Memorandum by the Genetic Alliance UK
(PEX 11)
SUMMARY OF
RESPONSE
— Current arrangements for "top-slicing"
are complex and result in unsatisfactory imbalances in the provision
of healthcare across the UK.
— The planned reorganisation of the health
service in England is an important opportunity for the current
inequity of specialised commissioning at the regional level to
be halted.
— There is a lack of understanding at the
local care provision level that the funding arrangements for specialised
commissioning allow PCTs to discharge their responsibility to
provide their patients with high quality services, whilst sharing
the risk associated with funding specialised services.
INTRODUCTION
1. Genetic Alliance UK (formerly the Genetic
Interest Group) is the UK charity for all those affected by genetic
health conditions. We work to raise awareness and improve the
health service provision available to those living with and at
risk from inherited conditions. Our membership represents more
than 130 voluntary organisations working for a wide range of conditions,
many of which are rare and/or pose complex health and social care
needs, and require good quality coordinated care from a wide variety
of local, regional and national centres in many areas of specialisation.
2. We welcome this inquiry and are grateful
for the opportunity to submit evidence. The views expressed in
this response are representative of Genetic Alliance UK's policy,
which has been endorsed by our trustee board and our membership.
Our response will focus on the financial arrangements necessary
to ensure that specialised healthcare of the highest possible
quality is delivered equitably across England as efficiently as
possible.
CENTRALLY FUNDED
HEALTH SERVICES
What proportion of the health budget is "top-sliced"
(ie reserved for central disbursement by the Department of Health
or NHS—and not allocated to PCTs)?
3. Current arrangements for "top-slicing"
are complex and result in unsatisfactory imbalances in the provision
of healthcare across the UK.
4. Primary Care Trust (PCT) funds are effectively
"top-sliced" twice to fund specialised services. The
first slice is for the funding of NHS Specialised Services (NSS)
which commissions specialised services for very rare conditions
on a national basis.
5. The second "slice" is for the
funding of specialised services commissioned on a regional basis
by Specialised Commissioning Groups (SCGs). SCG budgets are drawn
together by pooling a portion of every PCT's budget in their catchment
area. This is meant to enable SCGs to commission services set
out in the Specialised Services National Definition Set (SSNDS).
6. This arrangement, aggravated by the appearance
of the first top-slice on PCT balance sheets, creates resentment
amongst PCT managers, who form the view that their ability to
fund local services is damaged by loss of funding. Resentment
can manifest itself at the SCG level where there is pressure from
PCTs to restrict the proportion of the budget pooled as much as
possible; a cause of inequity in provision of specialised services
across England. No single SCG commissions the same set of services
from the SSNDS.
7. There is a lack of understanding at the
local care provision level that the funding arrangements for specialised
commissioning allow PCTs to discharge their responsibility to
provide their patients with high quality services, whilst sharing
the risk associated with funding specialised services.
8. Commissioning arrangements in England
are changing. National commissioning of specialised services (currently
the responsibility of NSS) will become the responsibility of the
NHS Commissioning Board; but the future of "regional commissioning"
has not been laid out. The structures for regional healthcare
organisation, Strategic Healthcare Authorities (SHAs) and SCGs
are not part of the new plans.
9. Genetic Alliance UK believes this is
an important opportunity for the current inequity of specialised
commissioning at the regional level to be halted. Genetic Alliance
UK believes that services in the SSNDS would be best coordinated
at national level.
10. Services in the SSNDS were selected
for regional commissioning because the population size necessary
to sustain them are larger than a PCT's catchment population,
but significantly smaller than the population of England (unsuitable
for national commissioning by NSS). We believe central decisions
regarding the location and catchment area of care provision centres
will deliver equitable care across England, whilst allowing the
highest quality of care to be provided by experts in a cost-effective
way.
11. The budget allocated to the NHS Commissioning
Board for commissioning of specialised services should be a total
of the commissioning budget of NSS and SCG commissioning budgets,
plus an appropriate amount to take account of the fact that SCGs
do not currently fund the full SSNDS roster of services. This
budget should also account for the likelihood of new candidate
services for specialised commissioning becoming available.
12. A further step to assuage the resentment
and misunderstanding that we describe in paragraphs 6 and 7 should
be to directly allocate funding to the body responsible for national
commissioning, and to stop the practice of showing the "top-slice"
on local commissioners' budgets.
What services are procured from this "top-sliced"
budget, and how do the government's plans for those services compare
with long term trends of demand, cost and efficiency?
13. The aim of centralised commissioning
of specialised services is to provide assurances that value for
money is being delivered for healthcare services that have a low-volume
of demand. The NHS and the Department of Health can be sure that
these services are delivered by experts to the highest possible
standard.
14. All complex healthcare services which
have a low-volume of demand should be commissioned and provided
in this way. As we have stated in paragraph 11, Genetic Alliance
UK believes that there should be scope in the budget for centralised
commissioning of specialised services to allow new services to
be added to the portfolio of services commissioned in this way.
15. Indeed, we believe there should be a
programme of active identification of services that would benefit
from this strategy of commissioning. It is accepted that specialised
commissioning is the best means by which complex services for
low numbers of patients should be provided; we believe this means
should be applied to all suitable services.
16. This call for an increase in the number
of specialised services commissioned centrally should not be seen
as a likely increase in costs for the NHS. Rather, the improvements
to the quality and efficiency of care that specialised commissioning
arrangements can bring should be recognised and communicated.
LOCALLY COMMISSIONED
HEALTH SERVICES
What are the implications of the government's
top-slicing decisions for the budgets for locally commissioned
health services? How do the resulting budgets compare with long
term trends of demand, cost and efficiency?
17. It is important that local healthcare
commissioners understand the benefits that specialised commissioning
and centralised funding bring to healthcare provision at a local
level, to patients, and to the NHS.
18. It should be recognised by local healthcare
commissioners that they do not have to commission complex and/or
expensive treatments for very small patient numbers (that are
likely to be unevenly distributed across England), and that the
savings made with gains in efficiency from commissioning such
services nationally are fed back into the national NHS budget.
19. Active communication of the benefits
of the national commissioning system, both in terms of economies
of scale and quality of care, will benefit local healthcare commissioners'
understanding and acceptance of specialised commissioning. This
communication, alongside a change in the method by which centralised
funds are presented to local commissioners (described in paragraphs
6, 7 and 12) will improve the image of specialised commissioning
in the local health provision context.
September 2010
| 
