Who failed Bob and Eve Tonkin?

Amongst the disturbing lapses in this case study of NHS Cornwall’s outsourced out-of-hours GP service there is an alarming report of the initial telephone conversation.

The caller, anxious to get urgent assistance to his suffering wife, recalls telephoning the out-of-hours GP service at about 7:40pm, when he is warned that “it could be a six-hour wait despite his assessment of the urgency of the problem because it was so busy”. (The call is logged by the Service Desk at 20:01)

This alone raises serious concerns about the quality of the contractual arrangements between the Primary Care Trust and Serco Healthcare. Such an excuse is not permissible. If it was an honest assessment by the agent who received the call, it flags a failure in the service and in the management of the service. But by which party to the contract: the PCT or Serco Healthcare?

Central to the delivery of an outsourcing agreement are the Service Level Agreements (SLA).  SLAs are the detailed definitions by which the quality of service to be delivered are constrained and monitored. The contract between NHS Cornwall and Serco Healthcare will (hopefully) include SLA related to response times, and these should include different response times based on the priority and impact of the telephone call.

The SLAs are there to be met, and regular service management meetings between PCT and Serco Healthcare will review Serco’s performance against the SLAs, using key indicators as measures. Such KPI might be, say, 99% of telephone calls answered within 6 rings”. If, as implied by this part of the story, SLAs were being set aside because the services were “too busy” or “undermanned” then there is clearly a problem.  The question then is, what happens when the SLAs are not being met?

Outsourcing a service successfully is a complex task; and the experience of many businesses is that no matter how thoroughly the outsourcing is done, it doesn’t bring expected benefits.  It may be that these were never properly defined or implemented:  it may be that outsourcing was done for the wrong reason, and the most common wrong reason is to outsource in a leap of faith (or desperation) that it will cut costs but leave a service intact or even improve it (the “more for less” challenge).

The tragic experience in this case was that although the NHS staff were superb,  interleaved between personal contact with NHS services is an outsourced service which failed these patients; or which could not meet their needs because healthcare professionals were spread too thinly.

Because that is the difference between an SLA for mending printers and an SLA for assigning care to patients. Best practise service level management is to avoid 100% performance indicators for SLA, because any single exception is immediately a failure. Unfortunately – tragically – a failure to provide adequate service to a patient can easily mean loss of dignity, excess suffering, or death.

Thus we return to the question: who is failing the public in Cornwall, the PCT or Serco Healthcare? Elsewhere in this report there are suggestions that Serco is not keeping or providing accurate data on the service, which would mean its performance cannot be fairly judged and improved.

Whether Serco Healthcare is not providing the service which it has been contracted to do or Serco is providing the service in the full spirit of the outsourcing contract to the SLA and performance indicators agreed, the responsibility for failure in the service must lie with the PCT. Whether the contract is not being met or it was inadequately drafted, or it was done for the wrong reasons, or it was badly implemented so that the processes cannot work, or it is inadequately resourced, or inadequately funded, or the relationship between PCT and Serco does not work effectively: the PCT is responsible and must be held accountable.  Outsourcing a service does not outsource responsibility or accountability: in fact, managing an outsourced service is a challenging management activity. It is not a hand-off that the managing business can then forget about.

The statement from the PCT is therefore dismaying: “We are confident the service is adequately resourced and meeting the required national quality standards.” This reads very like a denial of responsibility. The second half of this excuse “meeting the required national quality standards” returns us to the important point that targets make organisations witless. “This is not an abstract point: targets can kill.”

But the issues this awful experience raises move beyond whether the service is suitably resourced and whether it is being properly delivered and overseen.  The real issue is why the service was outsourced in the first place, and an important factor here is the role of cost-cutting. Cost cutting is driven from the very top of the management hierarchy: in this case, the Secretary of State for Health, Andrew Lansley MP.

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