Health and Social Care Bill

Memorandum submitted by The Royal College of Surgeons (HSR 18)

1. The Royal College of Surgeons welcomes the opportunity to submit written evidence to the Public Bill Committee on the Health and Social Care (Recommitted) Bill. The College supports the aims of the reforms to modernise the healthcare system. We believe that cutting bureaucracy and giving patients and their clinicians the right to decide the best treatment for individuals is fundamentally right. We believe that commissioning should be based around the patient who should be supported by the relevant clinicians and healthcare staff.

2. The RCS welcomed the NHS Future Forum report and the Government’s response. We believe both reports have added clarity on many of the points raised by the College throughout the consultation process. The College has urged that the NHS should be allowed to get on with making the plans laid out in the Health and Social Care Bill a reality without delay.

3. Below are our specific comments to the Public Bill Committee on the Health and Social Care Bill on the key themes of the Government’s response which are relevant to surgery (clinical advice and leadership, patient accountability, choice and competition, developing the healthcare workforce and public accountability and patient involvement).

Clinical Advice and Leadership

4. The Government’s response states theNHS Commissioning Board to seek clinical advice through regional clinical networks and Clinical Senates’. The RCS has called for both clinical representation on the NHS Commissioning Board and for more detail on the sub-national commissioning structure in the NHS. The RCS welcomes these proposals as a positive addition to address these concerns in the Bill. The RCS has an established regional network of surgeons across the surgical specialties and we look forward to utilising these networks to engage with the new NHS structures as they are established.

5. The RCS awaits further detail on the membership of the Clinical Senates, how they will be involved in advising the NHS Commissioning Board and how these Senates will engage with other healthcare professions as well as the Medical Royal Colleges. The RCS would also like to see more detail on how Clinical Senates will be able to engage with local clinical commissioning groups, and what the geographical structure of Clinical Senates will be.

6. The RCS similarly awaits further information on the embedding of clinical networks, how these networks will be involved in advising the Commissioning Board and how the clinical issue of focus for each network will be decided.

7. The Government’s response also states thatat least one secondary care specialist doctor appointed to clinical commissioning groups’ governing bodies. The RCS has consistently called for meaningful engagement between clinical commissioning groups (CCG) and surgeons. We therefore welcome the commitment for secondary care clinicians to work with the CCGs, via their governing bodies. However we would like to see more detail on how the governing bodies will be involved in the day to day operations of the CCGs, what obligation the CCG will have to take forward any advice given by the governing body and report its decisions back to the governing body, and how the clinical representatives on the governing body will be recruited and appointed.

8. It is also stated in the Government’s response thatThe NHS Commissioning Board to draw on the expertise of a range of healthcare professionals. The Board will establish close links with the Royal Colleges and other professional bodies, so that partnership working across a wide range of experts is firmly entrenched at a national level’. The RCS welcomes this commitment for the NHS Commissioning Board to draw upon the leadership and clinical expertise that already exists in the Royal Colleges and professional bodies. The RCS has established national and regional networks which draw together the breadth of surgical expertise from within the profession so we are able to provide advice and support at all levels.

Choice and Competition

9. The RCS welcomes the commitment for competition on quality, rather than price where this would benefit the patient. The RCS has been clear that a defined standard of treatment and care should drive commissioning and not the lowest price, and it is reassuring that this commitment has been strengthened in the proposed legislation.

10. The RCS also welcomes the commitment to establish through Monitor further safeguards against the ‘cherry-picking’ of services. The RCS has outlined its seven principles and standards for competently commissioning a surgical service, which include making provisions for follow-up and acute readmissions, the education and training of staff and measurement of outcome (see Annex A). If commissioners adhere to the seven principles and standards it should ensure the delivery of comprehensive and competent services that avoid provider destabilisation by cherry-picking. Furthermore the proposed introduction of an evaluation of clinical complexity to support tariff setting will ensure that patients with complex needs are able to access treatments they need and that providers are reimbursed accordingly.

11. The College welcomes the Government’s change in emphasis on Monitor to encourage ‘integration not competition’ between all providers of health and social care. This is especially important in surgery, where patients encounter many different health professionals along their care pathway. The RCS looks forward to working with Monitor to help implement and develop integration across clinical pathways.

12. However the RCS are cautious about plans for the phased extension of any qualified provider and the potential for this to destabilise existing services and clinical interdependencies. The College looks forward to further detail about how this phased extension will happen and the required safeguards.

13. We welcome the Government’s commitment for aDuty to promote research across all levels of commissioning’. There is a continuing need for the promotion of research and innovation and the RCS welcomes the additional commitments made by the Government. As a member of the Association of Medical Research Charities (AMRC), the RCS has said that it is necessary for all commissioners from local to national to consider research and for it to be promoted amongst clinicians and also amongst patients who may be interested in participating in research.

Education and Training

14. The College welcomed the Government’s commitments in the recent ‘Developing the Healthcare Workforce’ consultation. In this consultation document we supported the commitments to fully engage clinicians in workforce planning processes and in the commissioning and delivery of education and training both nationally and locally. We also supported the reaffirmation of the ‘important role for the medical Royal Colleges in ‘devising and delivering education in their specialties’.

15. In the Government’s response to the NHS Future Forum’s report we welcome the commitment for ‘an explicit duty for the Secretary of State to maintain a system for professional education and training as part of the comprehensive health service’. The RCS also believe it is essential for clear and effective interim arrangements to be put in place to ensure the high quality training in the NHS is maintained while Health Education England and the associated structures are established. The College looks forward to working with Government as the plans for educating and training the healthcare workforce are developed.

Patient and Public Involvement

16. The RCS welcomes the emphasis in the Bill on the embedded rights of patients in the NHS Constitution.

17. The RCS believes that there needs to be a clear, transparent system for patients which enables them to understand which services are available, the quality of these services and how one can make a complaint or give feedback about the service they have received. The reinforced requirement of candour in the event of a mistake provides a clear opportunity to re-examine the causes of closed, blame cultures in the NHS and take positive steps to promote an open environment of learning and continual service improvement. In addition, as a clear and vital part of transparency in the NHS, the RCS believes that hospitals should publish information about their outcomes according to the NHS Outcomes Framework as well participate in national clinical audits. We believe that such a move would enable greater and more informed patient choice.

June 2011


Annex A

Commissioning a competent surgical service

College position statement

The Royal College of Surgeons believes that a defined standard of treatment and care set by the profession should drive commissioning and not the commercial interests or convenience of the provider. Standards of care and outcome requirements should be incorporated into the decision-making process for commissioning services in order to achieve the best care and outcomes for patients. Within the proposed arrangements for the delivery of healthcare, commissioners will be able to exercise clinical judgement and have the power to safeguard and ensure the quality and standard of care.

The College believes that in order to ensure the delivery of comprehensive and competent services commissioners should adhere to the following principles and standards when taking commissioning decisions:

1. Training the healthcare workforce – a contractual commitment to training and the ability to deliver the standards and outcomes agreed and published by the profession.

2. Educating the healthcare workforce – a contractual commitment to provide appropriate education and continuing professional development opportunities for all health professionals.

3. Clinical audit – contractual agreements to ensure participation in clinical audit and publication of audit outcomes.

4. Research and development – contractual agreements to ensure participation in high quality research which is essential for advancing and improving patient care and outcomes.

5. Commissioning a complete service – ensuring the service includes arrangements for full emergency provision at the appropriate level to manage the follow-up of patients, including complications.

6. Measuring outcomes – outcomes to be measured coherently to enable comprehensive benchmarking across the NHS, with the data made available to the profession and used to inform practise and improve patient safety.

7. Appropriate impact on the local healthcare economy – when commissioning a service, a full assessment must be made of the impact of the decision on the patients’ pathway of care (i.e. ensuring that the patient will experience a seamless pathway across different providers) and the impact of the commissioning decision on related services (e.g. clinical interdependencies) in order to safeguard patients’ access. Such assessments should include a consideration of the best available evidence used to support the decisions.

The College further believes that in order to maintain these standards for quality, commissioners of healthcare should ensure providers are able to make sufficient time available in the form of Supporting Professional Activities (SPA) within the consultant contract to allow consultants wishing to be involved in training, education, audit, research etc to do so. By acting in this way commissioners will demonstrate a high degree of senior level commitment to all the elements of a clinician’s role which contribute significantly to an increasingly safe and high quality health service.

Prepared 11th July 2011