Written evidence from the Specialised
Healthcare Alliance (COM 07)
1. The Specialised Healthcare Alliance (SHCA)
is a coalition of 54 patient organisations supported by eight
corporate members, which campaigns on behalf of people with rare
and complex medical conditions for whom key services cannot be
sensibly planned, procured and delivered at a local level. It
is chaired by Baroness Pitkeathley.
2. The Alliance submitted written and oral
evidence to the Health Select Committee's inquiry into commissioning
before the General Election in May 2010. Our written evidence
included a brief history of developments in specialised commissioning
leading up to and following the Carter Report of 2006. This submission
concentrates on the continuing weaknesses we identified and whether
the coalition government's White Paper addresses them effectively
in the context of some of the questions posed by the new Committee.
EXECUTIVE SUMMARY
3. The White Paper holds out the prospect
of addressing the major weaknesses in regional specialised commissioning
identified in the Health Select Committee's last report. Crucial
detail, however, remains to be elaborated.
4. The scope of the NHS Commissioning Board's
remit for specialised services needs to be clearly defined. In
the Alliance's view, the only credible basis for doing so is the
current edition of the Specialised Services National Definitions
Set. This should be in its entirety, though subject to regular
revision.
5. Similarly, the Board's regional structure
needs to be clarified and sufficiently extensive to sustain effective
engagement with the NHS at local level, eg to ensure that referrals
management is consistent with more timely diagnosis of rare and
complex conditions. The Alliance recommends a minimum of eight
offices. This would also make it easier to retain the best of
the important expertise in the current Specialised Commissioning
Groups (SCGs).
6. Urgent priority should be attached to
costing patient pathways covered by the National Definitions Set
to inform the budget required by the Board for specialised commissioning
purposes from April 2012. A buffer fund may be required to accommodate
likely inaccuracies in the sums retained by the Board or devolved
to GP commissioning consortia, especially in the first years of
the new arrangements.
7. In the meantime, PCTs are likely to become
increasingly distracted by the move towards GP commissioning consortia.
The NHS Commissioning Board should therefore assume early oversight
of specialised services from April 2011, initially working through
the existing SCGs.
8. The accountability of the Board for commissioning
specialised services needs to be clearly defined with recourse
for individuals and groups who feel they have been poorly served.
These patients must also be enabled to play a role in the new
Healthwatch arrangements.
CURRENT POSITION
9. Historically, specialised commissioning
has often been overlooked in the initial development of policy
despite accounting for an estimated 10% of NHS expenditure, affecting
large numbers of highly vulnerable people. The attention given
to it by the Health Select Committee and in the White Paper is
therefore most welcome.
10. Our previous evidence expressed concern
about stalled progress in implementing the fundamentally sound
Carter reforms of specialised commissioning, stemming from the
reluctance of Primary Care Trusts to pool sovereignty and resources.
We suggested that this reluctance might grow as PCTs sought to
protect local services in the downturn, to the detriment of clinically
and cost effective specialised care. We also highlighted that
as a pooled responsibility between PCTs, specialised commissioning
sat in a limbo, where it was not properly regulated or performance
managed.
11. In order to address these weaknesses,
we suggested that regional Specialised Commissioning Groups should
be re-located within SHAs and funded directly. We also proposed
that nationally commissioned services should no longer be funded
by top-slicing PCTs but directly, with performance management
conducted by the DH. These suggestions found support from the
previous Health Select Committee, while observing that there was
some risk that they could lead to a lack of coordination and disruption
in services more locally.
12. In its response to the last report on
commissioning, the coalition government broadly accepted the deficiencies
in current arrangements, pointing out that under the White Paper,
all national and regional specialised services encompassed by
the National Definitions Set would be the responsibility of the
NHS Commissioning Board. The response expressed the view that
this should "ensure that patients with rare conditions can
be sure of high-quality and cost effective treatment and are treated
equitably with people who have more common conditions. It will
also help ensure more effective implementation of Sir David Carter's
2007 (sic) review."
13. At the national level, important changes
have been introduced since the General Election, with a single
Advisory Group on National Specialised Services providing advice
to the Secretary of State on which services, products and technologies—usually
for patient populations below 500—should be commissioned
nationally. This advice will be developed on the basis of an ethical
decision-making framework which, in the Alliance's view, could
act as the starting point for a more consistent, value-based approach
to funding decisions in the wider NHS.
14. At the regional level, the current PCT-based
arrangements remain in place with a significant risk of deterioration
during the transition to the structures outlined in the White
Paper.
THE WHITE
PAPER AND
SPECIALISED SERVICES
15. The Specialised Healthcare Alliance
agrees with the government that the White Paper's proposal to
place specialised commissioning with the NHS Commissioning Board
has the potential to address the shortcomings identified in the
Health Select Committee's last report. Much important detail,
however, remains to be agreed. In particular, early clarification
is required in the following areas:
(a) The number of regional offices and their
role will be important in maintaining effective links between
the NHS Commissioning Board and the wider NHS, especially if GP
commissioning consortia are local in character. From a specialised
commissioning perspective, we would see it as desirable to have
no fewer than eight regional offices to reflect patient flows
and the character and culture of different health economies. These
offices should facilitate liaison to ensure the engagement and
input of GP consortia and effective provision of those primary
and community care services best commissioned at local level for
people with specialised conditions;
(b) While it makes sense for the NHS Commissioning
Board to assume responsibility for assessing commissioning from
the CQC where GP consortia are concerned, a third party needs
to assess the Board's performance for those services which it
commissions. The DH would seem best suited to fulfil this role
or, alternatively, it could remain with the CQC for those services
commissioned by the Board;
(c) As PCTs focus on supporting the establishment
of GP consortia, the danger is that their already inadequate commitment
to specialised commissioning will wane with potentially damaging
results for patients. We would therefore advocate an early transfer
of oversight to the NHS Commissioning Board, initially working
through the existing regional Specialised Commissioning Groups
and their constituent PCTs;
(d) During this period a high priority should
also be attached to costing the services covered by the National
Definitions Set to enable accurate budgets to be set in 2012-13.
The survey conducted by the SHCA in late 2009 for the Committee's
last inquiry found that the extent to which SCGs were commissioning
the National Definitions Set was highly variable and in no case
complete. The SCGs' current levels of expenditure do not therefore
represent the aggregate funds the NHS Commissioning Board will
require for specialised commissioning purposes.
These points are relevant to several of the
key issues raised by the Committee. Others are covered below.
CLINICAL ENGAGEMENT
IN COMMISSIONING
16. Clinical engagement in specialised commissioning
is generally above average, with clinicians often appreciating
the greater degree of knowledge which specialised commissioners
possess. This situation should be strengthened as a result of
the White Paper with the NHS Commissioning Board also being well
placed to address unwarranted variations in clinical practice,
providing scope for innovation is not squeezed out in the process.
17. The greater problem arguably arises
in relation to GPs and referral. Late diagnosis is a major problem
with rare conditions and has important ramifications for clinical
outcomes. In a recent study, the King's Fund observed that GP
commissioners are likely to turn to referral management when they
take responsibility for the bulk of the NHS commissioning budget.
It will be important for the NHS Commissioning Board to ensure
that referral management adopts an even-handed approach between
over-, under- and mis-directed referral to protect and promote
the interests of people needing speedy specialist assessment and
care.
18. More generally, a range of approaches
will be required to ensure the engagement of GPs and their consortia
with specialised commissioning. In addition to the role of the
regional offices in facilitating liaison (see above), consideration
should be given to an extended range of clinical networks in key
therapeutic areas, which might also engage local authorities where
public health is a major upstream influence on downstream levels
of disease. It is important to ensure that those with rare and
complex conditions can access generalist services at the local
level which meet their needs.
HOW OPEN
WILL THE
SYSTEM BE
TO NEW
ENTRANTS?
19. The White Paper gives Monitor the role
of promoting competition and guarding against purchasers acting
anti-competitively. A key tenet of the Carter Report on specialised
commissioning is that specialised commissioners should be able
to designate providers of specific specialised services using
a robust, transparent process.
20. The Alliance supports the Carter Report's
view that designation of specialised providers helps to secure
an appropriate concentration of clinical expertise and activity
to safeguard patient access to high-quality, cost-effective services
located to maximise geographical convenience. It is important
that Monitor's terms of reference recognise the need for some
curtailment of free competition in this area.
ACCOUNTABILITY FOR
COMMISSIONING DECISIONS
21. The proposed remit of HealthWatch is
couched in almost entirely local terms. Specialist providers will
usually be delivering services to patients from outside the local
area and sometimes right across the country. It is important that
HealthWatch makes provision to capture the views of such users
to help inform specialised commissioning as well. HealthWatch
England may be the most appropriate vehicle for doing so.
22. As touched on previously, the Specialised
Healthcare Alliance also has concerns about the accountability
of the NHS Commissioning Board for its commissioning performance
(who will guard the guardians?). This needs to be to the Department
and, through the Secretary of State, to Parliament.
HOW WILL
THE NEW
ARRANGEMENTS STRENGTHEN
COMMISSIONERS AGAINST
PROVIDER INTERESTS?
23. The establishment of a dedicated NHS
Commissioning Board should itself help to re-balance the relationship
between purchasing and provision, which is vital to the delivery
of high-quality care and best value. This needs to include the
status of commissioning, which has long trailed that of hospital
management. The proposals for specialised commissioning, which
concentrate resource and expertise through the Board, should be
especially effective in delivering these results.
24. Similarly, the new arrangements should
improve the position of people with rare and complex conditions
who have historically been vulnerable to locally led commissioning.
A heavy responsibility will however reside with the NHS Commissioning
Board to protect the interests of everyone covered by the National
Definitions Set and some form of recourse will be necessary for
those who may be let down.
HOW WILL
THE SYSTEM
FACILITATE SERVICE
RECONFIGURATION?
25. Specialised services by definition cater
for larger populations crossing local and regional boundaries,
sometimes up to national level. The configuration of services
is important in ensuring sufficient patient volumes to support
clinical standards and safety on the one hand, while offering
the best possible access on the other.
26. Current overview and scrutiny arrangements
mean that proposals to re-configure national services need to
be referred to local committees right across England, generating
considerable cost and delay. The Alliance sees merit in the NHS
Commissioning Board being able to consult on such proposals with
the Secretary of State acting as final arbiter.
October 2010
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