£20bn for the NHS? – not spent like this please

Johnathan Lewis, CEO Capita (right) and Simon Stevens, Chief Executive, NHS England (left) at Monday’s Public Accounts Committee.

By Tony Collins

Capita apologies for working “blind” on NHS outsourcing contract – but no humility from NHS England

Capita’s CEO Johnathan Lewis was contrite and authoritative when he appeared before public accounts MPs in the House of Commons on Monday.

He apologised unreservedly for what the committee chairwoman Meg Hillier called “a shambles”, which was Capita’s £330 seven to ten-year contract to run a range of services for GPs, dentists and ophthalmologists, as well as handle invitations and test results for cervical screening.

Capita’s Primary Care Support Services contract began in 2015 and complaints about the service from medical practitioners began to flow months later.

Capita made mistakes, said Lewis who was supported by his colleague Stephen Sharp, who reports directly to Lewis on public sector contracts. One mistake was that Capita tried to save money too soon by folding the work of 47 local NHS offices with 1650 staff into three offices without fully understanding that each office had a different way of working and a different way of delivering NHS services.

[A similar mistake helped to floor the £10bn National Programme for IT in the NHS (NPfIT), where suppliers and Whitehall officials tried unsuccessfully to use computers to standardise working practices and services in hundreds of hospitals before they fully understood the widely-different approaches of each hospital.]

Lewis told the Public Accounts Committee on Monday,

“This was an extremely complex outsourcing of services that I think both parties would recognise were not fully understood when the work was outsourced – the volumes, the scope, the fact that the service was being delivered in different ways across the different regions that became NHS England. At the same time I recognise the pressure NHS England were under to reduce costs and hence the pressure on them to outsource.”

His colleague Stephen Sharp added,

“I think mistakes were made. During the bid stage, NHS England did say there were some inconsistencies and differences within the various operations. But once Capita got into all the offices and looked at it, the inconsistencies and differences were not inconsequential. It was more or less 45 different services being run from 45 different offices, so the closure programme, which we adhered to and carried on with, we maybe should have stopped. We just made the problem worse as we went along.”

Why didn’t you stop the office closures, asked Conservative MP Anne Marie Morris who added that “even the NHS said, ‘We think you need to stop’.”

Sharp replied,

“We were actually working blind for a period of time. It was only once the service had been running under our control for a few months that complaints started to come in and we started to see visibility that there were bigger issues than we thought there were.”

With hindsight he said he would not have closed offices “until we had got the procedures operating on a national basis”. He conceded that if NHS England and Capita had deferred closing offices, the first two years of savings of about £60m would not have been achieved.

Capita’s losses of £140m

Lewis said that Capita had invested £125m in the contract but, given the loss of profit margin, the losses would be closer to £140m. “We will not make money over the life of this contract,” said Lewis.

An MP asked: why not walk away?

Lewis replied, “Because we made a commitment to deliver this service and reputations depend on that commitment. We see the public sector as a segment of our market that helps us achieve a diversified revenue base. It is a segment where we have services and solutions, where we can create value for the taxpayer and that is why it is an attractive segment.”

Capita is now meeting 41 of the 45 KPIs and, though the company is making good progress against the remaining four KPIs, it doesn’t change the fact that “our initial execution on this contract was not good and for that we apologise unreservedly,” said Lewis.

There were failings on the part of NHS England too. Health officials were so anxious to achieve the savings from closing offices and replacing old IT that couldn’t be relied on that they failed to test new national, standardised working practices and services before they asked a supplier to implement this strategy.

The result was that officials at NHS England had no clear idea of how much work they were outsourcing. They left due diligence to Capita; and Capita admitted at the hearing it did not do enough due diligence at the bid stage. If it had understood how much work was involved it would have bid a higher price or not bid at all.

NHS England also failed to involve most of the potential end-users – GPs, dentists and ophthalmologists in the design and planning of new services that would directly affect them such as pensions and payments.

Lewis said.

“There are other stakeholders that have historically not been brought into this process to the extent that they should have been, such as the BMA [British Medical Association] in how we might implement the digitisation of pension payments and the management of its pensions, or the Confederation of Dental Employers with regard to ophthalmic payments.

“We want to bring them into the process in ways that they have not been historically because we think that that will ultimately lead to a more successful roll out of the technology… They rightly have influence over the process. If we are going to roll out a process for digitising the 20,000 paper documents that cover the process by which you get refunded for an ophthalmic prescription today, surely those people need to be involved in the final roll-out and configuration of that solution.”

Absence of humility?

When MPs questioned the top official at NHS England, Simon Stevens, there was little sign of humility, contrition or regret. He left an impression that the same problems could end up being repeated by a different supplier under a different contract. One Conservative MP Bim Afolami found himself “sticking up for Capita”.

Afolami said,

“Do you feel, Mr Stevens, that criticism of this contract is in any way unfair on Capita? The more I hear, the more I feel that Capita has taken the sharp end of this and NHS England, despite slight reputational difficulty, has saved £60 million. To what extent do you feel that you should take more of the blame here and Capita should take less of it?”

Stevens emphasised the £60m savings but made no mention any of the contract’s specific problems such as the thousands of patient records that went missing, dozens of women left off cancer-screening lists, the qualified GPs who were unable to work for months while the system delayed verifying their entitlement to go onto a “National Performers List”, the GPs who ran short of basic supplies or the GPs and ophthalmologists who suffered financial detriment because of delayed payments.

Said Stevens,

“First, let me say that this has clearly been a rocky road, and the National Audit Office accurately described the bumps along the way, which are regrettable. That should not obscure the fact that, notwithstanding the economic pain that Capita has experienced, the contract has saved taxpayers £60 million in lower administrative costs in the National Health Service over the first two years of its life … that £60 million of savings is not to be sniffed at; it is the equivalent of 30,000 operations.”

Comment:

Campaign4Change has repeatedly criticised Capita’s performance on Barnet’s outsourcing contract, in part because Capita and the council have been markedly defensive – thin-skinned.

It was refreshing, therefore, to hear Capita’s newish CEO Jonathan Lewis being openly contrite over highly-visible failings in the NHS contract. He gave the impression to public accounts MPs of being a CEO who is determined to put right the failings for the sake of Capita’s reputation. The cost of correcting the problems seemed a secondary consideration.

With Lewis at the helm, Capita’s share price has continued to rise in recent weeks.

Less impressive at Monday’s hearing was Simon Stevens, NHS England’s chief executive, who seemed to imply that NHS England had done nothing wrong.  It was a reaction we’ve come to expect from top civil servants after an IT-related programme disaster. It’s never the fault of officialdom.

The reality is that NHS England was almost as culpable as Capita. NHS England rushed the whole outsourcing exercise – which doomed it from the start. It didn’t listen to critics who warned that primary care support services were too locally diverse and inherently problematic to standardise as part of a national  outsourcing deal.

Instead of first piloting and agreeing with GPs, dentists and ophthalmologists fundamental changes in working practices that would be needed across the country, NHS England went ahead with signing a co-called transformation deal with Capita.

NHS England paid only lip service to engagement with the new system’s end-users in the medical professions. By its own admission Capita, because of its own internal shortcomings, went into the contract blind.

What’s worrying is the way civil servants blithely repeat mistakes of the past and later say they did everything right.

The National Programme for IT in the NHS – NPfIT – failed in part because it was rushed, the implications of “ruthless standardisation” were not fully understood at the outset and there was a lack of proper engagement with potential end-users in hospitals and GP practices. All these same mistakes were made by Capita and NHS England on the Primary Care Support Services contract.

When ordinary human beings become senior civil servants there seems to be a requirement that they lose at a cellular level the facility to express humility and contrition. That loss is replaced by an overly prominent complacency. Whatever goes wrong is not their fault.

Stevens said in essence that NHS England did everything right. Through its unpublished project reviews, the Major Projects Authority – now the Infrastructure and Projects Authority –  endorsed NHS England’ s plans. All the so-called experts gave the outsourcing deal what Stevens called a “thumbs-up”.

It would have been surprising if Stevens had said the public sector was in any way to blame.

At least Capita has learned the lessons. It has a financial interest in doing so.

Ministers can learn from Capita’s candid chief executive

NHS England’s management of Primary Care Support Services contract with Capita – National Audit Office report

Monday’s televised Public Accounts Committee hearing with Capita’s Jonathan Lewis and Simon Stevens of NHS England