The unseemly collapse of Cambridgeshire and Peterborough’s older people’s services contract is another smoke alarm for the NHS and social care – and highlights the folly of putting highly complex care out to tender. The £800 million contract over five years sounds a lot until you realise it’s supposed to transform care for frail, vulnerable older people often with multiple diagnoses across England’s largest clinical commissioning group. The plan was to join up services and keep the neediest patients well and out of hospital (particularly emergency departments) – and to discharge those patients who neither need nor want to be in hospital more quickly.
Cambridgeshire and Peterborough CCG spent over a year and £1 million on ‘the tendering process’ with the help of assorted management consultants and NHS England’s Strategic Projects Team (SPT). Part of the payment for the contract was to be dependent on successful outcomes (such as keeping patients out of hospital). Several private companies looked at the deal and pulled out, and the tender was awarded to the NHS, or rather ‘UnitingCare’, a limited liability partnership established by Cambridgeshire and Peterborough Foundation Trust, and Cambridge University Hospitals FT. It began running services in April 2015 and 1,200 staff were transferred to the new employers. After 8 months UnitingCare and the CCG have terminated the deal as it is “no longer financially sustainable”.
Cambridgeshire and the SPT have form in calamitous tendering. When Circle pulled out of Hinchingbrooke Health Care Trust, at least it tried to explained its reasoning in public before passing the buck onto the CQC, but no detail has been given on the latest failure. NHS England is planning to roll out similar schemes with capitated budgets for entire populations and payment by outcome, but if the budgets remain absurdly tight and neither the commissioners nor providers have the financial nous or knowledge of complex systems to make it work, there could be a few more ‘de-tenders.’
One difficulty with outcomes based payments is that the ultimate outcome for all of us is death. It can be a gentle and welcome release or a very long, expensive and unpleasant process. Keeping death at bay is more to do with individual behaviour and life circumstance than health services. All providers of social care are struggling to give high quality care for the elderly on such a tight budget. The demands of paying for the living wage, pensions, travelling time, regulatory and training burdens, and the longer visits these patients needs makes it almost impossible to break even.
Debt and bankruptcy amongst social care providers could spell disaster for the NHS. There are currently more than 12,000 organisations, from big corporate chains to small family-run businesses, charities and social enterprises, fighting for custom. Less than 10 per cent of social care is now provided by councils or the NHS (long term care fell off the NHS with little debate under the Thatcher government). There are three times more care home places than hospital beds, and half a million people have home care services to be able to live at home. Many of these providers are in dire financial straits particularly the larger chains that rely on local authority funding.
The amount local authorities pay for this care has fallen 5% in real terms over 5 years. Many care homes now charge up to 40% higher for self-funding people to compensate for the shortfall in local authority funding. Others are simply refusing to accept state funded placements. Rumours abound that another ‘Southern Cross’ style failure of a big social care provider is imminent.
As with the NHS, there is a shortage of nurses and high spends on agency staff. In 2014, the Care Quality Commission found 20% of nursing homes did not have enough staff to provide good, safe care. The CQC also lacks the resources to pick up and close down rogue operators who keep re-registering under different names. The social care system has been underfunded for decades, and failed to keep pace with increasing life expectancy, frailty and dementia. In shifting social care to a private business model, both good and bad care homes go bankrupt in times of austerity. And now state providers in the new NHS market are pulling out of care for the most vulnerable and needy patients because the figures don’t add up. Those most in need of care are least likely to get the care they need. Without investing in social care, the NHS will be forever in debt. Happy New Year.
MD’s book, Staying Alive – How to Get the Best from the NHS – is available here