked for under the Freedom of Information Act.

They relate to a strange procurement case I have written about before in northeast London.

The documents reveal a pretty stern judgment of the clinical commissioning groups’ processes, one disturbing fact and some insights into how Monitor (reminder: it still exists) looks at competition cases.

Disturbing fact first. Care UK complained that the northeast London CCGs had not given sufficient weight to the quality problems at Barking, Havering and Redbridge University Hospitals Trust when they awarded it the contract rather than the private provider, which was the incumbent.

The problems were set out at length in the Care Quality Commission’s report of 2013, two years before the procurement.

These problems were well documented. HSJ reported in March this year that BHRUT had discovered more than 1,000 elective patients who had waited more than a year for treatment.

This dwarfed the national total for the month, but it now turns out that wasn’t the whole story. Part of the evidence considered by NHSI/Monitor and released this month said that “trust data submitted in November 2014 indicated 2,202 cases” where patients had waited more than a year.

This is the largest number yet seen for year-plus waiters.

BHRUT stopped reporting its elective waiting times nationally in February 2014. It put the total of year-plus waiters at 1,015 for February 2016.

Trusts sometimes stop reporting their waiting times data because of validation problems. Happily it can also mean the full extent of their 52-week backlog remains unknown.

How large could the total have been in February 2014?


Irony fans have already found much to enjoy in this case (private provider Care UK accuses an NHS commissioner and provider of seeking to introduce price competition and lower quality).

But the CCGs’ defence of a sub-tariff offer made by BHRUT was that the work carried out at the North East London Treatment Centre was less complicated than the average and it would save the local health economy money to reflect that.

NHSI/Monitor rejected this.

Without producing masses of evidence the competition regulator’s preliminary findings said that the concerns about BHRUT’s governance and theatre management ought to have led the CCGs to reject any kind of lower quality specification.

But the CCGs weren’t proposing to lower the quality specification, just to pay a lower price for the existing casemix.

NHSI/Monitor did not censure the CCGs for their overall approach of weighting quality and finance issues evenly – something Care UK had said was unfair.

Instead the regulator said the CCGs should have had more regard for the quality issues raised in the CQC’s report.

This is a point worth bearing in mind if you’re involved in a local procurement – has a provider been beaten up by the CQC recently?

NHSI/Monitor were also tough on some of the processes used by the CCGs. Processes London Eye suspects might apply more widely than just northeast London.

Insufficient justification was given for some of their scoring. Also, Care UK seems to have been disproportionately punished for not mentioning child safeguarding after commissioners proposed a paediatric ENT service.

It seems the CCGs wanted the place, set up as an ISTC (Independent Sector Treatment Centre) in 2006, to be run as an ISTC – high volume, lower complexity, lower cost.

This might have helped the health economy get on top of the backlog problems that saw them record 2,202 year-plus waiters (and maybe more).

But NHSI/Monitor concluded: “Based on the available evidence, at this stage our preliminary view is that the CCGs have not complied with the principles for local [tariff] variations.”

The CCGs failed to show that they had taken into account the CQC’s quality concerns in the reduced tariff considerations, the regulator said.

Competition may soon be making a come-back in NHS policy, and the implications for commissioner and providers are worth bearing in mind.

Would the northeast London CCGs have had a better chance of getting away with it if they had been in a sustainability and transformation Plan at the time? Would anyone dare challenge a plank of an STP that had been centrally approved?

London Eye features a look at what’s going on in England’s biggest health economy. London has the best and worst regarded hospital trusts in the country. It has excellence and dysfunction in commissioning and primary care. I will cover all of this.

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