3 COMMISSIONING FOR SPECIALISED
The structure of specialist commissioning
43. Although services in the NHS are commissioned
by PCTs, there are particular arrangements for commissioning specialised
services. Specialised commissioning seeks to ensure that the needs
of those with rare diseases, or who require specialised services
not available in all local hospitals, are met effectively. Examples
of such services include heart, lung and liver transplants, children's
heart surgery and neurosurgery, specialised burn care and the
treatment of illnesses such as severe immune deficiency or rare
These services are often expensive and unpredictable so PCTs have
come together to commission such services collectively and thereby
share the financial risk. These services are often best provided
in a small number of regional specialist centres so doctors and
nurses can develop their skills by seeing as many such patients
44. Following the Carter Review
(see Box 3 below) in 2006 these services are commissioned in the
following ways, as the National Specialised Commissioning Group
The National Specialised Commissioning Group
has responsibility for overseeing specialised commissioning in
England. It facilitates collaborative working between the Specialised
Commissioning Groups, for example through national programmes
such as the national paediatric cardiac surgery and paediatric
neurosurgery programmes, which are currently underway. It also
oversees the national commissioning function. Its voting members
are 10 PCT Chief Executives representing the 10 regional Specialised
The 10 Specialised Commissioning Groups in England,
coterminous with the 10 Strategic Health Authorities, commission
services on behalf of their constituent PCTs. They plan and commission
those services from within the Specialised Services National Definitions
Set that their PCTs direct them to commission. Together they have
an annual budget of about £4.5 billion; approximately 5%
of NHS spend. This does not represent all spending on specialised
services as some services continue to be commissioned locally
by PCTs. The Strategic Health Authorities are responsible for
the performance management of the Specialised Commissioning Group
in their region.
The National Commissioning Group is a standing
sub committee of the NSCG. It is predominantly a clinical group
and commissions over 50 services nationally for England (and in
some cases for Wales, Northern Ireland and Scotland) with an annual
budget of about £480 million.
The National Specialised Commissioning Team commissions
services on behalf of the National Commissioning Group and supports
the work of the National Specialised Commissioning Group, such
as the national paediatric cardiac surgery and paediatric neurosurgery
programmes. The Team also helps facilitate collaborative working
between the Specialised Commissioning Groups.
Figure 1 below shows the accountability arrangements
of the National Specialised Commissioning Group.
Figure 1 - NSCG ACCOUNTABILITY ARRANGEMENTS
Box 3: The Carter Review, May 2006
|The genesis of the Carter Review was the recognition that PCTs were not collaborating effectively in the specialised arena to the potential detriment of people in need of specialised care. The need for collaboration hinges on optimizing the development and use of clinical resources for relatively smaller patient populations for whom the NHS is also uniquely well placed to share financial risk. The Carter Review was commissioned by the DH to help the NHS plan provision for some of the rarest conditions and expensive treatments, investigate how the NHS commissions specialised services and make proposals for improvement. |
The Review recommended a number of changes to ensure the commissioning process was "robust and fair, understood by all, engaged patients and offers value for money". One of the key recommendations of the Carter Review was the creation of the National Specialised Commissioning Group (NSCG), to co-ordinate the commissioning of specialised services, the National Commissioning Group, and of 10 regional Specialised Commissioning Groups, one for each SHA. Carter laid down that services should be funded through budgets pooled between constituent PCTs in each SCG on the basis of weighted capitation. There was also to be a review of the Specialised Services National Definitions Set.,
45. The National Definitions Set contains a list of 35 services
which SCGs are supposed to commission.
Box 4: Specialised Services National Definitions Set
There are 35 specialised service definitions covered by the Specialised Services National Definitions Set. The second edition of the Specialised Services National Definitions Set (SSNDS) was completed in December 2002. The third edition is being created during 2009-10.
The purpose of a definition is to identify the activity that should be regarded as specialised and therefore within the remit of PCT collaborative commissioning. A service is specialised if the planning population (i.e. catchment area) for that service is greater than one million people. This means that a specialised service would not be provided by every hospital in England; generally, it would be provided by less than 50 hospitals.
Each definition is drawn up by an iterative process involving providers (clinicians, hospital managers, and information and coding staff), commissioners, patients' groups and the Department of Health. It is then endorsed by the relevant national organisations, signed off by the National Specialised Commissioning Group (NSCG) and published on the NSCG website.
Criticisms of specialised commissioning
46. It seems to be widely acknowledged that the implementation
of the Carter Review has had a significantly positive effect on
the commissioning of specialised services. The creation of SCGs
in particular has been welcomed as a step forward and we received
encouraging evidence on the work of some of these,
as well as that of a supra-regional consortium of SCGs.
However, we were told that progress in implementing the Carter
Review is slow and patchy, meaning that there is significant inconsistency
between different parts of the country.
In addition, some witnesses thought that the Carter Review had
left some substantial issues unaddressed.
47. We heard that, while the revision of the National Definitions
Set is welcome, many still regard it as too rigid in defining
a specialised service as one "with a planning population
of more than one million people".
Deborah Evans, Chair of the South West SCG, told us:
there are lots of things that have come under the definition
set we now regard as matters that PCTs can and would expect to
commission within their normal pathways.
She cited as examples cardiology and cardiac surgery, and child
and adolescent mental health services, in both of which cases
SCGs were only involved in commissioning "the very complex
end" of service provision. Getting the right "dynamic
] between the PCT and specialised levels" was particularly
important in creating better care pathways for people with chronic
conditions, helping to join specialised commissioning at the local
level with other services, including social care.
48. The most important criticism of the Carter Review which we
heard was that it had not gone far enough in strengthening specialised
commissioning. We were told that, while the creation of SCGs and
the NCG had reinforced specialised commissioning, they were hobbled
by the fact that PCTs still retained ultimate responsibility for
specialised commissioning and control of the purse strings. The
Specialised Healthcare Alliance told us:
Carter depends on the willingness of PCTs to share sovereignty
and resources in a way which is counter to their instincts and
the rhetoric of localism.
According to the Alliance, PCTs were often reluctant to pool risk
properly, by combining funding with other PCTs on a weighted capitation
49. We were informed that SCGs had no authority over PCTs, since
the former were actually sub-committees of the latter. This means
that SCGs have no power to oblige PCTs to participate in collective
commissioning, or to make them commission services locally when
they are not commissioned at the regional level.
Mr Murray, the Director of the Alliance, told us about lack of
attendance by PCT Chief Executives at SCG meetings, indicating
that the PCTs concerned were treating specialised commissioning
as a low priority.
50. The Alliance further told us that the status of SCGs meant
that they existed in a kind of "limbo", unable to be
subjected to regulation, performance management, scrutiny and
accountability in the way that PCTs were.
This meant, for instance, that while the DH had developed a "World
Class Specialised Commissioning" programme for SCGs, this
was not mandatory in the way that WCC was for PCTs.
51. The Alliance voiced the fear that, during the impending period
of financial restraint, PCTs would "look to protect local
services in the downturn to the detriment of clinically and cost
effective specialised care", something which SCGs would be
powerless to prevent.
52. Accordingly, the Alliance argued strongly in favour of making
SCGs commissioners in their own right, channelling funds directly
to them instead of giving them to PCTs and locating them at SHA
level (rather than being hosted by a PCT). The Alliance also made
the same argument in respect of the NCG, arguing that it should
be funded directly (rather than through top-slicing of PCTs, as
at present) and performance managed by the DH, with Ministers
continuing to be involved in decisions about service provision.
53. However, Ms Evans told us that this would cut
across patient pathways and could damage the quality of care:
I do not believe it is in the interests of patients
to take all the money to do with specialised commissioning away
from PCTs and put it with another body [
] the challenge
but also the strength of PCTs is that they look after a whole
population and look across a whole pathway. I do not think it
makes sense to take the very specialised end of, say, renal services
and give it to another body and then say that all the other aspects
of renal services, like looking after people in primary care,
early detection of disease and end-of-life care, should be put
] The best interests of patients are for us to
make the dynamic between PCT commissioning and SCG commissioning
work. Rather than give up on it we should make it work better
and that is in the interests of patients.
54. The implementation of the Carter Review has
made significant improvements to the commissioning of specialised
services over the past four years. However, we are concerned that
insufficient progress has been made, with significant local variations;
and that some important issues remain outstanding.
55. Carter recommended the revision of the National
Definitions Set; this does not appear to have gone far enough.
The DH must indicate what it will do to ensure that the fourth
edition commands wider confidence and support among commissioners.
56. Worryingly, the evidence which we received
indicates that many PCTs are still disengaged from specialised
commissioning. Furthermore, there is a danger that the low priority
many PCTs give to it will mean that funding for specialised commissioning
will be disproportionately cut in the coming period of financial
restraint. In addition, specialised commissioning is weakened
by the fact that, as a pooled responsibility between PCTs, it
sits in a "limbo", where it is not properly regulated,
performance managed, scrutinised or held to account. There is
much to commend the Specialised Healthcare Alliance's proposal
to bypass the PCTs altogether, making the National Commissioning
Group and the Specialised Commissioning Groups into commissioners
in their own right, although there is some risk that this could
lead to a lack of co-ordination of, and disruption to, services.
We recommend that the DH undertake a review of the problems we
have highlighted, taking into account the Specialised Healthcare
31 Ev 182 and http://www.ncg.nhs.uk/ Back
Review of Commissioning Arrangements for Specialised Services.
Independent Review requested by the Department of Health, May
Ev 182 Back
Ev 183 Back
The third edition of the National Definitions Set is being released
in spring 2010. Back
Ev 149-151, 262-263 Back
Ev 151-154 Back
Ev 272, 299 Back
Ev 108 Back
Q 253 Back
Q 259; cf. Ev 35, 75, 197 Back
Ev 271 Back
Ev 272, 274 Back
Ev 145, 258 Back
Q 261 Back
Ev 273; cf. Ev 146 Back
Ev 144, 274; Qq 256-258 Back
Ev 272 Back
Ev 271, 274; cf. Q 267 Back
Q 254 Back