Commissioning and funding of
services
136. Much of the evidence we received from health
professionals involved in the treatment of patients with allergy
related to the ways in which services were funded. A source of
concern to a number of our witnesses was the extent to which specialist
services for allergy were funded as research institutes, out of
budgets for university research, rather than by the NHS. Stephen
Durham, Professor of Allergy and Respiratory Medicine at the Royal
Brompton and Harefield Trust, told us that only two-elevenths
of his post was funded by the NHS. The service he provided was
largely supported by clinical research fellows and a specialist
research nurse, a situation he described as "clearly unsatisfactory".[141]
Professor Warner suggested that if Southampton University's research
agenda was to change, the specialist service he offered could
"disappear overnight".[142]
He told us:
I am the professor of child health (Southampton),
so I am responsible for all paediatrics, not just for allergy
immunology. There is no guarantee when I retire that I will be
replaced by someone with an interest in allergy immunology; it
could be an endocrinologist or a cardiologist.[143]
137. Professor Holgate, for the NASG, noted that
80% of the full-time allergy practitioners were paid for from
academic and research salaries and that "they are using their
research time to deliver a clinical service", something which
he thought was "unacceptable".[144]
138. The Minister recorded his surprise at the suggestion
that this was unsatisfactory. His view was that allergy treatment
relied heavily on leading-edge scientific research, and that it
was thus entirely appropriate that specialists had close connections
with research institutions, in a "marriage between the leading
research and clinical practice".[145]
Addressing the concerns raised by Professor Holgate, the Minister
rejected the "unspoken implication" that a service would
disappear from an area if a particular university chose to alter
its research agenda. Instead, he argued:
It would be the responsibility of the local Primary
Care Trusts working within the framework of the Strategic Health
Authority in that area then to say "If that is not going
to be there in the future we need to find another service and
commission services, so we will recruit another allergy specialist
and we will set up another service to replace that."[146]
139. Clear evidence to contradict the Minister's
contention that, if an individual specialist service closed down
another would be commissioned by PCTs to take its place if there
was local demand, came in the submission from Dr Rita Brown. She
had run a specialist clinic in the Royal Berkshire Hospital, Reading.
This closed down in the year 2000 when she retired, even though
it had been seeing over 1,000 patients a year, and had a 12-month
waiting list.[147]
The consequence was that there was no longer any local provider
and patients had to travel long distances to receive treatment.
Other evidence we received indicated that the closure of the Reading
clinic had boosted the pressure of numbers to attend the clinic
in Southampton.[148]
140. Kate Hopkinson and Dr Richard Powell, from the
Queen's Medical Centre, Nottingham, reported that their clinic,
which had a consultant and two nurse specialists, had received
over 60 new allergy referrals a month. The team had been struggling
to keep patient waiting times down to an acceptable level. However,
a recent application to local PCTs to maintain the service had
failed to secure funding and "recommendations were returned
to dissolve the allergy service currently provided".[149]
141. Even where specialist commissioners determine
there is a need for services, funding does not automatically follow.
Professor Adnan Custovic and Dr Andrew Bentley of the North West
Lung Centre at the Wythenshawe Hospital, Manchester, told us that
the North West Regional Commissioning Group had decided in 2001
to review the current provision of allergy services with a view
to determining future provision. This found that:
- There was no regional allergy
service and most patients were not being appropriately identified
and treated;
- There was little or no provision for primary
care allergy testing in the community and no community care for
people with allergy;
- There was no full-time allergist-led NHS service
provided in the North West;
- The provision of services in the North West was
inadequate as evidenced by the long waiting times of patients
referred to the patchy service that did exist;
- Most patients with allergic disease in the North
West never saw an allergist; and
- Patients and GPs had difficulty in accessing
the currently available services and, as a result, desperate patients
sought help from non-validated sources.[150]
142. The Specialist Commissioning Group therefore
concluded that there was a need to develop a service, and put
forward a proposal for setting one up in January 2003. But, to
date, "it has proved impossible to persuade local commissioners
to provide financial support for the development of the service".[151]
143. Professor Wardlaw, for the BSACI, felt that
the current commissioning arrangements were not working well,
and that the general ignorance of allergy amongst commissioners
underlay the neglect in the provision of services. The NASG had
demonstrated the lack of priority accorded to allergy by commissioners
by contacting those responsible for commissioning:
We were given the names by the Department of
Health of the 30 PCT leads who are responsible for allergy commissioning
and we wrote to all of them some time ago and of the 30 only seven
replied, and of those seven, allergy was not a priority for any
of them.[152]
144. Even when an allergy service of some kind is
available locally (either research funded, or receiving no specific
allergy-directed support), local commissioners seem all too often
unaware of its existence. Dr Katherine Sloper, a consultant general
paediatrician at Ealing Hospital NHS Trust, who runs an allergy
clinic, noted:
The Ealing PCT Commissioning Department was not
aware of the unmet or increasing needs for patients locally who
have serious allergies. They are now interested in exploring with
me how the community and hospital can support each other in developing
allergy services, and we will be meeting together to look at these
services. The Ealing PCT Commissioning Department has not identified
the need for allergy services apart from recognising that some
patients were seen in the allergy clinic at St Mary's Hospital.
They did not know that there was a local Paediatric Allergy Department.
They do not fund any local adult service, and I know from the
experience of patients who have asked me about it, that adults
have not been able to have any specialist advice.[153]
145. The view of several of those submitting evidence
to us was that allergy does not register anywhere in local plans
for a majority of commissioners who were more concerned with areas
where national targets and priorities had been set. Professor
Wardlaw, for the BSACI, articulated this view:
We have the Department of Health targets with
the Cancer Plan and the emphasis on cardiovascular sciences. So
what you tend to get is you have a pot of money and there is a
lot of horse-trading going on, a lot of emphasis on waiting list
targets and that sort of thing … you need strong champions
locally to try to press for service development, and again allergy
has suffered because there are not any local champions.[154]
146. Dr Ladyman informed us that PCTs were currently
developing their Local Delivery Plans for the commissioning of
services. He recognised that there was "not the genuine recognition
of the needs of allergy sufferers when the last round of Local
Delivery Plans were written" but said he "would be very
surprised if Primary Care Trusts around the country this summer,
when they start sitting down to write their Local Delivery Plans,
were not thinking, 'We need to do a bit better for allergy.'"[155]
Our evidence makes us far from sanguine that this will be the
case. And we find the degree of understatement on the part of
the Minister rather alarming. Government policy places the commissioning
process as a main driver for change in the NHS. Failure by the
commissioners to notice an epidemic on the scale of allergy currently,
even when it is being misclassified as other illness (indeed,
exactly when it is being so misclassified), suggests that the
system is failing allergy sufferers.
147. Difficulties in stimulating local budget holding
commissioners were discussed at a meeting between Jon Cruddas
MP and the Minister in January 2004.[156]
At that time the Minister promised to ask the Chief Medical Officer
whether he would be prepared to oversee the development of an
"action plan" to guide and support local allergy commissioning.
We are not aware of the outcome of the discussions between the
Minister and his Chief Medical Officer; but we believe that the
development of such a plan would be a helpful step forward.
148. Additionally, more targeted commissioning mechanisms
are already available in the NHS. One way to promote change through
commissioning, albeit one which would face a number of difficulties,
would be for the required regional allergy centres to be commissioned
through the specialist commissioning process. Such services are
defined by the Department as those that have low patient numbers,
and are generally high-cost, requiring a certain critical mass
of patients to make treatment cost-effective.[157]
The Specialised Service National Definition Set includes 36 such
services, one of which is allergy services relating in particular
to severe allergic disease and anaphylaxis. [158]
Due to the high-cost, low-volume nature of these specialised services,
the Department recommends that services within the Definition
Set are planned and commissioned for larger areas and populations
than is normally the case. For regularly used hospital services,
one PCT will normally work with local acute trusts to plan services
for the residents of the geographical area for which they are
responsible, which are normally coterminous with local authority
boundaries. Specialised services are commissioned by regional
groups of PCTs for their combined populations (normally over one
million people) often with one lead PCT acting on behalf of the
others. All PCTs contribute towards the cost of specialist treatment
for their pooled area, and therefore some of the financial risk
associated with very high-cost unpredictable treatment is spread
between the consortium. No additional funding exists for specialised
services; funds must be allocated from PCTs' normal budgets, which
are based upon the size of their local population. Besides the
allocated funds, extra financial resources are often required.
Spending on specialised services is currently estimated to be
around 10% of PCTs' budgets, or around £4 billion every year.
149. The Manchester case described above, and others,
such as Addenbrooke's, where bids for local specialist commissioning
failed,[159] or Southampton,
illustrate the difficulties in making this process work to establish
regional allergy centres covering populations of 6-8 million.
There is little or no perception of a problem of unmet need among
the local budget holders. And quite a large number of them would
need to change their minds, agree to work together and pool resources,
to get something off the ground. In reality, there are insurmountable
difficulties facing this route to change. The difficulties are
structural (the large numbers who would need to combine to provide
regional level funding for the key resource/regional centre).
They are managerial, with no data on the actual scale of allergy
treatment and little incentive to give priority to this area in
the face of competing demands. But above all they are caused by
a lack of perception that there is a problem and an absence of
local leadership. Local champions and clinical leadership are
needed to achieve this prerequisite of change.
150. One potentially helpful development is that
set prices for allergy services have, from 2004-05, been included
in the national tariffs or Health Resource Groups (HRGs) supporting
the new Payment by Results system.[160]
HRGs should ensure that valid prices for allergy treatment are
harmonised across the NHS, enabling PCTs to plan the use of their
budgets better in future.
151. The introduction of a national allergy tariff
and the allergy code are important steps, as they mean allergy
can now be registered in NHS systems. It is clearly necessary
to ensure that tariffs are appropriately priced, implemented uniformly
across the NHS, and do not introduce financial incentives for
particular patterns of referral. The tariff must follow the GP's
decision on the patient and not determine where the patient can
go.
152. A further, and possibly more direct route to
achieve change is through the National Specialist Commissioning
Advisory Group (NSCAG), a centralised Departmental body that intervenes
in local commissioning arrangements in special circumstances,
identifying, funding and contracting specialised services centrally,
advising the Secretary of State on commissioner guidelines, and
funding the cost of new developments. NSCAG generally becomes
involved in the commissioning of services that it has defined
as 'Supra Regional' or where there is an overriding economic or
clinical justification for national contracting, or where something
has gone wrong, or where there is a previously unrecognised need
to do something, and to do it quickly. Supra Regional services
are those that are very specialised, and are therefore required
to be provided in a small number of centres, planned and run on
a national basis.
153. Some 32 services are currently designated as
'highly specialist' or 'national'. New services are considered
every year. To be considered, a service fitting the NSCAG criteria
must:
… be facing insurmountable problems for
which the only workable solution is thought to be designation
and central funding. In addition, the application should provide
detailed evidence of the reasons why the existing funding mechanisms
are unable to accommodate the service and the anticipated consequences
if the application is not successful.[161]
154. Additional budgets required to finance newly
designated services come from NHS growth money for new services
or from levies on all PCTs to cover the costs up to the level
of a service already funded within the NHS. If the Department
is prepared to recognise the problem and act on it, a mechanism
exists to initiate the work on the creation of the specialist
centres.
155. Given the serious inequality of access to
specialist allergy services, the key role which regional centres
would play in turning matters around and the absence of active
allergy commissioning locally across the NHS, we believe that
there would be merit in the National Specialist Commissioning
Advisory Group treating the specialist allergy services as national
services, and thus eligible for specific NHS funding. To do this
would be to take a first step in the proactive commissioning of
allergy services.
156. We further believe that the underlying problem
of how to stimulate and inform local PCT commissioners needs also
to be addressed. Fortunately, the Minister has already suggested
a way forward to begin to do this. We welcome the Minister's suggestion
that he should ask the Chief Medical Officer to prepare an action
plan and we look forward to its publication which we hope will
take account of the conclusions of our report.
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