Clinical correspondence handling at NHS Shared Business Services Contents

1Clinical correspondence handling by NHS Shared Business Services

1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health (the Department), NHS England and NHS Shared Business Services (NHS SBS) about clinical correspondence handling at NHS SBS.1

2.Until April 2016, NHS SBS was contracted by Primary Care Trusts (PCTs) to provide primary care support services, including redirecting clinical correspondence, in 3 areas: the East Midlands; North West London; and the South West. NHS England took over the management of these contracts when PCTs were abolished on 1 April 2013. NHS SBS is a limited company set up as a joint venture between the Department of Health and a private company, Sopra Steria. The Department has a 49.99% share in NHS SBS.2

3.Concerns about the quality of the primary care service being delivered by NHS SBS were raised as early as 2011, when Ben Bradshaw MP raised the issue with the former Minister for Health. He suggested that the quality of primary care support services that were already being run by NHS SBS were worse than those that they replaced, and were getting worse. The former Minister for Health assured him that the contracts with NHS SBS were underpinned by robust management arrangements, including key performance targets to measure the quality of the service that they provide.3 The Department did not take this opportunity to review the performance of NHS SBS.4

4.NHS SBS inherited a small backlog of unprocessed mail when it took over the redirection service in 2011. NHS SBS had regular reports about the size and extent of a backlog in misdirected clinical correspondence as it developed from 2011 onwards. Internal monthly reports in 2011 and 2012 noted the backlog in the East Midlands, which by June 2015 was estimated to consist of 351,500 items of correspondence. Similar backlogs were found in other regions. Senior people in NHS SBS were aware of the backlog of cases and the risk that patients could be harmed as a result, but did not develop a plan to deal with it.5

5.NHS SBS told us that those dealing with the matter mistakenly thought that correspondence forwarding was a low-value, less important activity and did not recognise the significance of the backlog or its potential impact on patients. As a result the issues surrounding the backlog of cases were not properly escalated. The managers concerned did not follow NHS SBS’s formal process, which was to alert the chief finance officer of the risk. In turn he would then have alerted the audit committee and NHS SBS would have formulated its response. Senior managers withheld information about the backlog from the board for several years.6

6.In June and July 2015, a more junior colleague raised the issue of the backlog in the context of documents that were being destroyed. The manager responsible confirmed that the documents in question were being destroyed correctly, which was another missed opportunity to escalate the issue. As it was, the NHS SBS chief executive was not told about the problem until 3 March 2016. Six members of staff in NHS SBS were disciplined for this failing, four of whom are no longer employed by the company.7

7.When NHS Engand took over the contracts for primary care support services and mail redirection from the PCTs in 2013, it did not identify that the contracts lacked Key Performance Indicators for redirecting clinical correspondence. It told us that there was no opportunity to review, amend or renegotiate the terms of those contracts before the contracts were transferred to it. Neither did it review the contracts later. NHS England did not ensure that it had adequate processes in place to assure operations across the organisation, despite the NAO warning in 2014 that this was not good enough.8

8.NHS England’s management of its contract with NHS SBS did not identify that forwarding clinical correspondence was not seen as an important activity by NHS SBS. NHS SBS said that it had mistakenly been regarded as a low-value, less important activity. Although, the contracts with PCTs included key performance indicators for certain services they delivered, none of the contracts had key performance indicators related to the redirection service. The NAO’s good practice guidance on contract management recommends that all contracts have performance measures, for example, targets covering all aspects of services provided. These should be linked to financial incentives and penalties. In fact, only 21 of the 26 contracts explicitly stated that redirection services were required.9

9.NHS England did not make sure that misdirected clinical correspondence was handled properly outside the NHS SBS contracts. In May 2015, NHS England wrote to GPs in the areas served by NHS England’s in-house primary care service to tell them that correspondence sent to the wrong GP practice should be returned to the original sender. Although NHS England did not send this instruction to NHS SBS, by November 2015 NHS SBS stopped providing the redirection service.10

10.The Department has held 49.99% of NHS SBS’ shares since it was created in 2004. As a joint owner of the enterprise, the Department is entitled to take up 3 seats on NHS SBS’ board. Since 2014, the Department has only taken up 1 of these 3 places. The Department asserted that having more representatives on the NHS SBS board would have made little difference to the build-up of the backlog, as the board was not told about it before NHS SBS reported it to the Department and NHS England in March 2016. The Department was present at the NHS SBS board meeting where the issues of the backlog were first raised.11

11.NHS SBS is one of six companies that the Department owns or part owns. The Department accepted that it had not focused enough on the governance of these companies in the past. It told us that since the incident it has reviewed its governance processes for all 6 companies and centralised all of its governance responsibilities to a single team to ensure that it has people in the role who are much more professional governors. It also told us that it has reviewed who its board members are and governance arrangements for its investments. Currently, the Department is taking 2 of its 3 seats on the NHS SBS board.12

1 C&AG’s Report, Investigation: clinical correspondence handling at NHS Shared Business Services, Session 2017–19, HC 41, 27 June 2017