Health and Social Care Bill

Memorandum submitted by the Institute of Commissioning Professionals (HSR 42)

1.0 Institute of Commissioning Professionals

1.1The Institute of Commissioning Professionals ( IoCP) was founded in 2007 to improve commissioning education and standards. Our membership is into three figures but members are senior commissioners from the NHS, Local Authorities and the Voluntary Sector.

1.2 We have introduced a qualification for commissioners based upon the National Occupational Standards for Commissioning, Contracting and Procurement. In addition, in order to improve patient safety and commissioning competence, we are pursuing voluntary registration of commissioners with the Council for Healthcare Regulatory Excellence. Further, a book on Achieving Commissioning Excellence has been published which describes how to embed commissioning excellence within an organisation. The IoCP is integral to leading the way in commissioning practice and increasingly is seeking to set professional standards.

1.3. The Institute of Commissioning Professionals is pleased to have the opportunity to comment on clauses of the Health and Social Care Bill that have been recommitted for examination by the Public Bill Committee. We have paid particular attention to clauses of the Bill that we feel may have particular implications for the health and wellbeing of the population and where the impact of expert commissioners will help to secure improvement.

2. Arrangements for provision of health services (Clauses 9-11)

2.1. Without a clear understanding of the term commissioning and the impact of the introduction of the term ‘Commissioning’ into Clinical roles, then the reforms are vulnerable to severe operational disruption due to legal issues, conflict of interest, registration and the Public Contracts Regulations.

2.2 For avoidance of doubt, commissioning is about ‘What to acquire’. How to acquire can follow a number of routes including right to provide and mutualisation as well as procurement and contracting.

2.3 As breaches in Employment Law and Clinical Negligence settlements are major drains on NHS resources, then with unfettered clinical commissioning pursued by those who have little knowledge and experience of Procurement Law, a third area of rising costs will emerge as suppliers challenge unlawful decisions. It is unlikely that the current clinical negligence insurance arrangements cover commissioning negligence. The responsibilities for commissioning risks require clarification.

2.4 Due to inherent risks in procurement, the Government Chief Procurement Officer is advocating a ‘license to procure’ and there is no acknowledgement of its application to clinical commissioners.

2.5 IoCP therefore agree with the proposed amendment to Clause 9 which extends the responsibility for each clinical commissioning group (CCG) to commission services for "every person present in its area". Commissioning must be undertaken competently to agreed standards, law and best practice.

3. NHS Commissioning Board (Clause 19)

3.1. We support the establishment of clinical senates to advise clinical commissioning groups and the NHS Commissioning Board. As the NHS Future Forum suggests, the establishment of a clinical senates centred around user groups will re-enforce the work of NICE.

3.2. We support the amendments to the Bill suggested that embed the involvement of patients more firmly in the work of the NHS Commissioning Board and at local level.

3.3 The IoCP membership have particular expertise in user participation, JSNA analysis and market development in order to catalyse innovative services and improved outcomes and would hope to be involved in development of this programme and in the development of commissioning standards and education.

3.4. The involvement of secondary care clinicians on clinical commissioning groups is also an important step to ensuring joined-up commissioning and that the pathways are appropriate for those with complex needs, such as the disabled with multiple conditions.

3.5 Clarification of the letter from the EC to the Department of Health giving exemption to GPs in private practice from the Services Directive in the mid 1990s is required to help to clarify and avoid any conflict of interest issues.

4. Abolition of SHAs and PCTs (Clauses 28-29)

4.1. The University of Portsmouth comments; "Our experience is that in the largest counties e.g. Hampshire with an annual budget of over one billion pounds, the commissioning role is achieved  in separate specialist roles as a series of tasks. In these largest organisations separate professions are appropriate of statistical analysis of need in Public Health, then contracting in a purchasing profession and marketing to obtain public feedback.

 However in the majority of counties, and this will apply in future to all Commissioning Consortia, the annual budgets are lower and one person is responsible for commissioning one health pathway from beginning to end. There is then a need for commissioning to become a profession. 

In addition, the major opportunity for saving money currently is improving understanding between the separate 'silos' of GP, hospital and council. Each separately do their jobs professionally, but suboptimally for the whole patient experience. In our opinion this is an additional reason why the most senior leaders need professional understanding of commissioning as a whole."

4.2. The clustering arrangements have reduced commissioning capacity just when demand is due to increase.

4.3 A further comment from a respected Healthcare academic was ‘ previous and current reforms are placing a lot of emphasis on the importance of 'commissioning' and yet this isn't something that has been seen as a function or a profession in its own right historically. To really give commissioning the chance to succeed we need to make sure that there is the right infrastructure in place to make it a career of choice for future health and social care commissioners - and I'm sure the aim of IoCP is to help do this."

5. General duties of Monitor and choice and competition (Clause 56)

5.1. We support the adjusted role of Monitor, and support choice and competition where they drive better care for patients. However, Monitor sees that the NHSCB is responsible for skills development of clinical commissioners. If competition is distorted by poor clinical commissioning practice, then Monitor has an interest in improving practice.

5.2. We particularly welcome the introduction of a clearer duty on Monitor to secure appropriate clinical advice in carrying out its functions and seek clarification on whether they will also be seeking appropriate commissioning advice.

6. Duties and Role of CQC

6.1 The Panorama programme on Winterbourne View outlined acknowledged failures in CQC and inspection. The role of commissioners in making an inappropriate and expensive placement was not highlighted. But surely "he who pays the piper calls the tune"? If more market based solutions to regulation are to be encouraged, such as bad publicity and resultant closure, then clinical commissioners hold the key to quality, service and value. Likewise they require to be competent and beyond reproach.

7. Public involvement (Clauses 178-180)

7.1. New media arrangements and independent websites such as Patient Opinion should be encouraged to improve focused patient involvement.

8. Summary

8.1 There is a presumption that commissioning is just a set of activities. If activities are done well, then they become a skill, if not, then they are a failure. The IoCP is aware of the previous Parliamentary Health Committee’s view of commissioning practice. The lesson is to develop a profession based not just on a series of activities but on commissioning excellence. In order to safeguard the NHS, the IoCP recognises and sees the need for improved commissioning skills in order to provide safe and effective care. All commissioners need to play their part competently and ethically and voluntary registration can help bring that about.

9. Oral Evidence

9.1 The Institute of Commissioning Professionals would be happy to give oral evidence to the Public Bill Committee should it be helpful to their consideration of the Bill.

July 2011

Prepared 19th July 2011