Health and Social Care Bill

Memorandum submitted by the British Society for Rheumatology (HS 91)

BSR is a medical specialty society promoting excellence in the treatment of people with arthritis and musculoskeletal conditions, and supports those delivering it. BSR has a 25 year history of promoting high quality standards of care, and providing education, training and support to those working in rheumatology. With more than 1,500 members including rheumatologists, scientists, trainees, allied health professionals and others from the UK and overseas, BSR also has close links with a number of patient groups, including Arthritis Care, National Rheumatoid Arthritis Society (NRAS) and Arthritis and Musculoskeletal Alliance (ARMA).

Executive Summary

· BSR strongly supports greater patient involvement and the emphasis on putting the patient at the centre of care and the concept of ‘no decision about me without me’.

· BSR welcomes the opportunity for increased chances of working directly with frontline colleagues in primary care.

· Specialists, including consultants, other health professionals and key stakeholders must be involved in commissioning in addition to General Practitioners.

· GP consortia must have robust and transparent commissioning processes.

· GP commissioning must include provision of services for complex and long term rheumatological conditions.

· Many musculoskeletal (MSK) conditions require long term multi-disciplinary and multi-specialty input. The introduction of competition in commissioning of services could create the risk of fragmentation of existing good quality clinical networks.

· The NHS Commissioning Board (NCB) should have responsibility for ensuring that regional variations to services do not increase health inequalities for people with arthritis.

· A medical expert on musculoskeletal disorders is needed on the NCB to ensure Rheumatology services are appropriately commissioned across the country and are not dependent on GP awareness.

· Providing a service commissioned by a number of consortia, where each consortia is commissioning different levels of service could lead to clinicians spending much time identifying what they can and cannot do for a patient and loss of coordination and strategic planning.

· BSR welcome the greater emphasis on quality and outcome measures rather than focussing on targets that may not be clinically relevant.

· BSR supports the strengthening of NICE and would welcome opportunities for further engagement in production of guidelines and development of national audit tools.

· BSR welcomes the greater emphasis placed on chronic diseases. We hope that it is recognised that most MSK conditions are chronic, potentially progressive and disabling and/or life shortening.

Full response

1. BSR promotes the involvement of patients in decisions about their care, and promotes a patient specialist partnership, as this helps to promote high quality care. Therefore, BSR supports the strengthening of the patient voice and the creation of HealthWatch. However, in order to strengthen the patient and carer voice, current systems need to be evaluated.

2. Patient involvement needs to work at all levels; nationally, locally and at individual levels. BSR works nationally with organisations such as ARMA and Arthritis Care to influence policy for those with MSK. At a local level, clinicians are working with local patient groups to help develop better services and commissioning. All clinicians discuss treatment options with their patients, and work with their patients so that they are able to make an informed choice about the treatment they receive.

3. BSR welcome the opportunity for GPs and other clinicians to be involved in commissioning services. In order for commissioning to be successful, it will be important to ensure that all stakeholders, particularly specialists, are involved in the planning and commissioning of all services. This is particularly the case for specialist services and for those with complex and long term conditions.

4. BSR believe that to ensure that services for people with MSK conditions are effective and equitable; the NCB should have an MSK expert to advice and support their work, supported by a clinical network. The recent report from the National Audit Office identified low awareness of RA among the GP community. Having expertise at a national level will help to ensure that essential services for these patients are not overlooked.

5. BSR is concerned that communication and coordination between consortia and secondary care will not be effective without specific guidance and support in place. Input from specialists will be needed for the consortia commissioning decisions. This will allow them to plan pathways across primary and secondary care, strengthen referral patterns and improve the flow of information about the quality of care.

6. There is fear that if GP consortia are to be smaller than PCTs, a loss of coordination and strategy will occur in the commissioning of hospital services. Robust governance arrangements that emphasise the quality of care rather than its locus of delivery should drive commissioning. Safeguards need to be in place to prevent bias towards primary care provision over secondary care, which cannot be justified on quality grounds. For example, clinical governance arrangements need to include a statutory requirement for external scrutiny.

7. BSR is concerned that the introduction of competition could lead to the fragmentation of services. The chronic, systematic and disabling nature of many MSK conditions requires long term multi-disciplinary and multi-specialty input. The value of the introduction of competition in commissioning of services needs to carefully be considered to ensure that fragmentation of existing good quality clinical networks does not take place.

8. To reduce the risk of such fragmentation of services occurring, specialists as well as public health doctors must share positions within the governance structures of GP consortia so that they can contribute their knowledge and expertise to commissioning care. Consortia should also have access to networks of MSK specialists, such as currently takes place in cancer and cardiac networks. It is suggested that the NCB should develop sub-groups of clinicians that look at specialised commissioning in the different specialties.

9. The commissioner provider separation should not be too rigid, as it could obstruct both cost effective service development and integrated multidisciplinary working across specialties .

10. GP consortia can most effectively take responsibility for improving the quality of the primary care provided by their constituent practices through a system of Benchmarking for Best Practice. Consortia will need to work with the NCB to ensure there are appropriate indicators of best practice. However, these should be flexible enough to recognise the varied nature of consortia and practices.

11. For an effective relationship between NCB and GP consortia to be developed there should be a system of internal and external review where results are made available to the stakeholders such as the NCB, GP consortia, service providers, commissioners, service users and the general public. It will be vital for the NCB to actively ensure that regional variation in services is minimised so all patients can access the services they need. There will need to be transparency to enable people to be aware of what services will and will not be commissioned in their locality and the reasons why. The NCB need to monitor GP consortia to ensure those that are experiencing difficulty, such as financial overspend or risk of failing, are identified at an early stage and robust processes are in place to ensure continuity of services for patients.

12. The NCB needs to gain a broad range of views about GP consortia. This should be at a regional and local level, as well as the views of stakeholders. It will be important for the NCB to have well defined processes to gather this information. BSR anticipate that this will include formal consultation in addition to informal information gathering. It will be particularly important to ensure that a mechanism to engage all of society, including hard to reach groups, is developed.

13. It is possible that the NCB could publicise/disseminate best practice examples and awards for those consortia that show the greatest efficiency or greatest effect on service users. This could support efficient and effective local commissioning. The NCB should establish a research programme to allow good practice from the UK and worldwide to be identified.

14. The relationship between GP consortia and individual GP practices is key. More detail is needed on this area to ensure there is a sustainable relationship.

15. Involving all stakeholders in consortia is vital. Although challenging, it will be imperative that the broadest range of stakeholders is involved and that processes are developed to engage with hard to reach groups. If this does not take place there is a risk that a true representation of the community you are seeking to serve, is not gained. Each consortium will need to develop relationships in their locality. However, it would be useful for models of best practice in this area to be shared to help each consortium build these relationships effectively. Consultation will need to be proactive and passive and not reliant on those easy to reach.

16. To promote and sustain multi-professional involvement in commissioning other Health Professional representation needs to be on the GP consortia. Such individuals should have experience of the commissioning process, thorough knowledge of or the links to consult with experts across the other health professions and the ability to reflect the needs of the varied patient case-loads across the locality. There needs to be representation for nursing services, pharmacological services and support services.

17. There has already been progress in increasing close working between the NHS and local authorities and further work in this area is welcomed. However, decisions taken by either party can impact adversely on the service of the other providers. For example, if a local authority cuts access to adult social care, this can impact on the NHS ability to discharge patients back to the community. At a time when there is increased pressure on local authority and NHS budgets such scenarios are highly likely and consideration needs to be given to how decisions can be taken more collaboratively.

18. Some consortia will commission services from the private and voluntary sectors. It is vital that these are recognised as key stakeholders and engaged in the work of consortia.

19. It will be important to ensure that Health and Wellbeing Boards have a clear remit and are expected to deliver key outcomes. Without this there is a danger that they will be ineffective.

20. There are certain aspects of current practice in MSK services that would need to be preserved in the transition to new arrangements. For example, a multi-disciplinary team is a vital part of the care that patients with MSK conditions receive. Other important aspects include clinical audit, strong clinical governance and holistic services as opposed to fragmented ones.

21. There should be national standards and outcome measures for musculoskeletal conditions. Given the complex nature of many MSK conditions, there need to be a wide range of indicators, and it may be that 150 indicators are not enough. BSR is concerned that areas not covered by an indicator could fall down the priority list.

22. There needs to be adoption of national standards/outcome measures such as those exemplified by NICE guidance for Rheumatoid Arthritis as well as Cardiovascular Disease. However, there have been gains made through targets such as lowering waiting times, and it is important not to lose focus on the gains made.

23. BSR has extensive experience of working constructively with NICE since its inception, particularly on Technology Appraisals for biologic drugs and Disease Management Guidance for Rheumatoid Arthritis. BSR considers that production of quality guidelines and audit tools are required to improve quality of care for individuals with rheumatic diseases, and such guidelines should feed into on-going discussions on quality metrics and whenever possible into Quality Outcomes Framework (QOF) for primary care.

24. Specialists should support the Board and Monitor for pathways appropriate for a national tariff. Government is seeking to align tariff arrangements with clinical pathways and link quality measures to payment arrangements. There is the opportunity for specialists to use their knowledge to support the Board and Monitor in relation to the pathways that would be appropriate for a national tariff, as well as advice on what is needed to support those pathways and their implementation.

March 2011