Health and Social Care Bill

Memorandum submitted by Asthma UK (HS 34)

Summary

1. The Health and Social Care Bill has the potential to make improvements to health outcomes but it will not deliver those improvements without aspects of the Bill being strengthened. The key areas which need to be strengthened are reporting on improvements in primary care by commissioning consortia, patient and public involvement in commissioning and multidisciplinary involvement in commissioning.

2. As the majority of both routine and acute management is provided by primary care, [1] Asthma UK is advocating for clearer duties on reporting from commissioning consortia on improvements in the quality of primary care services. Secondly, regarding the commissioning of services to ensure that they are appropriate for people with asthma, Asthma UK is concerned about the downgrading of patient and public involvement in the Bill. Thirdly, Asthma UK recommends strengthening the duty on the commissioning bodies to obtain appropriate advice to ensure the appropriate involvement of multidisciplinary teams in the planning of services and care pathways, to ensure efficient and effective services.

About Asthma UK

3. Asthma UK is the charity dedicated to improving the health and well-being of the 5.4 million people in the UK, including the 4.5 million people in England, whose lives are affected by asthma. We work together with people with asthma, healthcare professionals and researchers to develop and share expertise to help people increase their understanding and reduce the effect of asthma on their lives.

Asthma

4. The prevalence of asthma in England is 8.9%. [2] Asthma is a long-term condition that requires regular monitoring and therapeutic adjustment. However, survey research has consistently shown unacceptable morbidity associated with low expectations on the part of asthma patients. [3] These low expectations include seeing asthma as an intermittent acute disorder rather than as a chronic condition. [4] A key strategy for improving outcomes and quality of life is therefore to shift the emphasis from the acute management of asthma (with its associated exacerbations and high-cost emergency admissions, of which there were 67,766 in England in 2009-10 [5] ) to supported self-care with asthma managed as a long-term condition.

5. In this submission Asthma UK is advocating for clearer lines of accountability in the Health and Social Care Bill to improve quality in primary care so that outcomes for people with asthma can be improved. Secondly, regarding the commissioning of services to ensure that they are appropriate for people with asthma, Asthma UK is concerned about the downgrading of patient and public involvement in the Bill, where GP Consortia and The NHS Commissioning Board have a weaker duty to involve patients and the public than Primary Care Trusts and Strategic Health Authorities currently have.

6. Finally, Asthma UK recommends strengthening the duty on the commissioning bodies ‘to obtain appropriate advice’ to ensure the involvement of multidisciplinary teams in the planning of services and care pathways, to ensure efficient, effective and well-integrated services. This is particularly relevant for the 5% of people with asthma who have severe asthma – people who are living with severe asthma symptoms despite taking high doses of medicine correctly – and who need to use many different NHS services for their healthcare needs. [6] We also hope that the promotion of multidisciplinary working will help to ensure that the work of the newly-established respiratory networks will continue to promote service improvement for people with asthma.

Quality improvement in primary care

7. The majority of both routine and acute management is provided by primary care. [7] Asthma UK is advocating for clearer duties of public reporting between the NHS Commissioning Board and Commissioning Consortia to demonstrate continuous improvement in the quality of primary medical services so that outcomes for people with asthma can be improved.

8. The White Paper proposed that the NHS Commissioning Board commission primary care services and consortia should have a key role in improving the quality of general practice services. The explicit duty for commissioning consortia ‘to assist and support the Board [to secure] continuous improvement in the quality of primary medical services’ (Section 22, page 30, line 15) is a welcome addition, as Professor Chris Ham of the King’s Fund elucidates:

‘Experience shows that quality improvement in primary care is best undertaken at a local level based on a thorough understanding of the work of practices and the use of performance data to bring about improvements. The NHS Commissioning Board will not be able to take this task on alone because it will lack the expertise and be too remote from the provision of care on the ground.’ [8]

9. However, as Asthma UK is interested in the continuous improvement of primary medical services and bearing in mind that there are potential conflicts of interest between commissioning consortia reporting on quality in primary medical services, we would like to see an explicit duty to publish standardised reports relating to quality in primary care. Asthma UK recommends amending section 22, page 34, line 42:

‘An annual report must, in particular, explain how the commissioning consortium has discharged its duty under sections 14L and 14P.’

10. Asthma UK recommends that section 22, page 34, line 42 is amended to include section 14M (section 22, page 30, line 15), the ‘duty in relation to quality of primary medical services’:

‘Each commissioning consortium must assist and support the Board in discharging its duty under section 13D so far as relating to securing continuous improvement in the quality of primary medical services.’

11. The relevant section ‘reports by commissioning consortia’, section 22, page 34, line 42 would then read:

‘An annual report must, in particular, explain how the commissioning consortium has discharged its duty under sections 14L, 14M and 14P.’

12. As well as making information about quality improvement in primary care part of their published reports, Asthma UK also recommend that commissioning consortia make information available to patients and the public about quality in primary care. Asthma UK recommends strengthening section 22, page 30, line 28:

‘(d) enable patients to make choices with respect to aspects of services provided to them as part of the health service.’

This section should be strengthened to reflect the White Paper consultations An Information Revolution and Greater Choice and Control to read:

‘(d) enable patients to make informed choices with respect to aspects of services provided to them as part of the health service.’

This will help to ensure that quality is recognised and rewarded in primary care services.

Patient and public involvement in commissioning

13. Effective patient and public involvement leads to improvements in health services and more efficient and effective care pathways. [9] The Health and Social Care Bill downgrades the current duty to involve patients and the public in commissioning. This is contrary to the White Paper’s statement that ‘patients will be at the heart of everything we do’. [10]

14. The current duty on commissioning bodies (PCTs and SHAs) to involve patients and the public is described in Section 242 of the NHS Act 2006. This duty to involve is being retained for Foundation Trusts in the new NHS architecture. However, for the new commissioning bodies (the NHS Commissioning Board and commissioning consortia), the Bill places a weaker duty to public involvement and consultation in separate sections of the Bill.

15. Section 242 of the NHS Act 2006 places a duty to ensure that persons to whom services are being or may be provided are, directly or through representatives, ‘involved in and consulted on:

(a) the planning of the provision of those services,

(b) the development and consideration of proposals for changes in the way those services are provided, and

(c) decisions to be made by that body affecting the operation of those services.’

16. In the Health and Social Care Bill parts(a), (b) and (c) above are repeated (with minor changes in wording) in section 19, page 18, lines 23-33 and section 22, page 31 lines 4-11, but the duty to involve is downgraded. In healthcare the definition of involvement encompasses a range of activities, on a ‘continuum’ of involvement. The stages, in order of increasing levels of involvement are: providing information, consulting, partnership and delegated power. [11] Looking at the relevant sections of the Health and Social Care Bill (reproduced below) it can be demonstrated that there is a downgrading of patient and public involvement by the new commissioning bodies, away from people being involved and consulted and towards a situation where commissioners will be able to solely provide information.

17. Section 19, page 18, line 20:

‘The Board must make arrangements to secure that individuals to whom the services are being or may be provided are involved (whether by being consulted or provided with information or in other ways)-

(a) in the planning of the commissioning arrangements by the Board,

(b) in the development and consideration of proposals by the

Board for changes in the commissioning arrangements where the implementation of the proposals would have a significant impact on the manner in which the services are delivered to the individuals or the range of health services available to them, and

(c) in decisions of the Board affecting the operation of the commissioning arrangements where the implementation of the decisions would (if made) have such an impact.’

18. Section 22, page 30, line 42 repeats the above duty for commissioning consortia.

19. Asthma UK believes that the key to commissioning effective and efficient services is understanding and capturing the needs of the patients and public who use those services. The Health and Social Care Bill, in its current form, does not encourage this. Asthma UK has been working with eight other national charities [12] to develop a consensus view on this issue and we support the amendments put forward by this group.

Multidisciplinary involvement in commissioning

20. The bill places a duty to obtain appropriate advice on the NHS Commissioning Board (section 19, page 17, line 17) and Commissioning Consortia (section 22, page 30, line 32). It states that the Board and consortia must:

‘make arrangements with a view to securing that it obtains advice appropriate for enabling it effectively to discharge its functions from persons with professional expertise relating to the physical or mental health of individuals.’

21. Asthma UK, in concert with eight other national health charities, is concerned about the lack of emphasis on input into local service design and commissioning by expert health and social care professionals and patient groups. This is particularly relevant for the 5% of people with asthma who have severe asthma – people who are living with severe asthma symptoms despite taking high doses of medicine correctly – and who need to use many different NHS services for their healthcare needs. Furthermore where the commissioning of whole pathways of care for some conditions will fall under the remits of public health, the NHS Commissioning Board and GP consortia, this risks the fragmentation of service provision.

22. Integrated and effective care depends on collaboration between professionals, but the current duty on the National Commissioning Board and GP Consortia to ‘obtain advice’ from health professionals is not a strong enough requirement for integrated working. Multi-disciplinary involvement of specialists, Allied Health Professionals, education, social care and patients is required to enhance continuity of care and improve quality standards for patients. We recommend that the duty to ‘obtain advice’ is strengthened to a duty to ‘consult’ expert health and social care professionals, expert patient groups and organisations.

February 2011


[1] Neville RG, Clark RC, Hoskins G, Smith B. National asthma attack audit 1991-2. General Practitioners in Asthma Group. BMJ 1993; 306:559-562.

[2] Department of Health (2001) Health Survey for England 2001.

[3] For example, Pinnock et al (2010) Setting the standard for routine asthma consultations, Primary Care Respiratory Journal , 19(1), p.76.

[4] Jones et al (2000) Qualitative study of views of health professionals and patients on guided self management plans for asthma. British Medical Journal , 321, 1507-10.

[5] Hospital Episode Statistics 2009-2010 . Combined admissions for primary diagnosis of J45 ‘Asthma’ and J46 ‘ Status Asthmaticus’ . Available at: http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=203

[6] Asthma UK (2010) Fighting for Breath: the hidden lives of people with severe asthma .

[7] Neville RG, Clark RC, Hoskins G, Smith B. National asthma attack audit 1991-2. General Practitioners in Asthma Group. BMJ 1993; 306:559-562.

[8] Professor Chris Ham (2011) Ten questions to ask about the Health and Social Care Bill. Available at: http://www.kingsfund.org.uk/blog/health_bill_question.html

[9] NHS Institute for Innovation and Improvement (2011) The rough guide to experience and engagement for GP Consortia , p.4.

[10] Department of Health (2010) Equity and Excellence: Liberating the NHS , p.1.

[11] Frances Hasler (2008) Partners in Part icipation? Involving people who use Social Care services in The National Centre for Involvment, Healthy Democracy , p.83-94.

[12] Alzheimer’s Society, Asthma UK, Breakthrough Breast Cancer , British Heart Foundation, Diabetes UK, Rethink mental illness, the Stroke Association and National Voices .