NHS getting ready for another procurement scrub

I found the news in today's Financial Times that the NHS is in talks regarding the future of Commissioning Support Units an interesting brain teaser - what would I do?

The 19 CSUs were set up last year to support the Clinical Commissioning Groups (CSGs) in designing health services, providing back office computer services, payroll and procurement services. Now NHS England is considering the options for their future. Yet, it appears it's the CSUs who have to decide on their own future - how will that work and what freedom will they have to plough their own furrow?

Anyway, it does seem strange that there wasn't a clear strategy when CSUs were set up as opposed to 19 CSUs starting to deliver services and then debating their future so soon.

The usual outsourcing organisations could bid for all or part if the services, but is the current environment (e.g SFO now probing tagging contract) likely to be conducive to productive discussions when the government seem to lack confidence in so many of the providers and also the ability to successfully contract manage?

Alternatively, could the CSU services be provided through the contract let recently for government shared services? That may be difficult since it didn't appear to be in scope. One could of course ask why it hadn't been included in the scope?

Could the Crown Commercial Service provide the procurement aspects? It seems odd that the CCS would allow independence of such a vast amount of spend so early in its life, but then again why haven't they been providing the procurement services up until now, and if they have, have they failed to win over hearts and minds?

Should the NHS aim to let one job-lot contract for the whole of the 19 CSUs and, if so, how will they shape the contract? If NHS England went down that route, how would they avoid being held hostage to the provider? How would they gain the ownership of the CCGs?

Could each of the CSUs become a centre of excellence and each deliver a specialist shared service to the others, say one CSU leading on payroll and another on procurement?

If theoretically it was possible for CSUs to become centres of excellence, with the sole aim of supporting CCGs, why couldn't the CCGs 'cut out the middle men' and just agree among themselves which of the CCGs would become centres of excellence?

Would my position be different depending who I was advising? Well, I think to be honest, if I were in a CSU or one of CCGs, my inclination may well be to let all the others sign-up to a central deal and then use that as the starting position to get better deals from those who were unsuccessful in winning the main contract. When you compare the classic Prisoner's Dilemma scenario doesn't it sometimes make sense to actually avoid collaboration and standalone in procurement?

Well, it gave me something to muse on during this morning's flight in the absence of the facts - what would you recommend?

A very public negotiation

Last week I suggested we were seeing brinkmanship in the NHS between ministers and GPs. Today, the next hand appears to have been dealt with the announcement that GPs can expect to see an increase in their ranks of 2,000 by 2018.

Needless to say the Royal College of General Practitioners applaud this announcement:

If we have more GPs able to spend longer with patients and communities then we can adapt to meet the needs of the 21st century.

Let's try to deconstruct the Royal College's justification. If GPs are more involved in CCGs how will they be able to spend more time with their patients? Indeed why wasn't this issue raised when CCGs were first grasped with open conflicts of interest? Are the Royal College seriously arguing that GPs are unable to adapt to the 21st century without an increase in numbers? Other public service providers are expected to adapt with lesser numbers and greater use of digital. Indeed is it not the case that there is greater self-diagnosis of potential GP door-steppers using web-based sources. Are the Royal College really justifying the case for GPs, and I assume their own longer-term negotiating power.

On the other hand, will the Department of Health question that rationale and why the Royal College haven't taken responsibility for ensuring GPs have been adapting to the 21st century? Will the DoH ask for evidence of impact? In this game of brinkmanship, surely the DoH should have used those levers earlier in the game?

However, if I was in the Royal College, I'd say thanks and wait for the next offer - DoH want CCGs to succeed and politicians will want a good NHS story as they approach the next election.

Fortunately this negotiation is appears to being played out in the public domain - we can all watch and learn.

Brinkmanship at the NHS

I've been discussing Clinical Commissioning Groups and the various twists and turns for some time - there's no denying they're turning into one of those procurement case studies which just keep on giving.

A very quick summary:

1. In 2004 the government negotiated, what is widely viewed as, a bad deal with GPs. The GPs got more money and were able to opt out of providing an 'out of hours' service.
2. GPs involved with CCGs expressed concern that they lacked the skills to handle the procurement aspects for CCGs.
3. NHS Guidance on procurement appears flawed and has to be rewritten just as it is required.
4. CCGs are identified as having clear conflicts of interest within procurement.
5. Demand on A&Es increases as a result of the systemic displacement from GPs opting out of providing 'out of hours' services.
6. GPs say patient care is suffering through the need to be involved in CCGs.
7. GPs are viewed as 'badies' and ministers hope to renegotiate the 2004 contract.   
8.  GPs trade union are threatening a withdrawal of the NHS' flagship Clinical Commissioning Groups. 

I'm sure there's no suggestion that GPs have less to gain through CCGs since the conflicts of interests were highlighted. Nor, I'm sure, is there any connection between the suggestion that the GPs contracts should be renegotiated by ministers and at the same time CCGs are precious to ministerial aspirations for the reform of the NHS.

You could of course view the whole thing as a shambles. But then again you could say it's just brinkmanship. It does have the appearance that one side is better at negotiation than the other though. 

"NHS tendering 'a threat to patients' "?

I suspect many of you will not have access to today's Times but it has  a fascinating letter from Dr Hilary Cass (President, Royal College of Paediatrics and Child Health), Prof Sue Bailey (President, Royal College Psychiatrists), Dr Clare Gerada (Chair, Royal College of General Practitioners) and Prof Lindsey Davies (President, Faculty of Public Health).  Yes, the sort of people who you may be inclined to listen to if you were not deaf.

Their letter includes:

... we are concerned that Clinical Commissioning Groups will be forced to open services to competition against their will - creating an unnecessary bureaucratic and financial burden on commissioners, and unnecessary drain on vital NHS funding. There is also a real danger that the enforced tendering of one service may damage another independent service in a different part of the same organisation or care pathways which are key to providing high-quality healthcare to thousands of children and mental health patients every year.

We urge the Government to think again about how the section75 regulations are framed and their potential consequences. We want to see a full debate in Parliament and engagement with the Medical Royal Colleges and health professions to ensure these regulations are redrafted in the best interests of patients.

That's a fairly clear statement to the effect that key stakeholders have yet to be convinced on the way forward.

I have no reason to doubt the NHS procurement staff who, for many years, made clear that helping clinicians engage with professional procurement has been a major challenge; indeed many consider gaining their ownership of procurement initiatives the equivalent of winning an Olympic Gold.

Are these medical luminaries fighting against the changes as they see the erosion of their own vested interests or is patient care their sole motive? Are these very clever people, who appear to have resisted all forms of NHS reform, just creating yet another filibuster?

NHS Commissioning looks poorly

I had thought we had done away with public flogging but today's Public Accounts Select Committee certainly gave me cause to doubt that. What was even more bizarre was that some of the witnesses appeared to be wearing self-written sandwich boards which said "I haven't really prepared for this grilling and I don't plan to demonstrate any humility today and certainly not accept personal accountability".

It was a gruelling session for all those involved and the patience of the MPs seemed to be sorely tried - I may return to some of the evidence in more detail. Four points though are worth reflecting on and one worth discussing:

1. Hospital consultants appear to have negotiated wonderful contract which led to being paid more and being less productive. 'Pay more for less' just isn't that best outcome for a buyer from a negotiation.
2. The reason why we are 'paying more for less' is, believe it or not, being a consultant has become more complicated in the last decade. I'm sure that's not what they meant to say but they made a point of reiterating that argument.
3. There was great play made of the presence of annual plans for clinical consultants. The committee appeared to struggle to understand why their presence alone was worthy of credit while the lack of an associated performance management system.
4. There is a need to really understand what you have authority to do - our friends seemed unsure whether Treasury Guidance, because it had been around for some time, still needed to be adhered to.

However, there was another strange twist in the Clinical Commissioning Group saga, now we find "Commissioners should only use competition where there is evidence it works". I would have liked the Committee to have been more probing on this statement and what the guidance will say. Given the conflicts of interest we discussed on Friday this does not strike me as a good foundation for achieving value for money:

• What will be acceptable evidence that competition works?
• What incentive would there be to try to prove competition works?
• Will it be possible for potential challenges that 'competition doesn't work'?
• What incentives will there be to ensure that those who have demonstrated poor negotiation in hospital consultants' contracts will be able to negotiate contracts without competition? 

It is certainly is an interesting precedent to set and one which I am sure others will crave for. Why on earth did the Public Accounts Committee let that pass?

Conflicts in Clinical Commissioning Groups

I overheard a discussion on the Thursday morning' s Today programme which made reference to BMJ published research suggesting one in three of GPs involved in the new CCGs have a conflict of interest - I couldn't access the report but you can read more here. The actual expenditure at stake is £62bn.

Last week I discussed the chaotic nature of how new commissioning rules are being cobbled together inside a month.  We also know from Ben Goldacre's excellent Bad Pharma that, in spite of self-professed business acumen and nous, GPs are not immune from the wily salesman.

The NHS Code of Conduct, insofar as procurement is concerned, implies that it is okay for those who have declared a conflict of interest to participate in discussions but be excluded from the decision making. To me that is insufficient and needs to be significantly strengthened during the rewrite to the new procedures to ensure that those who have a conflict of interest absent themselves from any related discussion and, any perceived undue influence in the procurement process is treated with sufficient seriousness to act as a deterrent.

We know procurement fraud costs money, we know there is a lack of personal accountability, we know the Code is weak, we know there are a lack of skills - what we don't know is how big a scandal some of those involved in CCGs could be walking into out of ignorance.

This change management process does not inspire confidence - anyone aware of the risks having been assessed?

P.S. Sunday Times 31 March 2013 headline, 'GPs' Private Firms Grab NHS Cash' , now there's a surprise (not).

PPS in a later blog I expand on this and suggest where conflicts could arise.

Unhealthy diagnosis for NHS commissioning reform

The NHS chief publicly begs for his job arguing that he didn't make any mistakes but has learnt from his mistakes. Then, because he made a promise to lead the NHS reforms two years ago he justifies that he should be allowed to stay, whether or not he was paid to be personally accountable for needless deaths and misery. It is also clear that there has been no succession planning - quite simply, he implies, with the Prime Minister's endorsement, there is no one else in the whole world would could oversee the NHS reforms.

As if we were in any doubt about Nicholson's view of the world, the efficiency element of the reforms is named the Nicholson Challenge. Not that I would want to cast doubt on the effectiveness of the man's leadership, but it appears even the delivery of Nicholson Challenge is challenged.

So just as we learn that there is an indispensable man leading the NHS reforms, and recognising that the efficiency strand delivery is questionable, and with less than four weeks to go before the new commissioning regime kicks in, we also learn that the commissioning rules need to be rewritten.  After all this time discussing the commissioning reforms is it really conceivable that a sprint rewrite will be a good job.

We have one person at the top of the pile with a history of losing focus (his own admission) and new commissioners who now discover the rules are being rewritten.

So all the ducks seem lined up for an almighty mess. Change management case study ready and waiting - pity we all look set to suffer. I wonder is anyone identified as personally accountable?

Bad Pharma - procurement book review

I suspect that Ben Goldacre's 'Bad Pharma' would not immediately come to mind as a recommended procurement read. Let me correct that misconception. While the book is primarily about the pharmaceutical industry, it has a sub-plot of market manipulation of buyers. It highlights how sales-forces, conferences, professional bodies, advertisements, magazine articles, and even academic journals are used to manipulate, within strategic marketing plans, to deliver sales. It is a book which should be read by every procurement manager, regardless of industry - all those who touch the edge of procurement decision making need a healthy level of scepticism, if we are to deliver the best deal. If you are in doubt about its relevance, then I would ask you: 'how have you have formed opinions about the percentage savings anticipated, the basis for selecting some procurement solutions, and the judgements on perceived 'best practice?'

However, the book, like Goldacre's earlier 'Bad Science', should also be on the reading list of anyone undertaking research or involved in the peer review process. I have no doubt that rigour, reliability and validity in research would be improved. A good thing all round.

On the downside

Doctor in Commissioning

How long has GP commissioning been argued about?  How long has it been implied that GPs and their group practices could take on a wider commissioning role with assumed procurement expertise?

Today we hear that GPs have a tendency to hand out anti-depressants too hastily.  Meanwhile I'm reading Ben Goldacre's excellent book on Bad Phama which suggests that decisions by GPs are frequently distorted by skewed information from journals and the market which shape their decision making.

To me these are both indicative of poor procurement practice and, to use a widely used medical term, question the efficacy of GP commissioning. Why?

1. Good procurement is concerned with seeking out that best whole life cost solution.  Prescribing  drugs unnecessarily doesn't sit well with that as it suggests a narrow options appraisal, a lack of Whole Life Costing for patient, the NHS and even the GPs surgery;
2. Good procurement is about challenging potential requisitioners (patients) and whether there is need to consume (buy), albeit via the NHS, anything at all;
3. Good procurement is about ensuring the best possible unbiased search of the market and avoid being swayed by the marketing (see Goldacre's analysis of the existing pharma marketing).

The pursuit of GP commissioning may well be on a sound foundation of trying to get as close to the patient needs as possible, but there are some fairly basic procurement principles which need to be more generally practiced too.

Now, since it's the weekend a loosely relevant good ol' YouTube: