Select committee inquiry
NHS Shared Business Services inquiry
Closed
What the inquiry looked at
“NHS Shared Business Services (SBS) provides back-office services such as finance, HR and procurement to NHS trusts. It is a limited company owned by the Department of Health and Sopra Steria, a private company. In 2015 NHS SBS generated revenues of £87million from its services to trusts. In March 2016 SBS informed NHS England and the Department of Health that it had discovered a backlog of 435,000 items of unprocessed correspondence including sensitive clinical correspondence. This backlog had grown from 8,146 items in 2011. As of May 2017, the review of the backlog had found 1,788 cases of potential harm to patients as a result. A National Audit Office investigation found that managers at SBS had been aware of a clinical risk to patients since January 2014 but did not develop a plan to tackle the backlog. NHS England estimates that handling the incident will cost £6.6million for administration alone. The Public Committee will ask representatives from the Department of Health, NHS Shared Business Services and NHS England how they are continuing to investigate the issue, how they are assuring against harm to patients resulting from it, and how they can ensure such problems are not allowed to escalate again.”
The committee's words, from the inquiry page on parliament.uk ↗.
What it found
In the committee's words, from the summary of 4th Report - Clinical correspondence handling at NHS Shared Business Services ↗
The failures in the handling of sensitive clinical data by NHS Shared Business Services Limited (NHS SBS) are staggering. Even as the Committee was looking into problems dating back at least three years, NHS England was uncovering more mishandled correspondence.
We were deeply unimpressed by the lack of grip NHS England still has on the handling of clinical correspondence, and dismayed to be informed of a further backlog of 162,000 items which need to be assessed. Our evidence session was frustrated by the late provision of additional information by the NHS England Chief Executive. It would have been more helpful if this information had been supplied in time to allow Members to consider it. The Committee will return to this subject once it has further information.
Proper handling of clinical correspondence is an essential part of administering care for patients. NHS SBS, the company contracted to redirect up to 700,000 items of mail a year, badly failed the patients and General Practitioners for whom it was supposed to be redirecting correspondence. Almost 2,000 patients are still being assessed by NHS England to determine whether they have suffered harm as a result of the delay in handling their correspondence. NHS England has assumed without evidence that a further 102,000 patients have suffered no harm as a result of the delay. We welcome NHS SBS’s admission that it made mistakes and that the service it delivered was not good enough. However, NHS England and the Department of Health both failed in their oversight of NHS SBS.
What the government said
No government response is linked to this report.
How the inquiry ran
Each dot is a dated item listed on this page, from the inquiry's opening on 27 September 2017 to 29 November 2017.
- Oral evidence 16 Oct 2017
- Report 29 Nov 2017
- Correspondence 20 Nov 2017
What it recommended 3 recommendations · 21 conclusions
1NHS England failed to appreciate the seriousness of misdirected correspondence and still has not put...
Recommended (the committee's words)
NHS England failed to appreciate the seriousness of misdirected correspondence and still has not put effective measures in place to ensure clinical correspondence is handled properly. Forwarding clinical correspondence was not identified as an important activity by NHS England or NHS Shared Business Services (NHS SBS). NHS England did not ensure that the contracts it held with NHS SBS included key performance indicators for the redirection service. 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, but did not check that the new policy was being followed. NHS England estimates that around 5% of GPs are not adhering to the new process and continue to send misdirected correspondence to the new contractor, Capita. Recommendation: NHS England should set out how it will ensure that all clinical correspondence is correctly handled, processed and redirected, where appropriate.
2NHS England does not know the full extent of the problem as it continues to...
Recommended (the committee's words)
NHS England does not know the full extent of the problem as it continues to identify new items of misdirected correspondence. When dealing with the original backlog, NHS England relied on third parties to provide it with assurance that all items had been found. In 2016, its own Internal Audit concluded that it could not be sure that all misdirected correspondence had been identified. Despite this, NHS England did not immediately order a further search. NHS England has now identified another 150,000 items of unprocessed correspondence. NHS England has also found a further 12,000 items of correspondence that was misdirected by NHS SBS as part of the transfer of the primary care support service contract from NHS SBS to Capita. Recommendation: NHS England should set out by 31 December 2017 how it can be sure that all unprocessed correspondence has now been identified.
3Eighteen months after the problem first came to light, NHS England still cannot confirm that...
Concluded (the committee's words)
Eighteen months after the problem first came to light, NHS England still cannot confirm that no patients have been harmed by the repeated failures in the clinical correspondence redirection service. The clinical review of the backlog of 709,000 items of correspondence that was mishandled by NHS SBS is still ongoing. By October 2017, from the 709,000 items, there were still nearly 1,000 cases of potential harm and a similar number of cases are awaiting final clinical review after potential harm had been identified. NHS England plans to send the additional 162,000 items of misdirected correspondence to the correct GPs by the end of December 2017 for their review. NHS England expects to complete the clinical review of these items by the end of March 2018. Recommendation: NHS England should write to the Committee by 31 March 2018 to confirm the results of the review and what action it will take in response.
4It is unacceptable that NHS England has given up trying to find out whether any...
Concluded (the committee's words)
It is unacceptable that NHS England has given up trying to find out whether any patients have been harmed simply because 2,000 GPs have not confirmed whether they have reviewed clinical correspondence about their patients. In February 2017, NHS England paid 7,330 GP practices a total of £2.5 million to cover the cost of the time GPs spent assessing the potential for patient harm in items 6 Clinical correspondence handling at NHS Shared Business Services of mishandled correspondence. NHS England did not follow its own procurement policy when it agreed with the British Medical Association that GPs would be paid in advance for reviewing the correspondence. Despite receiving payment from NHS England, by October 2017 around 2,000 GPs had still not confirmed to NHS England that they had completed their review of 102,000 items of correspondence. NHS England has given up trying to find out from GPs whether patients may have been harmed by the delay. NHS England has written to GPs who have not reviewed clinical correspondence about their patients to inform them that it is assuming that they have completed their review and have not identified any patient harm. Recommendation: NHS England should obtain positive assurance by 31 March 2018 from every GP reviewing correspondence that they have completed their checks and whether they have identified any cases where patients may have been harmed.
5Attempting to resolve misdirected clinical correspondence has so far cost an estimated £6.6 million and...
Concluded (the committee's words)
Attempting to resolve misdirected clinical correspondence has so far cost an estimated £6.6 million and the total cost is still unknown. To date it has cost in the region of £6.6m to find and assess the 709,000 items of correspondence mishandled by NHS SBS. NHS England estimates that it will cost another £1 million to assess the additional 162,000 newly-reported items of misdirected correspondence. The total cost is dependent on how many more cases are found and how complex they are to resolve. NHS SBS has agreed to cover NHS England’s costs in dealing with the incident, although these do not include any potential future fines or negligence claims from patients who have suffered harm. However, NHS SBS has not agreed to pay any form of compensation over and above NHS England’s costs. Recommendation: NHS England should write to the Committee by 31 December 2017 to confirm: • how it will ensure that in future all contracts with third party suppliers include adequate compensation in the event of any failure to deliver; and • how much it will cost to deal with the additional items of unprocessed clinical correspondence that have been found since the NAO report.
6The Department’s weak oversight of its joint venture with Sopra Steria, a private company, meant...
Recommended (the committee's words)
The Department’s weak oversight of its joint venture with Sopra Steria, a private company, meant that opportunities to identify the issues at NHS SBS were repeatedly missed. The Department holds 49.99% of the shares in NHS SBS, and Sopra Steria holds the remaining shares. The Department is entitled to three seats on its board but did not take up two of them. As early as 2011, Ben Bradshaw MP raised concerns about NHS SBS’ performance in the House of Commons. Despite this, the Department did not review how well NHS SBS were delivering the contracted services. The Department told us that it is has recently reviewed how it governs all six companies in which it is involved since the issues with NHS SBS emerged and confirmed it has now taken up two of the three available seats on the NHS SBS board. Recommendation: The Department should set out for the Committee how the changes it has made to the governance of its six investments will ensure that it has adequate arrangements in place to oversee the services being delivered by these organisations. Clinical correspondence handling at NHS Shared Business Services 7 1 Clinical correspondence handling by NHS Shared Business Services
7When NHS Engand took over the contracts for primary care support services and mail redirection...
Concluded (the committee's words)
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
8NHS England’s management of its contract with NHS SBS did not identify that forwarding clinical...
Concluded (the committee's words)
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
9NHS England did not make sure that misdirected clinical correspondence was handled properly outside the...
Concluded (the committee's words)
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
10The Department has held 49.99% of NHS SBS’ shares since it was created in 2004.
Concluded (the committee's words)
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
11NHS SBS is one of six companies that the Department owns or part owns.
Concluded (the committee's words)
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 7 Qq 25–32 8 C&AG’s Report paras 1.6–7 9 Q 18–20; C&AG’s Report paras 3, 1.4 10 Qq 75–80; C&AG’s Report para 1.8 11 Qq 12–14, 24–29, 43–45, C&AG’s Report, Appendix 2 Clinical correspondence handling at NHS Shared Business Services 9 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 12 Qq 14–15, 45–46 10 Clinical correspondence handling at NHS Shared Business Services 2 Responding to the backlog of clinical correspondence
12NHS England set up a National Incident Team (NIT) immediately after it was told about...
Concluded (the committee's words)
NHS England set up a National Incident Team (NIT) immediately after it was told about the backlog in March 2016. In April 2016 the NIT reviewed the unprocessed correspondence. High priority items, including cervical screening results and child protection notes, were assessed and returned to GPs as a matter of urgency, with a request that the NIT be told promptly if the patient had come to harm as a result of the delay. Lower priority items were sorted and returned to the correct GP practices by the end of December 2016. GPs were again asked to tell the NIT if any patients had come to harm as a result of the delay.13
13NHS England agreed with the British Medical Association that GPs would be paid in advance...
Concluded (the committee's words)
NHS England agreed with the British Medical Association that GPs would be paid in advance for reviewing the backlog of correspondence. In doing so, NHS England broke with its own policy of not normally making payments in advance. In February 2017, NHS England paid a total of £2.5 million to 7,330 GP practices for the time spent assessing the potential harm to their patients.14
14By October 2017, around 2,000 of the 7,330 GPs had not confirmed whether they had...
Concluded (the committee's words)
By October 2017, around 2,000 of the 7,330 GPs had not confirmed whether they had reviewed the clinical correspondence about their patients, despite NHS England having paid them to do the work. The unreviewed correspondence relates to over 100,000 patients. We were concerned to hear that NHS England has given up trying to find out whether there is any patient harm from those GPs who have not complied with the NIT’s instructions. NHS England told us that it discussed its approach with its national clinical leads and agreed that this was an appropriate response. The NIT has written to those GPs to inform them that it is assuming that they have reviewed the correspondence and identified no patient harm.15
15By October 2017, NHS England had identified 5,562 cases from the 709,000 items of backlogged...
Concluded (the committee's words)
By October 2017, NHS England had identified 5,562 cases from the 709,000 items of backlogged clinical correspondence which required further clinical review as there was evidence of harm suffered by the patient. Of these, the further review of 1,938 cases is not yet complete. These cases are awaiting a final clinical review to decide if the patients involved have suffered harm as a result of the delay. This figure excludes the items of correspondence where GPs have not responded to the NIT. The NIT aims to complete the process by the end of December. As yet, there has been no evidence that any patient has been harmed by the service failure.16
16When dealing with the original backlog, NHS England relied on third parties to assure it...
Concluded (the committee's words)
When dealing with the original backlog, NHS England relied on third parties to assure it that all material had been found. NHS SBS also used its internal auditor to check whether the process it had followed had successfully identified all archived materials. In September 2016, NHS SBS’s auditor concluded that it could provide reasonable assurance that all unprocessed correspondence had been found. However, when NHS England had its internal auditor check that the NHS SBS internal audit report was reliable, it said that there was no assurance that all misdirected correspondence held by the company had 13 C&AG’s Report, paragraphs 3.3, 3.6–3.9, Figure 5 14 Qq 103, 111–114 15 Qq 93, 95–99 16 Qq 1, 3 Clinical correspondence handling at NHS Shared Business Services 11 been identified. This was because NHS SBS had used a risk-based approach to a search of NHS SBS archives, not a finger-tip search. Despite this, NHS England did not order a further search.17
17The overall cost of identifying and reviewing the backlog of 709,000 items is in the...
Concluded (the committee's words)
The overall cost of identifying and reviewing the backlog of 709,000 items is in the region of £6.6m. This sum may go higher as it does not include the cost of any potential future fines (for example, from the Information Commissioner) or negligence claims from patients who may have suffered harm.18
18NHS SBS has agreed to cover NHS England’s costs in dealing with the original incident.
Concluded (the committee's words)
NHS SBS has agreed to cover NHS England’s costs in dealing with the original incident. This amounts to £4.34 million. It covers the £2.5 million direct payments for clinical reviews and £1.84 million of additional costs. However, NHS SBS is not paying any compensation over and above NHS England’s costs. In addition, NHS SBS is paying its own costs which it estimates at £2.26 million.19
19Further service failure in the redirection of clinical correspondence
Concluded (the committee's words)
Further service failure in the redirection of clinical correspondence
20Since the C&AG’s report was published in June 2017, NHS England has reported a further...
Concluded (the committee's words)
Since the C&AG’s report was published in June 2017, NHS England has reported a further 162,000 cases of misdirected correspondence that need to be reviewed. NHS England told us that it had identified 150,000 items of unprocessed clinical correspondence. It explained that even though NHS England’s contract with Capita for primary care support services does not include a mail redirection service, some GPs have mistakenly continued to send misdirected correspondence to Capita. The correct procedure is to return these documents to sender. NHS England estimates that around 5% of GPs are not adhering to the new process. NHS England has yet to ensure that GPs understand and follow the new process properly, though it accepts that it is NHS England’s responsibility to make that happen. It told us that these cases would be reviewed by GPs in the same way as the first backlog.20
21NHS England has also found a further 12,000 items relating to correspondence that had not...
Concluded (the committee's words)
NHS England has also found a further 12,000 items relating to correspondence that had not been processed by NHS SBS. NHS England told us that this additional backlog came to light as a result of a finger-tip searches of boxes of paperwork that had been sent from NHS SBS to Capita at the end of NHS SBS’ contract. The additional correspondence has since been held in Capita’s document management storage facilities. Capita had assumed them to be records for filing and therefore had not done anything with them.21
22NHS England is continuing to search for further unprocessed correspondence.
Concluded (the committee's words)
NHS England is continuing to search for further unprocessed correspondence. As a result, the number of patients impacted by the service’s failure to properly handle clinical correspondence may increase. NHS England told us that its search technique is “pretty rigorous” and includes searches in areas it would not have had a prior reason for thinking may contain such records. We welcomed NHS England’s committment to informing the Committee if any further cases are discovered.22
23The National Incident Team (NIT) plans to assess all 162,000 additional items and return them...
Concluded (the committee's words)
The National Incident Team (NIT) plans to assess all 162,000 additional items and return them to the relevant GPs. NHS England committed to having completed this process by the end of December 2017. GPs will be asked to review the documents and 17 Qq 122–126; C&AG’s Report, paras 3.21–3.22 18 Qq 45, 115 19 Qq 45, 103, 115–116 20 Qq 6, 75, 80; C&AG’s Report, para 1.8 21 Qq 6, 59, 61 22 Qq 54, 59 12 Clinical correspondence handling at NHS Shared Business Services report if any of their patients have been harmed as a result of the delay. As with the original backlog, the NIT is prioritising the high priority cases. The NIT will then ensure that there is a more detailed clinical review of any cases where GPs think patients may have been harmed. NHS England estimate that the whole process will take until March 2018.23
24NHS England expects to it will cost at least another £1 million alone to have...
Concluded (the committee's words)
NHS England expects to it will cost at least another £1 million alone to have GPs to review the further 162,000 items of misdirected clinical correspondence. The total cost will depend on how many more cases are found and how complex they are to resolve.24 23 Qq 6, 50–52; C&AG’s Report, Figure 5 24 Q 59 Clinical correspondence handling at NHS Shared Business Services 13
Evidence
Oral evidence sessions 1
- 16 Oct 2017No witnesses recordedparliament.uk ↗