East of England NHS up for sale
Eastern England’s NHS is “Up for Sale”, warns health union - See more in Press Release 3rd October - Tracey Lambert
A report on current privatisation initiatives, researched for UNISON Eastern Region
September 2011
A glance at the Strategic Projects web pages of NHS East of England reveals a gleeful approach to the privatisation of a variety of services. Those that have gone up for grabs range from the management of Hinchingbrooke Hospital (an incomplete and high-risk project that has nonetheless already been gratefully acknowledged by two awards from the pro-privatisation Healthinvestor magazine, and shortlisted for two more awards from other bodies) to the hiving off of most community health services in Suffolk, carved up into four “lots” – with only one local bidder among the nine shortlisted.
Other services out to tender include
- Anglia Support Partnership (a “business arm of the NHS” offering shared back office and other services to NHS organisations in Eastern England and elsewhere, for which all four shortlisted prospective partners are private companies);
- and complete ‘care pathways’ for services that spend a total of £300m a year in the region. East of England is ahead of the national pack on this issue, having outlined plans back in March of this year: according to Pulse magazine:
“Private companies are poised to bid to run huge chunks of NHS care across the country, as a host of PCTs follow NHS East of England's controversial lead in placing entire care pathways out to tender. NHS East of England plans to auction off £300m of services to GPs, private companies or a combination of the two, in pathways including respiratory and musculoskeletal medicine.” (Pulse 10 August 2011)
On top of this, Pathology services are being subjected to a controversial “intra NHS” tendering process to rationalise and centralise the existing services across the region into as few as three units, based in Cambridge, Norwich and Chelmsford. At present the dialogue and debate involves only NHS Trusts, (along with the complaints of doctors and even MPs in Suffolk, which as a county would be left without a major centre, with patients forced to wait longer for results of tests). But the resulting new arrangement seems certain to be just a staging post to a fresh full-scale competitive tendering and privatisation of services at the three centres, at a later stage.
NHS East of England is therefore acting as the high command of the government’s efforts to bring more private sector providers into the NHS: it is investing substantial public money in the process, and has established a “unique Commercial Advisory Board” to drive it, established in 2008 by Director of Strategy Dr Stephen Dunn, and now coordinated by Andrew McPherson, the director of the “Strategic Projects Team”.
This drive for privatisation is driven from above by government pressure, and fuelled by ideological conviction (in place of any evidence that the policies are effective). One common factor in each case is the complete lack of consultation – either with the staff delivering the services that are being parcelled up and offered up for tender, or with the local people who depend upon these services. All discussion of the Suffolk Community Services “divestment,” for example, is tellingly absent from the website of NHS Suffolk, and can only be found (together with a vacuous ‘newsletter’ ostensibly aimed at Suffolk residents) hidden away on the Strategic Projects Team website.
A number of services have already been split off and privatised, including some GP practices, patient transport services formerly part of East Of England Ambulance Service NHS Trust, and diabetic retinopathy services for the region.
Others have simply been split off and taken over by other NHS and public sector providers.
And community health services in Great Yarmouth and Waveney will float off as a “social enterprise” (non-profit private business) on October 1, becoming East Coast Community Healthcare.
This report will examine the various privatisation projects under way, and their implications for the NHS in Eastern England, the midlands (now joined into a common organisational structure in preparation for Andrew Lansley’s controversial health “reforms”) and the wider NHS.
Suffolk Community Health Services
Why the big sell-off?
The Strategic Projects website makes no bones about the fact that the decision to hive off community health services in Suffolk is motivated purely by ideology and a determination to introduce competition. Answering the ‘Frequently asked Question’ “Why is divestment necessary?” the SPT makes clear that there is no concern over the quality of existing services:
“Staff within Suffolk Community Healthcare provide an excellent service of which the PCT is very proud”.
There is of course no suggestion that any of the potential bidders could provide a service that is better than excellent.
But the same answer also argues that:
“The Department of Health considers that Primary care Trusts (PCTs) currently have a conflict in their role. PCTs commission services, buying them for their local community, but had been providing them as well. This means that there is little scope for “competition” …
Without attempting to show why competition is likely to improve upon an “excellent” service that has already been separated organisationally from the PCT, and established as Suffolk Community Healthcare, the SPT goes on to argue that the fragmentation of existing services would “allow PCTs to “focus energies on commissioning” – whatever that means.
And for staff caught up in this ideological nightmare, there is the bland and wholly unconvincing claim that:
“The overall aim of the divestment is to secure a sustainable future for these services and staff, while ensuring quality and value for money of the services”.
On the contrary, the staff delivering the service are the very last to be involved, consulted or considered as the SPT forces through a new system that opens up the £58m budget for community health services to private as well as external public sector providers.
Elsewhere, the SPT makes a series of spurious claims for its plans to hive off Suffolk’s community health services. If we set aside the doubtful assertion that “It will result in a sustained, well-managed service for patients, driving up quality and delivering value for money,” three of the “Five key facts about NHS Suffolk’s divestment process” are clearly false:
- Patients, their families and carers will see a more joined-up NHS service,
improving care.
- Partners - staff, the public, Suffolk County Council, GPs and healthcare
professionals – will be involved throughout the process.
- It will be fair and open.
In fact the division of the formerly integrated community health services into four separate lots, the splitting off of other services, and the determination to bring in untested providers, including those seeking profits for shareholders, mean that the service will be more fragmented than ever, with no guarantee that its current excellence will be maintained.
And far from being “involved throughout the process”, all but a tiny and senior handful of SCH’s 1,404 full time equivalent staff, along with the public, the County Council and almost all healthcare professionals have been left on the sidelines, as the process is driven through by a hit squad of regional health bosses determined to impose a new model.
Of course there is rhetoric about involvement. In May the first newsletter declared that:
“Understandably, everyone has lots of questions about how the process is shaping up … and how staff, services users, carers and other stakeholders can be part of what’s happening.”
But of course they couldn’t. Indeed the timeline makes no provision for discussion, let alone consultation with the public, or even with the staff whose jobs and conditions of service are on the line. The September 2011 ‘What’s next’ newsletter, hidden away on the SPT website, promoting a “Meet the bidders” session allegedly open to staff, specifically stresses how limited the encounter is intended to be:
“It isn’t the appropriate time for bidders to talk about the content of their bids or plans for SCH, because the evaluation has not been completed at this stage, however, it will be an opportunity to articulate, face to face, the interests and concerns of staff.”
Of course there was no guarantee that any staff who did participate would get any useful response to their concerns.
Even the Department of Health observers have appeared to be shocked by the blatant lack of any genuine involvement by staff and the wider public. The same NHS Suffolk ‘What’s next’ newsletter admits that there has been “a query [from the DoH Gateway team!] about wider stakeholder involvement” – not least about the restricted circulation of the tokenistic newsletter.
As a result NHS Suffolk promises to make a few more cosmetic attempts to make it look as if some form of consultation is taking place – while in fact proceeding as planned, with no regard to the views of staff or the Suffolk public.
“Fair and open”?
A process like this, with such deliberately restricted public involvement or consultation, and paying no regard to the views of staff, gives no grounds to believe that it is “fair and open”.
The decisions on shortlisting from 17 to 9 bidders have been taken without open debate or explanation of or consultation over the criteria used: and the curious lack of in-house bids from SCH for any of the four lots suggests that pressure has been brought to bear on managers and staff to shut off this option. As a result of this opaque process, whether or not Suffolk people agree, at least three of the four lots of community health services for people in the county will be handed over to a non-local provider with no track record in the area.
The bidders
Nine potential bids from as far afield as Nottingham, 140 miles away, have been shortlisted for the four “lots” of community services put on offer by the Strategic Projects Team, allegedly on behalf of a largely invisible NHS Suffolk – which appears to have had no involvement in the process, and has not even bothered to inform local people of the bidding war for their services. There are only the most passing references to the process (and no press releases) on the NHS Suffolk’s own website, and the only substantial information available is tucked away on the NHS EoE Strategic Projects web pages.
The nine shortlisted bidders – selected from the initial list of 35 from 20 organisations back on May 31, and the 17 that expressed an interest in June – include FIVE private companies:
- Serco Health (the all-purpose multinational company that does everything from transport to prisons, driving licenses, education, hospital ancillary services and speed cameras) – the only company to bid for all four “lots”:
- Assura Medical (owned by Virgin, which has just won a GP contract in Essex, and been selected as preferred bidder for a £450-£500m contract for community services in Surrey) bidding for just one lot;
- Essex Cares Limited, a privatised social care company, spun off from the County Council, which made just £265,000 profit on £22m turnover last year.
and two equipment providers:
- Medequip Assistive Technology “one of the longest serving providers of contracted out ‘Community Equipment Services’, having been awarded the first contract in early 1993”: its website offers a range of products including anaesthetic and enema equipment, rubber sheeting and aprons, nurses uniforms, catheters and incontinence products. It has 14 warehouses and 30 contracts around the country.
- Nottingham Rehab Services: Established in 1947, this is the wholly owned healthcare division of Findel Group plc; trading as Nottingham Rehab Supplies (NRS).
While the equipment providers obviously deal with some of the equipment used in community health care, at first sight none of these five companies offers much in the way of community health care, or any obvious reason why they should be brought into Suffolk to replace the “excellent” services that existed before the tendering process began.
Just four of the shortlist are NHS providers, of which only West Suffolk Hospital NHS Trust is local, and only bidding for specialist paediatric services: its managers are convinced that even this contract is destined for a private company.
The other three NHS providers notionally included on the shortlist, each of which has bid to take over all four “lots” of community services, are:
- Norfolk & Waveney Mental Health NHS Foundation Trust,
- Norfolk Community Health and Care NHS Trust,
- and North Essex Partnership NHS Foundation Trust, which has been running the services in the interim, and are not thought likely to win a longer term contract.
The services
The services now out to tender have been divided into four groups, which are:
1. Adult universal services - East
2. Adult universal services - West
3. Community equipment - Wheelchair/Assisted Technology
4. Specialist paediatric services
While 3 and 4 are self-explanatory, “Adult universal” includes integrated teams, bed services, heart failure specialist nurses, osteoporosis, independent living, adult speech and language therapy.
The SPT promise that “any split of services between the east and the west will be done as sensibly and sensitively as possible”. Another group of services – Foot and ankle surgery, salaried community dental services and marginalised adults “will be dealt with under a different process.”
A few other community health services, including Universal Children’s Services, Sexual Health services and Diabetic retinopathy services have already been “divested” – to Suffolk County Council, Cambridgeshire Community Services NHS Trust, and to Health Intelligence Ltd, a company for which in April this year the East of England deal given its first contract in this field, delivering screening services to 85,000 diabetic patients in 6 Primary Care Trusts.
This last example of a completely inexperienced company being handed a major and challenging contract underlines the fact that the determination to bring in private sector providers with little or no track record of successful provision of this kind of service and on anything like this kind of scale, rather than existing and well proven NHS Trusts, is a massive experiment. It is gambling with the provision of services for a population of over 700,000 people across Suffolk, around 150,000 of whom are aged over 65, with 83,000 in the more vulnerable 75+ age group.
Limited future options: no Plan B
Once existing public sector providers are replaced by private companies, it is not clear what options may exist for reversing the process if the services delivered fall short of the required standards, or if private providers pull out of services currently provided. While competitive market models allow for retrospective financial penalties and complaints mechanisms after things go wrong, failures in this key area of the NHS could have devastating consequences for some of the county’s most vulnerable people and their families, but also bring knock-on problems to GPs and expensive new pressures on hospital services.
Since NHS community health staff would have to be made redundant or transferred out of the NHS if services are privatised, privatisation is likely to bring longer-term negative consequences for the retention and recruitment of top quality staff.
Although existing NHS staff employed in SCH could transfer to a private company with some conditions protected under the EU TUPE legislation, this is not a permanent guarantee, and does not cover NHS pensions.
Nor does it cover staff who change jobs, or are promoted: they may find that they are no longer covered by TUPE and their protection is lost. None of the staff transferred will any longer be part of the NHS pay structure.
And while there is no option for staff to choose redundancy rather than transfer with their job to a private company, the PCT admits there are no guarantees that a private company will retain all of the staff who transfer. Instead it may immediately seek to maximise its profits by imposing redundancies, or by putting on pressure for some staff to leave, especially if they hope to weed out some of the more experienced and higher-paid staff.
Future new entrants will not be covered by TUPE, and can therefore be recruited more cheaply on much less favourable terms and conditions. And in any case companies that find TUPE obstructs their quest for profits can move swiftly to give notice of a change of contract as soon as the changeover has taken place.
The concept of competitive tendering for these services also means that providers are always on relatively short-term contracts, with constant turmoil and disruption as companies have no incentive for any longer term investment or strategy. Instead they are obliged to jockey for short term advantage and to maximise their profits ahead of the next round of tendering.
So there are good reasons why Suffolk residents as well as health workers should be concerned at the implications of these changes, and should have been consulted fully from the start on the implications of a change.
Instead NHS East of England and NHS Suffolk have been consistently determined to ensure that they are excluded from the process.
The Project Board sums up this approach: it was set up without consultation, and includes just ONE token staff side representative of the 1,400 SCH staff, and a single hand-picked ‘member of the public’ from a local LINk – alongside no less than 17 assorted managers from NHS East of England, NHS Suffolk, Suffolk County Council, and two local GPs. Having loaded the dice, stacked the deck and rigged the roulette wheel, the chances of the Project Board coming to any decision not already embraced by the Strategic Projects Team are minimal.
The process
The nine shortlisted bidders have until December to submit their responses to the ITT (Invitation to tender) documents, and there is to be a further selection process for “recommended bidders” in the new year. By this stage any element of competition has been completely removed from the process, and the preferred bidder can look to maximise their advantage.
The stage will have been reached with no proper involvement of the public concerned about services which are vital to many individuals, families and communities, or health workers who have worked hard over many years to deliver a service which before this process began was already described as “excellent”.
The Strategic Health Authority, driving the process, and the PCT as its silent, passive and largely invisible county collaborator, have offered nothing but a handful of brazenly insincere words and a few ridiculous and tokenistic gestures to show that they value the work of the existing staff and their managers, or have any appreciation of the plunging morale in a service that is to be arbitrarily carved up and shared out among a variety of companies and organisations with no local roots.
It seems that the lure of awards from the private sector and the ideology of the competitive marketplace have been sufficient to extinguish any remnant of commitment to the public service ethos in the senior management of NHS East of England and the depleted numbers at NHS Suffolk.
It does not have to be like this. Relatively few community health services have been handed to private providers across the country, and even in East of England most of the services so far have been taken over by neighbouring or regional NHS Trusts rather than handed over to profit-seeking businesses. This is a better way to offer continuity for staff and guaranteed services for patients.
Why should Suffolk become a guinea pig for an experimental policy that risks doing serious damage to admittedly “excellent” services in the frenzied pursuit of the notional advantages of an untested competitive system?
Anglia Support Partnership
Anglia Support Partnership (ASP) is a provider of back office services with 80 contracts in 49 NHS and public sector bodies, stretching geographically from Eastern England to Northern Ireland. It has a turnover of £36m and employs 600 staff.
But following a review of its business back in March 2010, reinforced by Andrew Lansley’s subsequent complex Health and Social Care Bill and the government’s squeeze on “back office staff”, it recognised the possibility to expand its provision of shared services, and decided to advertise for a new “owner or partner” to help resource this, estimating the contract value at £400m.
The search for a strategic partner was announced in October 2010. Over 70 organisations submitted an initial expressions of interest, 11 of which completed their pre-qualification questionnaires (PQQ). Eight of these were shortlisted to submit outline proposals, and from this four were further shortlisted and invited to submit detailed proposals. Not surprisingly all of the responses that have been shortlisted are from the for-profit private sector:
- Capita Business Services Limited, the giant outsourcing multinational company with a turnover of £2.7 billion a year, a 19% return on capital, and profits of £364m before tax. 50% of Capita’s contracts are in the public sector, and 5% in health.
- MITIE Group PLC, another large (FTSE 250, £1.8 billion turnover) all-purpose company employing 61,000 staff and offering a very wide range of services – none of which appear quite to fit into the brief of ASP and its back office functions;
- the ubiquitous Serco (the general service provider, with contracts in 30 countries, 100,000 staff, £2.2 billion in revenue and profits before tax of £124m
- Sodexo Limited, the biggest of the four, a French owned multinational with revenue of €15.3 billion (8% of it in the UK and Ireland), and the world’s 21st largest employer with 380,000 employees.
So the obvious question about each of these massive companies is what they see in the possibilities of a deal with ASP, with its £36m turnover and minimal surplus. All four companies accustomed to hefty profits on their investment, which would imply either forcing up the prices of ASP services – with serious consequences in the context of frozen and falling NHS budgets – or further squeezing ASP staff, through job losses and demanding additional unpaid work effort, to generate the required margins – possibly at the expense of quality.
The shortlisted companies were required to submit detailed proposals for evaluation in October, with final proposals by November 4, and the Board deciding on the approved bidder in November or December.
The handover to the new strategic partner is set for the beginning of next year – all without any actual consultation process with ASP’s 600 staff.
Some of the questions published in ASP’s catchily-titled newsletter ‘Strategic Direction’ show the scale of staff concern and management indifference:
“When will downsizing happen? Will this be before or after TUPE transfer? Staff have concerns about redundancies. Should we look for new jobs yet?
“We acknowledge the concern and the uncertainty facing staff at present.
“At this stage in the process we are unable to share the bidders outline proposals, due to the nature of the submissions being commercial in confidence, as well as these being the outline proposal.
“However, we should not presume that there will be downsizing or redundancies as a result of this process and there is no need for staff to start looking for new jobs.
“All staff employed by ASP at the point of transfer will transfer to the chosen bidder with the assurance of longer term contracts from principal customers for the services that ASP provide.
“This again comes back to seeing and sharing the detailed proposals of the preferred bidder but we should remember that the value of ASP resides in its people, their knowledge, experience, and relationships with customers.
“Bidders see that there could be many more customers for the services which ASP provides in which case the main challenge would be growing capacity to meet that demand.”
Once again commercial secrecy is invoked as a reason for keeping staff in the dark, and making a nonsense of the trite platitude that “we should remember that the value of ASP resides in its people, their knowledge, experience, and relationships with customers”.
In fact, as we can see from the treatment of staff in Suffolk Community Healthcare, no special rules are being applied to the ASP process: it is simply following the normal procedure for privatisation in NHS East of England, and its Strategic Projects Team which is to regard staff as a part of the office furniture, and treat them with rather less respect than a farmer selling up his livestock as well as buildings and machinery.
Auctioning off whole Pathways
In May this year NHS East of England’s Associate medical director, GP Dr Steve Laitner, spelled out the thinking behind the idea of putting entire areas of care, such as respiratory treatments, into the hands of a single contractor, to develop what is now described as an “Integrated Pathway Hub”.
In an article for Pulse magazine (May 21) Dr Laitner argued that [despite the rhetoric in Andrew Lansley’s Health Bill, which claims to be about putting the control into the hands of GPs] the complexity of the commissioning process for such sectors of care is too great for most GPs to manage:
“There is a growing realisation that commissioning is never going to succeed if we expect commissioners to hold multiple contracts with various providers for each area of health need.”
Of course this job is being made more complex all the time by organisations like NHS East of England (and Lansley’s threatened “reforms”) breaking up existing services into ever smaller units, which are then tendered out – and seeking to draw in a greater range of unknown and untested providers.
So if GPs are not really going to do the job of commissioning, who will? Dr Laitner’s article evades mentioning some of the obvious big players from the private insurance industry at home, in Europe and the US, which have been desperate for the chance to get their hands on such big lumps of NHS budgets and shape the system along the lines they prefer.
United Health and Kaiser Permanente are two of the most common names dropped into this type of discussion. Kaiser Permanente in particular has spent years building up a devoted fan club of health academics and NHS bosses, impressed by the integration of its services – largely achieved by the fact that as a private insurer they do not deal with anyone seriously poor, and (unlike any of the equivalent services in this country, especially now that community health services are being broken up by PCTs and SHAs across England) their services are all run by the same company.
But Dr Laitner goes on to edge us towards the idea that ‘GP commissioning’ need really be no more onerous than handing out a few contracts to “prime contractors” who will do all the detailed work, to save the GPs worrying about it:
“GP commissioners have a choice. They can either continue to build up the necessary types of skills in house or acquire them through a partner or supplier.
“But they have another, much more important choice. They can continue to do what their commissioning predecessors did, and micro-commission and micro-manage complex health systems and pathways.
“Or they can do what other industries do – contract with a prime contractor who is responsible for the whole ‘job’.
To make the deal even more attractive for the private sector, they can actually cash in directly themselves as well, or as Dr Laitner puts it:
“The prime contractor will itself be providing a substantial part of the care pathway …
“So the prime provider is both providing and contracting” [i.e. commissioning]
Hang on a minute: isn’t that what the PCTs used to do – the situation which the Department of Health felt to be so unacceptable that the whole NHS in England is being forced to go through yet another costly and destabilising reorganisation? NHS East of England itself has explained the tendering of services by pointing out that:
“The Department of Health considers that Primary care Trusts (PCTs) currently have a conflict in their role. PCTs commission services, buying them for their local community, but had been providing them as well. This means that there is little scope for “competition” …
So why is it OK for a private sector contractor to GPs to combine both commissioning and providing services, but ruled out for PCTs and the public sector?
Dr Laitner argues that one advantage is that:
“This creates strong incentives to manage complex and long term conditions effectively and focus on earlier and cheaper interventions”.
But why should the same system create these positive incentives for the private sector, but bring only stultifying bureaucracy and monopoly if the control is in the hands of a public sector body?
Once the control has been handed to the IPH contractor, most GP commissioners may have no further role in the commissioning or running of the service: but there is the chance that some of them may be asked by the “prime contractor” to deliver some parts of it. What Dr Laitner does not point out is that any cash savings that may be generated in this way can be shared out between those involved.
He argues that “the third sector is going to be crucial” – naming a few charities. But he does not stress the private sector interest, although he adds that NHS East of England has also had “a huge amount of interest from community trusts, acute trusts, primary care providers and independent sector organisations.”
The Pulse report in March was much more straightforward, when below the headline “Elderly care pathways hived off in first major pilot of new NHS market”, it said:
“These plans - signed off by NHS East of England - will hand private firms, NHS providers or acute trusts a fixed amount of money, creating an ‘incentive’ to increase profit margins by delivering cheaper care out of hospital for frail and elderly patients and those with respiratory and musculoskeletal problems.” (March 11 2011)
A comment article in Pulse the same day warned that:
“It hands providers the chance to boost profits by reducing referrals and driving down costs. …
“… the prospect of GPs being paid for keeping patients from hospital, and potentially denying them the treatment they need, is no longer hypothetical, but there in the black and white of SHA reports, and no doubt too in the glossy brochures of corporate business plans. It is a move the GPC must oppose. For GPs to take a cut of the savings they make by reducing referrals would undermine and devalue the profession.”
GPs in East of England may be among the minority that favour Mr Lansley’s proposals for more commissioning, and may even be among those who see no ethical or other problems in handing over contracts for the private sector to run Integrated Pathways that may offer them a slice of the action. But UNISON is not convinced that these proposals represent anything other than a further round of privatisation, with nothing to offer patients that could not be done equally effectively through PCTs, and nothing whatever for NHS staff.
Dr Laitner’s article evades these issues, but concludes by arguing that “We can use competition to drive integration”.
Can we? It’s not at all clear how, unless the “integration” is of the Kaiser Permanente type, part of a deal to hand all the services over to the private sector, where apparently the problems of monopoly and the imperative of competition do not apply.
On tendering out pathways of care, as on so many aspects of privatisation, NHS East of England is among the pioneers, with three key areas currently up for grabs:
- Respiratory
- The frail elderly
- Musculosketal
Once again major changes in health services, with far-reaching implications for NHS staff and for patients, are being pushed through on the basis of tenuous arguments, limited or non-existent evidence, and with a minimum of information, let alone discussion or consultation with those at the sharp end of the service.
Conclusion
Staff and patients in East of England have a real problem in bringing the Strategic Health Authority and its Strategic Projects Team to any kind of account: this will be even more difficult in the next period, when East of England is to be merged into a mega-region with the Midlands, and an even less responsive bureaucracy.
Up to now the SPT has been in the driving seat of almost all changes, and able to do pretty much as it likes, and there is no indication that either the SHA or the local PCTs are at all inclined to demand a change in attitude.
Having forced through the privatisation of a number of services and the fragmentation of many more, the SPT know that this wins them prizes and plaudits from the private sector, even if it alienates staff and the wider public who are being taken for granted as their jobs and services are being sold off.
The NHS is paying the salaries and running costs of bodies that appear dedicated to handing public services and assets over to private companies – and ensuring that neither staff nor public have any chance to affect this one-way process.
But taxpayers, service users and healthworkers need to demand evidence of what the powerful and well-resourced Strategic Projects Team, and the “Commercial Advisory Board” are delivering for their public sector employers.
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