Divide and Rule – the Postcode Lottery of the NHS’s new Clinical Commissioning Groups

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May 25, 2013 by Protect Our NHS

Protect our NHS group sent in two written questions to the North Somerset Clinical Commissioning Meeting this month:

• In the light of the appalling cover provided by Harmoni’s Out Of Hours service, can the CCG reassure the residents of North Somerset that they have taken sufficient firm contractual precautions that the same issues of understaffing will not occur under the new BrisDocs’ contracts? Can they tell us what sanctions they have included in the contract against non-compliance?

• As the sale of the WGH has been announced by local media this week, when are the residents of North Somerset going to be consulted about the sale?

Although we assume that we will be sent written answers the verbal answers from the CCG board were… unsatisfactory.

One of our group who attended stated in an mail afterwards that:

Dear Steve,

Attended this afternoon’s meeting with Mike and Dani.

The patients who have suffered as a result of Harmoni’s shortcomings will be astounded that the North Somerset CCG declared itself, this afternoon, well satisfied with the performance of Harmoni. All is well as far as CCG is concerned. Because of the commercial sensitivity of the subject we cannot be told what penalties (if any) exist in the contract, but nothing in the conduct of the company has given the CCG any cause to (even) think about penalty. There are however a few points (we were not told what?) on which the CCG is working closely with Harmoni and others to improve the service to patients (which is first and foremost the aim of the CCG)

On Weston General Hospital we are to take comfort that both the Lay Chair and the Clinical Lead are involved with the subject. It is required that Weston Hospital becomes a “Foundation Hospital” (Why?) but it is financially in the red. The other hospital trusts in Bristol have not jumped in, so it may be handed over to a consortium running different departments. One lay member of the CCG interjected that the hospital is definitely not for sale. (the words no longer mean what they once meant)

We heard very long answers to every question, entirely made up of a string of platitudes. But no answer yet to why they cannot impose a 30 minute maximum response time to (the National Car Park) ambulances (all equipped with wheel clamps?) they have or are about to commission.

Yours depressed

Compare and contrast this negative and obfuscatory response with that from the Clinical Lead for Bristol’s CCG in his response to the written questions asked by the Group prior to Bristol’s last CCG meeting in May.

1. Contract specification and monitoring

The media are full of stories about poor performance of some services in some areas. In March this year the National Audit Office (NAO) published a report about the out-of-hours GP service in Cornwall which can be found at:


The NAO carried out a forensic examination of the failings of the service. Its main conclusions were that Serco, the provider, had regularly had insufficient staff to fill all clinical shifts, had not enough health advisers to handle incoming calls, and had incorrectly reported performance data.

Protect Our NHS would like to ask what steps the Bristol CCG is taking to formulate contracts for health services which protect the people of Bristol, and in particular to ask if contracts for health services include:

• Quantified staffing levels for all staff required for the service
• Detailed and, where possible, quantified performance targets
• Regular monitoring of staffing levels
• Regular monitoring of performance targets
• Penalties for contractual non-performance
• Penalties for fraud
• Protection of whistleblowers within the service provider

Finally please could you reassure us that the CCG will report publicly on any incidences of contractual poor performance or fraud.

2. Mental Health Services Recommissioning

Now that the Bristol Clinical Commissioning Group’s (CCG) Governing Body has formally approved a full procurement process to secure adult mental health services, we would like to ask whether the following will be included in all contracts:

1. Assurances on staffing levels
2. An appropriate clause which addresses revocation where services are not up to standard.
3. The level and quality of training to be included

3. Children and Mental Health Services (CAMHS) Lumsden Walker Unit

Is the CCG aware of the closure later this month of this highly regarded Tier 4 CAMHS? Who made the decision and what role does the CCG have in the future of CAMHS in Bristol? And was there any cost benefit analysis made of the impact of the closure on the future mental health needs of the most vulnerable young people in Bristol?

The written response, while it will not satisfy the critics who say that service users and staff were not adequately consulted with over the closure of Lumsden Walker Unit – and we will be challenging this response – has the huge benefit of being considered, thoughtful and unpatronising.

Dear Mr Campbell,

I am writing in response to your email sent to Bristol CCG on behalf of Protect Our NHS. The questions you ask in your email were also raised at out Governing Body on the 7th May and we agreed that I would write to you with a full response.
In your first set of questions you raised concerns arising from the findings of the National Audit Office report into the Cornwall Out-of-Hours service.

You ask what steps Bristol CCG is taking to formulate contracts for health services that protect patients in Bristol; you then ask if our contracts cover particular issues.

Bristol CCG uses the NHS Standard Contract; the web link to this is http://www.england.nhs.uk/nhs-standard-contract/ .

In certain circumstances we will specify in our contracts the type of staff and grade required to fulfil the contract, however in line with the NHS Standard Contract, we do not necessarily specify the level of staffing required. The NHS Standard Contract does contain a clause to the effect that providers must delivery the contract in accordance with general good practice and this encompasses staffing levels. As, in general, staffing levels are not specified in contracts, they are not routinely monitored as part of the contract review process. Where we have concerns about a service, whether about service quality or performance, we will include staffing levels in our monitoring meetings and ensure that remedial plans cover all actions required to improve services.

You ask whether our contracts include detailed and quantified performance targets and I can confirm that this is the case. We regular monitor with our providers both performance targets and quality indicators. As explained above where we have any concerns we will work with providers to ensure that remedial actions are put in place.

You raise in your email whether our contracts include penalties for non-performance and fraud. Again I can confirm that our contracts allow for penalties. You also ask about whistle blowing. All NHS organisations are required to have in place policies and procedures that protect staff who want to raise concerns.

You ask about our procurement of adult mental health services. We are designing the specifications for this procurement and our expectation is that the tendering process will address assurances about staffing levels and the level and quality of training, both important matters. Our contract will include penalties which we will invoke should performance not meet our required standards.

Finally you ask about the decision to close the Lumsden Walker Unit which provided specialised Tier 3 CAMHS for children aged 5-12 years old with complex emotional and behavioural difficulties. I understand that the service was available 3 days per week in term time. As part of a review of community based CAMHS North Bristol Trust, the service provider, has proposed a new service model to meet the needs of these children. I understand that they have consulted with staff and service users and discussed it with CCG commissioners. Although highly regarded, the Lumsden Walker Unit could only support a small number of children for a limited time and the need for such services is growing across the city. An assessment and therapeutic treatment service will continue to be offered through complex needs clinics in line with the 3 area CAMHS teams rather than from a single base. The service will look and feel different to current service users, however the service will be able to offer support to a larger group of children including some of the most disadvantaged who were not using the old service.

I hope that I have been able to give you a more detailed response to the questions you have raised. I am delighted that you and your colleagues continue to attend our meetings and I look to seeing you at our 4th June meeting.

Yours sincerely,
Martin Jones Chair NHS Bristol CCG

These two differing responses demonstrate the great dangers of this new NHS structure.

• It will lead to a fragmented and, therefore, more expensive service. Patients will suffer post code lottery delivery .
• It will allow political interference at a local level as ill-informed CCG boards make decisions in one region that a neighbouring region would hesitate even to consider.
• It will allow vested interests to fester.
• It will mean that in regions where public interest and participation is neither welcomed nor respected, the will of the public and the patients will never be properly reflected.

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