What will happen to NHS commissioner’s function in £206m community services contract once Nottingham Accountable Care System is set up?

There is much scratching of heads about how the 1st Wave Acccountable Care Systems are to operate, come April 2108. Although thanks to NHS England’s rebranding, they are now called Integrated Care Systems, to avoid reminding people of their origins in the USA’s Medicare/Medicaid system.

The puzzlement is due to the furtiveness arising from NHS England’s encouragement of public servants to provide “work arounds” to current NHS legislation which specifies the duties, reponsibilities and powers of various NHS organisations and private companies that provide NHS services.

Since the rule of law is vital to ensuring probity in public life, this seems an entirely dubious strategy.

To help them through this morass, Greater Nottingham Sustainability and Transformation Partnership in their wisdom last summer awarded Centene UK a £2.7m contract.

Adding to the murk is the fact that Centene UK, assisted by executives from Ribera Salud (the discredited Spanish subsidiary of its USA parent company Centene Corporation), is looking to acquire primary care and mental health companies in the United Kingdom, according to recent reports from Valencia Plaza.

Ribera Salud recently appointed the former New Labour Health Secretary Alan Milburn to its Board of Directors,  to help it “continue with its expansion plans.” In addition, during the recent visit to Valencia of the United Kingdom’s ambassador to Spain, Simon Manley, a British manager of Ribera Salud contacted him to explain the company’s plans.

A hint at how Accountable/Integrated Care commissioning will operate is given in the Tenders Electronic Daily (TED) notification for a Nottingham City out-of-hospital community services contract, that Nottingham City Clinical Commissioning Group recently awarded to a company that says “We’re not the NHS”: Nottingham City Partnership Community Interest Company.

The notification includes a proviso that when the Accountable Care System is set up, a contract variation will kick in that transfers the NHS Clinical Commissioner’s function to either another provider or the Care Integrator – which various documents currently identify as Centene.

After Centene’s UK’s contract to set up the Accountable Care System ends, who will be the care integrator?

Nottingham City Council written evidence on Long term funding of Adult Social Care to the House of Commons Housing, Communities and Local Government Committee mentions:

“local authorities and health bodies jointly commissioning services through a publicly-owned integrator.”)

So it seems a new organisation will be set up that involves “health bodies” – not “NHS Commissioners”.  “Health bodies” could surely be providers, whether NHS or private companies. These could end up commissioning services. Is this lawful under existing NHS legislation?

And while we’re on the subject of companies providing NHS services  – Nottingham City Partnership Community Interest Company, which was awarded the out of hospital services contract,  is subject to NHS Improvement enforcement action , for suspected breaches to its licensing conditions. These relate to but are not limited to the company’s failings in corporate governance and financial management, with the result that there are not reasonable safeguards against the risk of the company ceasing to be a going concern, and the risk of the company ceasing to be a going concern if the ongoing financial recovery plan isn’t achieved. For Financial Year 2018, that means making “cost savings” of 5% of its “cost base”.

Tricky contract will change when Accountable Care System is set up

The Nottingham Clinical Commissioning Group’s out-of-hospital community contract seems very tricky: it is intended to vary when the Notts and Greater Nottingham Accountable Care System is implemented.

The Tenders Electronic Daily (TED) contract notification specifies that at that point, the out-of-hospital services provider will be expected to work with a Care Integrator (which is currently Centene UK, but presumably will change to the publicly owned integrator mentioned above. ).

The Tenders Electronic Daily contract notification becomes incoherent at this point, stating that the Care Integrator’s

“role will be to be part of bringing about support and facilitate [sic] the successful delivery of a the [sic] new model of care in England.”

England? Not just Nottinghamshire and Greater Nottingham?

Whatever, this tricky contract notification says that during the life of the contract, Nottingham City Clinical Commissioning Group will become part of the Nottinghamshire/Greater Nottingham Accountable Care System. This will be:

“a single risk bearing entity to managing [sic] the entire care continuum. The successful provider must form part of the ACS and…will be expected to help shape and deliver its part of the single risk bearing entity.”

This sounds like the Accountable Care Organisation contract – which NHS England is not approving now and which is the subject of two Judicial Reviews in the Spring and a public consultation at some unspecified point in time.

The contract notification says that when the Accountable Care System is implemented, this will require a contract variation which:

“will require the successful provider to provide its consent to the potential future transfer of the CCG’s role under the contract.”

This contract variation will mean transferring the contract from Nottingham Clinical Commissioning Group to another provider, or the Care Integrator.

It seems that Nottingham City Clinical Commissioning Group may have taken a gamble on the likelihood that NHS England will be approving the Accountable Care Organisation contract by the time the Sustainability and Transformation Partnership has figured out its business case to consider the options for partner organisations in managing the Accountable Care System components and has secured legal and procurement support to advise on this.

Centene and its subsidiary Ribera Salud play grandmother’s footsteps with the NHS

Centene’s involvement in setting up the Accountable Care System predates the Nottingham and Nottinghamshire Sustainability and Transformation Partnership’s award of a £2.7m contract to Centene UK last September – brokered by the notorious outsourcing company Capita.

Before then, during the Vanguard scheme in Rushcliffe, Centene Corporation from the United States and its discredited Spanish subsidiary Ribera Salud were brought in to “develop an Accountable Care System”

Even earlier, Ribera Salud had advised the Tory Government in 2012, when it was preparing the NHS Five Year Forward View which launched in October 2014.

However, having uncovered the company’s many failings, the Valencia government has kicked out Ribera Salud and restored the health service to public ownership, management and provision.

So Ribera Salud – whose Vice President Cynthia Brinkley is also a Director of Centene UK, which she set up in 2016 – is increasingly looking for survival outside Spain.

The Greater Nottingham Accountable Care System has given it a foothold.  No doubt between them Alan Milburn and the UK Ambassador to Spain will open further doors for the Centene subsidiary.

Correction and clarification 19.3.2018

I would like to thank a fellow campaigner for pointing out that in the original version of this blog post, I may have added 2+2 and arrived at something other than 4.

Updated 21.3.18 with information about Nottingham City Council’s written evidence on Long term funding of Adult Social Care to the House of Commons Housing, Communities and Local Government Committee which mentions:

“local authorities and health bodies jointly commissioning services through a publicly-owned integrator.”)

Updated 1 April 2018  with info about Nottingham City Care Partnership’s suspected breaches of its licence conditions, and NHS Improvement’s enforcement action.