First posted on 21 November, this article is now updated to include a reply from Calderdale Clinical Commissioning Group’s Chief Finance Officer and a small amount of information from West and South Yorkshire and Bassetlaw Commissioning Support Unit.
“Serious risk” is the highest category of risk in the NHS Calderdale Clinical Commissioning Group’s risk register.
This is the level of risk that the Calderdale Clinical Commissioning Group (CCCG) has identified in its relationship with the organisation that’s meant to be supporting it – the West and South Yorkshire and Bassetlaw Commissioning Support Unit (WSYBCSU).
How much control can the CCG keep over commissioning? And is CSU advice in the best interests of the CCG?
WSYBCSU’s recent advertisements on the Supply to Health Website appear to be an example of this risk. These ads state that the CSU is proposing to commission an urgent care ambulance service, by setting up a national framework agreement to accredit a pool of approved urgent care ambulance providers.
WSYBCSU’s advertisments state that it is doing this on behalf of the CCCG and many other NHS organisations. However, although it advertised CCCG as an “involved commissioner” for this proposed new urgent care ambulance service, the CCCG Chief Finance Officer said at the CCCG Governing Body meeting in November 2013, that this was nothing to do with CCCG.
After that meeting, the Chief Finance Officer, Ms Lawreniuk, investigated WSYBCSU’s new urgent care ambulance framework agreement and said,
“…whilst it is preferable that the CCG be asked beforehand on the potential usage of a framework agreement, it is not always the case especially where the scope of the framework covers either large geographical areas (in this case the whole of England) or other public sector organisations. The naming of the CCG In the advert provides the CCG with the ability to use the framework rather than setting out a clear intention to do so.”
Serious potential conflicts of interest
An added twist to the new urgent care ambulance service framework is that WSYBCSU is not only commissioning it, but the CSU will also provide an essential part of that service, through a partnership with a private company, 365 Response Limited, where a key director is also a key employee of WSYBCSU.
There are at least two potential, serious conflicts of interest around the CSU’s plan to both commission an urgent care ambulance service on behalf of NHS organisations whose commissioning activities it is meant to support, and to provide an essential part of that service itself, in partnership with 365 Response Limited.
One potential conflict of interest is that if the WSYBCSU advocates that CCGS and other NHS organisations commission urgent care ambulance services that the CSU is itself involved in providing, this is hardly likely to be disinterested advice in the best interests of the commissioning organisations, since WSYBCSU stands to profit.
The other potential conflict of interest lies in the fact that Ms Fatchett, a Chief Operating Officer at WSYBCSU is also a director of 365 Response Limited – the private company which is to act as a managed transport bureau, responsible for networking urgent care ambulance providers with NHS organisations that want to commission their services. WSYBCSU will oversee 365 Response Limited in this activity.
Verbal assurances from WSYBCSU
Calderdale CCG’s Chief Finance Officer Julie Lawreniuk said,
“Around the time of the Governing Body meeting…staff within the CCG had not at that time had a chance to clarify what was being proposed and what if any impact the proposed framework agreement would have on the CCG.
Since receiving formal notification of the work being undertaken the CCG has with other CCGs raised a number of questions with the West and South Yorkshire and Bassetlaw CSU concerning the involvement of 365 Response Limited to seek assurance that obligations under the NHS Procurement, Patient Choice and Competition Regulations which require that ‘a relevant body must not award a contract for the provision of health care services for the purposes of the NHS where conflicts, or potential conflicts, between the interests involved in commissioning such services and the interests involved in providing them affect, or appear to affect, the integrity of the award of that contract’ have clearly and demonstrably been met. Assurance has been now been received from WSYBCSU that the appropriate processes have been followed.”
Questioned about the evidence provided by WSYBCSU in support of their “assurance“, Ms Lawreniuk clarified that this was a “verbal” assurance and that WSYBCSU has not provided any documentary evidence to show that it has followed all conflicts of interest procedures.This would include the WSYBCSU employees’ and board members’ conflict of interest register, Minutes of all meetings where the proposal and contracts for the urgent care ambulance service framework were discussed, and memos of informal meetings.
Ms Lawreniuk asked WSYBCSU to provide Plain Speaker with this evidence. WSYBCSU sent Plain Speaker two documents:
- A Declaration of Interests paper dated 8 July 2013, listing the Declarations of Interest by the Directors of the West and South Yorkshire and Bassetlaw CSU (WSYBCSU), in line with the local standing operating procedure for the Standards of Business Conduct Policy of the NHS Commissioning Board (April 2012). This identified that Ms Fatchett, then a Director of WSYBCSU, had declared that she was Owner of 365 Response Limited, Owner of Nyon Advisory Limited, Wife of B Fatchett, SRCL Limited – supplier to the NHS and Owner of Health on the High Street Limited.
- the document spelling out the local arrangements for the Standards of Business Conduct policy
Background info about Clinical Commissioning Groups and Commissioning Support Units
The 2012 Health and Social Care Act created Clinical Commissioning Groups with responsibility for commissioning many of the NHS services provided in their area. It also set up regional Commissioning Support Units to help the CCGs, since CCGs are run by a Governing Body of local GPs without much previous experience of commissioning.
Public question about the nature of the “serious risk” attached to Calderdale CCG’s relationship with the Commissioning Support Unit.
At the 14th November Calderdale Clinical Commissioning Group (CCCG) Governing Body meeting, a member of the public who does not wish to be named asked the CCCG Chief Officer, Dr Matt Walsh, why the CCCG had assessed that its relationship with the West and South Yorkshire and Bassetlaw Commissioning Support Unit (WSYBCSU) carried a “serious risk”.
Dr. Walsh replied:
“This risk assessment is about local capacity in the Clinical Commissioning Group and the CSU to meet all the challenges we have to meet in commissioning services. We’ve rated the risk the way we have because this is a new relationship and we’re still learning.”
At the previous CCCG governing body meeting, on 12 September 2013, the Chair Dr Alan Brook had commented on the serious risk regarding the Commissioning Support Unit and the need for greater clinical involvement with the CSU staff.
The CCCG risk document states:
“There are a number of WYSBCSU risks associated with the bedding in of the new arrangements, leading to an inability of the CSU to deliver the service required by the CCG. 1) Potential failure in business continuity due to changeover of staff and development of new team structures. 2) Continued pressure on capacity and need to obtain the right balance in terms of specialist strategic input and staff fulfilling day to day operational requirement.”
CCCG is clear that there is a serious risk around embedding the new commissioning support arrangements – a serious risk that has been present for a considerable length of time. The question about the serious risk associated with the CSU was raised at the CCG meeting in July. It was level 16 risk then. 16 is not the highest risk score (which is 20), but is defined as ‘serious’ or ‘likely major’. Why, four months later, is the risk still this serious?