Examination of Witnesses (Questions 228
- 239)
THURSDAY 14 JANUARY 2010
PROFESSOR ROD
GRIFFITHS, MR
JOHN MURRAY,
MS DEBORAH
EVANS AND
MS TERESA
MOSS
Q228 Chairman:
Welcome to the second evidence session in our inquiry into commissioning.
For the record, perhaps you would give us your names and current
positions.
Ms Moss: I am Teresa Moss, director
of Nationalised Specialised Commissioning.
Ms Evans: I am Deborah Evans and
I chair the South West Specialised Commissioning Group and I am
chief executive of NHS Bristol.
Mr Murray: I am John Murray, director
of the Specialised Healthcare Alliance.
Professor Griffiths: I am Rod
Griffiths, chair of the National Specialised Commissioning Group.
Q229 Chairman:
Ms Moss, can you explain the structure of commissioning for specialised
services and the rationale behind it?
Ms Moss: Thank you for giving
me this opportunity. I will give a brief overview of specialised
commissioning. It is important to begin by stressing that the
NHS is here for everyone, not just those with conditions we can
diagnose and treat rapidly. The NHS is there even for patients
with very rare conditions which sometimes require expensive and
specialist treatment. We refer to very rare treatments and therapies
as specialised services. They are commissioned either regionally
by specialised commissioning groups, of which there are 10 in
England based in the 10 strategic health authorities or nationally
by the National Specialised Commissioning Group. The distinction
between those two tiers is really based on the rarity of the disease.
For national commissioning one really expects only 400 or 500
patients with those conditions needing that treatment a year.
We are talking of a wide range of specialised services. To give
examples, at national level we commission heart and lung transplants
and liver transplants; at regional level we commission bone marrow
transplants, children's heart surgery and brain surgery. They
really are very specialised services. By commissioning these services
centrally either on a regional or national basis we can achieve
very important benefits on behalf of patients. The first of those
is equity. If this was left to every PCT they would have different
arrangements. By doing it on a collaborative basis across a region
we can ensure more equitable access to these services no matter
where patients live. The second good reason for doing it is that
we can start to establish common standards that patients can expect
across the country which means better outcomes. There is another
issue about what we call risk sharing or cost sharing. The 152
primary care trusts around the country can share the costs of
these treatments so that no single PCT is overwhelmed by the cost
if they have a cluster of patients perhaps with a rare inherited
genetic disorder or a number of expensive treatments they need
to resource for their patients in a single year. That is another
important reason. Most importantly, by co-ordinating this commissioning
we can set up specialist centres and concentrate the services
for these rare conditions in specialist services. Clinicians become
very knowledgeable about those services and patients get a much
higher quality service. That is really important for patients
with a rare condition who have been from pillar to post trying
to find somebody who understands their condition.
Q230 Chairman:
The Carter Review of specialised commissioning took place in 2006.
We have had evidence submitted to us that some of the reforms
recommended by that inquiry have not been fully introduced. Do
you have a view about that?
Ms Moss: We have made a lot of
progress so far and there is still work to do on that. Sir David
Carter said we needed to review the processes that he recommended
about now. Where have we got to? He proposed that we set up the
arrangement that I have described in part. All of the regional
specialised commissioning groups in each SHA are fully in place
and are stronger than they have been in the past. We have the
national commissioning group in place and the National Specialised
Commissioning Group oversees national commissioning and also supports
those specialised commissioning groups to make pan-SCG decisions.
The groups are there and we need to keep developing the expertise
we have been building in those committees and get the further
benefits of those structures. He recommended that we completely
revise the specialised services national definitions set that
describes rare conditions and services in much greater detail.
We have completed that revision in the past few days. It was an
enormous task with enormous consultation around it. There were
contributions from a huge number of patient and clinical groups.
I believe that will be a valuable tool as we go into the next
phase of specialised commissioning. He also asked that we focus
on service mapping and costing to identify costs and quality indicators
so we could do effective benchmarking across the country for specialised
services. All of the SCGs have agreed a top 10 list of priority
areas and each leads on one of those to identify those costs and
quality indicators they can take forward and benchmark. That project
is well under way but it will need to be resourced if we are to
pick up the pace of it. From my perspective it is important we
do that so the specialised commissioning groups have that information
available to them; otherwise, we rely on patient groups to give
feedback on variations across the country and the services we
are commissioning and that cannot be right. There are lots of
examples of where we have made progress since.
Q231 Chairman:
Who is responsible for pushing through the reforms of the Carter
Review?
Ms Moss: It is done at different
levels. For national commissioning I lead that particular team
and NHS London does that on behalf of the other SHAs. For the
10 SCGs PCT chief executives are given the responsibility to chair
those local services. Sir David Carter laid strong emphasis on
SHAs providing a championship role to oversee the strength of
SHAs in specialised commissioning in their areas. It is important
to make sure that all the PCTs are fully engaged around the specialised
commissioning agenda.
Q232 Dr Stoate:
Ms Evans, who holds the purse strings?
Ms Evans: The arrangement is that
PCTs and their regional specialised commissioning groups make
an agreement about what will be commissioned by the specialised
commissioning group regionally. That amount of money is drawn
from the PCT baseline, so they agree on a sum of money and their
list of services and those are the things that the specialised
commissioning group commissions on behalf of PCTs.
Q233 Dr Stoate:
Are the SCGs free to make any spending decisions on their own
or do they have to listen to the PCTs?
Ms Evans: It has a very strong
and clear government arrangement which is that the specialised
commissioning group is formally set up as a sub-committee of every
primary care trust in a region. In my region there are 14 primary
care trusts. Each chief executive is a voting member of the specialised
commissioning group and collectively takes those decisions. Those
decisions are reported back to every primary care trust board.
Q234 Dr Stoate:
Is it fair to say that the national commissioning group has no
influence in this at all; it has to be done locally?
Ms Evans: The PCT level of governance
is very clear. We have to make sure that when we are formally
taking decisions about service change they are rooted at the appropriate
level. A lot of the decision-making is formally to do with the
primary care trust, but I do not think it is right to say that
the NSCG does not have a role. Each of the chairs of the specialised
commissioning group—I am chair for the south west—is
a voting member of the National Specialised Commissioning Group.
We sit collectively in that group and take decisions about the
priorities for work that is to be done and so on. The national
specialised group is also the place where NCG agenda and budgets
are discussed. Ms Moss may want to talk a little more about the
role of NSCG in that respect.
Q235 Dr Stoate:
Surely, the NSCG does not have any financial power. My understanding
is that the rules insist that it is all done locally. Does that
not lead to the risk of a postcode lottery among the different
groups, or is all of that being ironed out?
Ms Evans: My colleague was right
to put equity as one of the key things we are trying to achieve.
We try to do that in a number of ways. For example, when we look
at designation of services we consider the whole pathway and concentrate
on the specialised element of the pathway. We go through a process
of setting service standards which we expect to be met. Those
are set jointly with clinical, managerial and patient involvement.
We get a set of standards and then a process by which we designate
centres. What each SCG also has to do—we are able to draw
it together by looking across the country—is look at some
of the difficult issues about access. To use an example close
to home, in the south west when we were first established in 2006
we looked in a basic way across our region and asked whether we
had deficits in terms of specialised services. One that leapt
out was services for neuromuscular diseases where in outline we
appeared to be doing poorly in terms of outcomes. That suggested
we did not have good enough access and since then we have had
a programme to develop and invest in those services which is partly
under way now. We are at an early stage with some of these services
in being able to understand access and compare how well we are
doing across the country. That is work that increasingly we need
to strengthen. My colleague has already mentioned the service
mapping and costing groups which mean that each SCG will take
a lead. For example, one will look at both the costing and quality
issues in renal services; one will look at neurosurgery; another
will look at HIV, and so on.
Q236 Dr Stoate:
But what if you looked at your neuromuscular services and found
them wanting but decided you did not care much about them? What
would happen then? Obviously, I am caricaturing it. Let us say
you decided that you were pretty poor at it but it was not a priority.
Ms Evans: One of the reasons why
the role of specialised commissioning groups is very hard is that
it is our responsibility to make those decisions and be accountable
for them.
Q237 Dr Stoate:
To whom are you accountable if there is no national standard?
Ms Evans: All of us have to work
with the evidence we have and strengthen it as we go along; we
have to look at what we know about health needs. We have already
heard a lot about assessing health needs this morning.
Q238 Dr Stoate:
You are telling us about the process that you undergo, but if
you decided that it simply was not an issue because it was not
a priority for you and you would not do it what would happen?
Ms Evans: Clearly, we have made
those decisions and are accountable to our primary care trust
board, so each board carries that responsibility and would have
to account for it. It is also right to acknowledge that strategic
health authorities have a responsibility to performance manage
specialised commissioning groups. Their role is to make sure we
are doing our job properly. Obviously, they have decided to ask
the chief executive of NHS London to be responsible for having
a specialist in specialised commissioning and chairing the national
group. Therefore, we have performance management at that level
and accountability at the PCT board level.
Q239 Chairman:
On average specialised commissioning groups have about 15 PCTs
sitting on them. What happens if you do not reach agreement? How
do you get a consensus?
Ms Evans: We have very long meetings
if we do not get agreement. We have a clear national establishment
agreement which sets out how decisions will be taken. We have
a quorum. In our case there is a requirement that 10 of the chief
executives out of the 14 will be present at any one time, so it
is a demanding quorum. We have a formal route by which we take
decisions by majority if we have to. We prefer not to do it that
way and wherever we can we will sit down and hammer out the debate
until we have agreement round the table.
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