Insourcing: the necessary evil

I had the privilege of being an invited guest presenter at a recent NHS England meeting to discuss endoscopy insourcing. Specifically, I was asked to address the concept of 'what good looks like' and how NHS Trusts can ensure optimal outcomes from their insourcing services. This topic resonates deeply with me, given my background as an endoscopy matron with over 15 years of experience in the insourcing realm. Having held frontline roles in delivering endoscopy insourcing services and occupying senior operational and clinical positions within various insourcing providers, I am deeply passionate about this subject.

During the meeting, a fellow presenter—an NHS consultant—referred to insourcing as 'the necessary evil'. I'd like to take this opportunity to unpack this sentiment and perhaps challenge your perspective if you share similar views. Additionally, I intend to offer some insights for NHS Trusts contemplating insourcing as a potential capacity solution.

So, why is insourcing sometimes regarded with disdain? After all, it serves as a valuable clinical capacity lever that aids NHS Trusts in enhancing access to specialist services. Allow me to present some potential reasons for this negative perception but this list is by no means exhaustive.

When NHS teams undertake demand and capacity planning exercises, they inevitably consider various options to address mismatches. Typically, there are short-term and long-term perspectives. Long-term strategies often involve collaborative efforts across systems to optimise demand through services like Advice & Guidance, referral management, Single Point of Access service redesign, and the development of community service provision. In contrast, short-term measures may include bolstering internal capacity to attend to urgent cases or reduce waiting times with WLI lists or insourcing via an external team.

Initially, insourcing was positioned as a short to medium-term fix. Trusts recognised that they were paying subcontracted providers a premium for delivering specific urgent outcomes. This arrangement ensured timely patient care, maintained specialty-level and Trust-level performance, and importantly, avoided penalties for failing to meet the 18-week standard—a significant concern at the time.

However, fifteen years down the line, what was intended as a temporary solution has become a long-term fixture within the NHS, spanning various clinical specialties and diagnostic modalities such as endoscopy. Herein lies the problem.

It's natural for NHS staff to aspire to deliver services independently, without reliance on insourcing. Yet, there's now widespread acknowledgment, albeit reluctantly, that insourcing plays a necessary role in addressing lengthy NHS waiting lists. This recognition stems from the perpetual challenge of demand outstripping capacity in every specialty, exacerbated by factors such as historical underinvestment in infrastructure, the impact of the COVID-19 pandemic, and more recently, industrial action.

Familiarity breeds contempt

While insourcing is acknowledged as necessary, why is it perceived as 'evil'? The answer likely lies in its prolonged presence. If you fall ill at home and receive lifesaving interventions from ambulance crews, you'd undoubtedly be grateful. However, if weeks pass and their presence persists, it serves as a constant reminder of illness, potentially breeding contempt despite gratitude.

The question of quality

The quality of insourcing services has dramatically improved over the past 15 years. As NHS Trusts have become more experienced in commissioning these services, they have learned to ask better questions and to demand more from providers in terms of delivering excellent patient outcomes, patient safety and experience of care. Despite this, many NHS consultants remain convinced that insourcing services are inferior to their local services. There is a feeling that the insourcing teams feel no one is watching, so they are less motivated to deliver good quality care. However, I remain of the view that if services are commissioned thoughtfully, this should not be the case.

The Future of Insourcing

There is often speculation about the long-term future of insourcing. The proliferation of insourcing companies with almost 100 claiming to be a leading provider, suggests a widespread belief in the future. There is, of course a more cynical view that opportunistic recruitment agencies see this as a route to delivering disguised agency staffing, hence the proliferation. This very competitive landscape means that NHS organisations can now procure insourcing services at much better prices than they did 15 years ago. However, because of the fairly low barrier to entry, every man and his dog can now set up an insourcing company and proclaim to deliver a quality service. This makes it a lot harder to argue with those who view insourcing as inferior to local services.

My vision for the future involves getting back to pre-pandemic backlog levels and re-positioning insourcing as a short to medium-term, flexible capacity solution. Long-term strategies should prioritise moving services out of hospitals and focusing on demand management, recognising that expanding hospital capacity isn't the ultimate solution.

What Good Looks Like

For NHS Trusts considering insourcing procurement, here are some key considerations to ensure successful service commissioning:

• Establish a comprehensive service specification outlining key requirements, drawing upon templates provided by experienced providers.
• Require a detailed project implementation plan with clear timelines and deliverables from your chosen provider.
• Collaborate with your chosen provider to develop a service operational manual, capturing local operational policies and specific contract requirements.
• Review CVs and specialty-specific quality/outcome data for consultants shortlisted for the service.
• Engage designated clinical leads from both sides early and maintain ongoing communication throughout the contract's duration.
• Clearly define and agree what a good quality service look like and include both clinical and operational staff in this aspect
• Have a quality assurance framework with your provider and maintain zero tolerance for disguised agency staffing

If you represent an NHS organisation and seek guidance on what constitutes excellence in endoscopy or any other clinical specialty, or if you wish to review examples of the aforementioned documents, please don't hesitate to contact me at [email protected].

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