Further memorandum by Dr Daphne Austin
(COM 115A)
WORLD CLASS COMMISSIONING
Following on from the 2nd session of the Inquiry
I would like to respond to some of the comments relating to Specialised
Commissioning.
THE NATURE
OF SPECIALISED
SERVICES
It is erroneous to see specialised services
commissioning as commissioning for rare disorders Whilst this
might be the case for national commissioning it is not true at
regional and sub-regional level. Many of the services Specialised
Commissioning Teams commissioning are specialist services for
common disorders or conditions.
— Neonatal intensive care and special care
baby units are an integral part of maternity services. Most babies
are not very small babies but need stabilisation or care for only
a short period of time.
— Cardiothoracic surgery is comprises surgery
for people with coronary heart disease or valve disease.
— Radiotherapy is used overwhelming for
patients with breast, prostate and lung cancer.
— Renal dialysis for end stage renal disease
and again is an integral part of general renal services.
It is for this reason that the Department of
Health proposals for two levels of specialised commissioning below
the national level were supported. These proposals predated Carter
by about five years. This meant that PCTs collaborated in clusters
sharing a tertiary centre for common disorders—maternity
and neonatal services, cancer services, cardiac services and so
on. These often also coincided with network boundaries and planning
was across the entire patient pathway for that common disorder.
Local collaborative teams would still co-operate with each other
at regional level. So it was possible to optimise capacity across
the region for CABGs for example and also agree which area would
get access to regional capital funds to establish the next satellite
renal unit. For burns services however there generally is only
one adult and one children's centre serving one or more regions
and for these services commissioning was undertaken at regional
level.
RISK SHARING
Each SCG will have its risk sharing schemes
but in the West Midlands two different types have operated over
the years.
Capitation—services are funded
on a weight capitation scheme. These are only really appropriate
where PCTs might be exposed to extreme risk—as in the case
of the use of haemophilia blood replacement products either because
a local patient develops inhibitors or a severe haemophiliac who
has multiple trauma injuries. Here the risks are extreme and unpredictable.
Serious burns would also be appropriate. Serious burns have become
a rare event and it is likely that when they do occur a number
of people will be affected at the same time. However—the
whole region has to maintain the capacity which some years might
not be used to maximum effect. It would therefore be appropriate
to suitable to fund on a capitation basis.
Three year rolling averages—as
indicated above—most regional services are specialised services
for relatively common conditions. For these we generally use three
year rolling averages. Risk is managed in year and across a three
year period across the region which protects individual PCTs from
peaks. In the long term however the PCT will pay for trends in
usage.
At the Committee evidence session much was talked
about top slicing in order to fund all specialised services on
a capitation basis. I think few commissioners and public health
practitioners would support this. I will discuss equity shortly
but the top slicing which seems so attractive needs further examination.
The most important objection to funding on a
weighted capitation basis is that PCTs currently do not receive
their weighted and targeted funding. This fact seems to be constantly
ignored whenever postcode variation is talked about. PCTs that
form one of the local collaboration in the West Midlands is about
£100 million short of its target funding. If the PCT
which gets the least funding (Barnsley) were to be funded to the
same level as the best funded (Richmond and Twickenham) it would
receive a further £50 million.
If funding for specialised services were to
be top-sliced on the basis of weighted capitation or even as a
percentage of their funding—clearly the impact on the budget
and therefore the opportunity cost would not be evenly distributed.
Secondly because many specialised services are
services for common disorders—it is more logical for access
and funding to reflect the burden of disease in each individual
PCT. Coronary heart disease for example is distributed differently
according to the age structure of the population and deprivation.
A young population will not have as much CHD but more will be
needed for primary prevention, children services and maternity
services for example.
VOTING
I would agree with Deborah Evans that PCTs aim
to come to agreement through consensus rather than through the
vote. But voting rules exist and below are the rules for the West
Midlands. Our voting system is designed to serve both local and
regional collaborative commissioning (tiers I and 2 as indicated
in my presentation on 14 January)).
Summary of West Midlands SCG and LCCB voting rules
SCG: Majority voting 5:2
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| Pan Birmingham LCCB: | 2 votes (can't be split)
|
| Shropshire & Staffordshire LCCB: | 2 votes (can't be split)
|
| Black Country LCCB: | 1 vote
|
| Coventry & Warwickshire LCCB: | 1 vote
|
| Herefordshire & Worcestershire LCCB: |
1 vote |
|
Shropshire & Staffordshire LCCB: Majority voting where
meeting is quorate (minimum any four PCTs)
|
| South Staffordshire PCT: | 2 votes (can't be split)
|
| North Staffordshire PCT: | 1 vote
|
| Stoke PCT: | 1 vote
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| Telford & Wrekin PCT: | 1 vote
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| Shropshire County PCT: | 1 vote
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|
Black Country LCCB: Majority voting (2:1)
Pan Birmingham LCCB: Majority voting (3:2)
Coventry & Warwickshire LCCB: Both PCTs to agree
Herefordshire and Worcestershire LCCB: Both PCTs to agree
REASONS FOR
COLLABORATIVE COMMISSIONING
FOR SPECIALISED
SERVICES
I am somewhat surprised that equity is given as the main
reason for commissioning at the regional level.
Firstly on what grounds can one support addressing equity
of access and quality for certain groups of patients wholesale
above others? Variation in access and quality in services for
common disorders and in mainstream disorders is as great as it
is in specialised services. Why should access to specialised cardiac
interventions which may reduce admission rates and extend life
for some people than say providing basic dementia services or
tier 2 and 3 level mental health services for children?
And why is it inherently more important for specialised services
to be funded in order to provide the highest possible quality
of service than any other? Many ethicists and PCTs would challenge
this view. In an ideal World we would want to provide all needed
services to the highest quality to everyone. However in a resource
constrained health service the key question is which is the most
important equity or inequality to address? Sometimes this might
be health care for a rare disorder, a specialised services and
sometime not. However, top-slicing prevents this sort of debate.
Furthermore a system will be created in which any inequity either
in access or quality in these services always getting priority
when it comes to funding. A bias in favour of particular types
of services or particular types of conditions should, in my view,
be resisted.
Secondly, it is also important to consider the nature of
the services commissioned. Many are highly technical. To give
preferential treatment in all circumstances is to give preferential
to the nature of the treatment and not the patient group or the
health need per se.
Thirdly, if there is a view that rare disorders should take
priority then are more coherent policy for rare disorders is required.
In reality it is access to highly technical services which is
the main focus of concern. Most services for the 10,000 rare
genetic disorders and other rarer conditions or patient subgroups
are commissioned by both the national and regional level are relatively
small. Most problems are in co-ordination of care, and rehabilitation
and support for long term chronic conditions—but many of
these problems are common to services for other conditions.
Given the number of rare disorders and conditions alternative
solutions need to be developed to help facilitate developing specialist
interests amongst clinicians and enable clinicians and patients
to access maybe clinical teams with a specialist interest.
Collaborative commissioning has an important role to play
but one has to be very clear of the benefits and the purposes
of collaborative arrangements for any specific services.
CONSULTATION FOR
REGIONAL SERVICES
I think most SCTs would welcome consultation being simplified.
In our own region we have undertaken a needs assessment and designation
for neonatal services but it has been difficult implementing aspects
of because there is local resistance. Everyone supports designation
when they win but are not supportive when they see their local
service being downgraded. It has taken years to secure a location
for a third medium secure service for personality disorders and
sexual offenders in the West Midlands.
INDIVIDUAL FUNDING
REQUESTS
Specialised commissioning teams are not statutory bodies.
The responsibility for funding decisions sits legally with the
PCTs. If there is a challenge on an individual funding request
it is the PCT which will be taken to court and not the SCT or
the SCG.
Most SCTs therefore have an arrangement whereby the delegated
authority for funding decisions around individual patients is
limited. However this does not mean that the PCT makes decisions
in isolation. If our SCT forwards an IFR to the PCT—it does
so with an analysis of the case and a recommendation to either
to fund, not fund or indicating that the decision is a close call.
When a capitation risk sharing applies then it is more essential
that all PCT operate a common policy.
January 2010
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