Written evidence from the Royal College
of Nursing (COM 105)
1.0 INTRODUCTION
With a membership of more than 400,000 registered
nurses, midwives, health visitors, nursing students, health care
assistants and nurse cadets, the Royal College of Nursing (RCN)
is the voice of nursing across the UK and the largest professional
union of nursing staff in the world. RCN members work in a variety
of hospital and community settings in the NHS and the independent
sector. The RCN promotes patient and nursing interests on a wide
range of issues by working closely with the Government, the UK
parliaments and other national and European political institutions,
trade unions, professional bodies and voluntary organisations.
The RCN welcomes this opportunity to submit
evidence to the Health Select Committee investigation into Commissioning.
This submission will be formed by the areas set by the Health
Select Committee's call for evidence.
2.0 EXECUTIVE
SUMMARY
— The RCN maintains that there should be
sustained and structured nursing involvement during the design,
development and delivery of the proposed reforms, including designated
nursing posts on the NHS Commissioning Board and "GP consortia".
— The RCN believes that the Government
should use the term "clinical commissioning" rather
than "GP commissioning" to reflect the multi-disciplinary
nature of modern general practice and the role nurses are already
playing in the commissioning cycle.
— There is a need to pilot and then phase
in "GP consortia commissioning". Given the significant
reorganisation proposed, there is a need to build on and transfer
existing capacity and knowledge, which is evidence based and recognises
the risks involved.
— Recent World Class Commissioning scores
have shown that Primary Care Trusts (PCTs) are rising to the challenges
of commissioning. The knowledge and experience gained in developing
these scores should not be lost during the reform process.
— Reforms should be designed to address
health inequalities, which will need monitoring and addressing
to ensure that all health needs are met, particularly relating
to socio-economic disadvantage. The commissioning process needs
to have an overall view of the population, which will require
joint working to take place across agencies.
— The RCN maintains that it is important
that national political accountability is not lost in the new
system. "GP consortia" will need support in making difficult
decisions (such as when popular services are to be decommissioned)
and the Government must acknowledge its role in such changes.
— Nursing leaders play a pivotal role in
helping to close the gaps between hospital and community and health
and social care thereby ensuring the delivery of integrated and
seamless care to patients.
3.0 CLINICAL
ENGAGEMENT IN
COMMISSIONING
3.1 How will commissioners access the information
and clinical expertise required to make high quality decisions
about the shape of clinical services?
3.1.1 Commissioning services requires an
entirely different skill set from that of providing expert individual
patient care and depends on effective engagement with all clinical
disciplines. In recent years, the nursing profession has developed
commissioning expertise and played an increasing role in the process.
Under the new system, nursing must be represented at a senior
level in general practice commissioning consortia and on the NHS
Commissioning Board. Nursing expertise must also be recognised
and utilised at all levels of the commissioning process.
3.2 How will commissioners address issues
of clinical practice variation?
3.2.1 The RCN believes that GP commissioning
consortia should link contracts with providers to the relevant
national guidelines from NICE to ensure that issues around clinical
practice variation are avoided where possible.
3.2.2 In a community setting, as part of
its response to the Government's consultation on "Commissioning
for Patients", the RCN has identified two main ways consortia
can effectively take responsibility for improving the quality
of primary care provided by their own constituent practices—the
implementation of RCGP standards for practice accreditation and
a system of financial incentives. In addition, the Care Quality
Commission (CQC) will continue to have a role in ensuring a minimum
level of quality and standards.
3.2.3 There is also an important role for
commissioners in preventing the widening of health inequalities.
The RCN believes that there must be clear mechanisms for national
oversight in place to monitor and address unacceptable variations
in service quality and access to services.
3.3 How will GPs engage with their colleagues
within a consortium and how will consortia engage with the wider
clinical community?
3.3.1 The RCN believes that the Government
should use the term "clinical commissioning" rather
than "GP commissioning" to reflect the multi-disciplinary
nature of modern general practice. The RCN maintains that no single
profession can have the sole responsibility for commissioning
services and if the appropriate range of health and social care
professionals are not involved in the commissioning process, new
models will fail.
3.3.2 Nurses have a key role to play in
commissioning. They have a unique perspective on delivering care
and understanding the needs of patients. As such, they give an
invaluable insight into the practical issues of service delivery,
including advice on value for money, efficient and effective and
quality care provision.
3.3.3 The RCN therefore calls for appropriately
experienced nurses and midwives to be on the NHS Commissioning
Board and GP consortia to ensure that the nursing profession is
able to make its full contribution to the drive to improve health
and health care. In addition, as well as being part of a consortia
core commissioning team, other specialist nurses should be invited
to work with the team when particular services are up for review
and redesign.
3.4 How open will the new system be?
3.4.1 It is not yet clear how open the new
system will be as the proposed reforms are both radical and ambitious.
For this reason, the RCN advocates the piloting and phasing in
of the move to GP consortia commissioning. There are many unknowns
about how best to approach these changes. By piloting the best
mechanisms to most effectively engage GP consortia in influencing
the commissioning of national and regional services, reforms can
be tried and tested in small pockets around the country before
their implementation country-wide.
3.5 Will care providers be free to offer new
solutions which offer higher clinical quality, better patient
experience or better value?
3.5.1 The RCN believes that the reforms
need to be managed in a timely manner and piloted before being
rolled out nationally, as well as make use of existing expertise
in the current system. If this is the case, then it may be possible
for care providers to provide new solutions. However, the RCN
is concerned that the timeframe for the reform is ambitious alongside
the financial context of the need for the NHS to find efficiency
savings. In an RCN survey of members on the White Paper proposals,
only 20% of respondents agreed that the White Paper proposals
will result in better care for patients.
3.6 Will commissioners be free to access new
commissioning expertise?
3.6.1 It is not clear where this new expertise
would come from. The RCN believes that current commissioning is
improving and this existing expertise needs to be utilised in
new structures.
3.7 What arrangements will be made to encourage
the Third Sector both as commissioners and providers?
3.7.1 The RCN believes that there may be
value in individuals and organisations from the third sector being
invited to work closely with commissioning consortia staff to
explore options for future service improvement. The third sector
is sometimes able to provide the specialist information required
in order to develop excellent services for a particular client
group, eg palliative care services. In addition, the new system
will need to ensure that smaller, specialist providers, which
are often third sector providers and are integral to delivering
key NHS services, can still provide quality services in an environment
that promotes increased competition.
4.0 ACCOUNTABILITY
FOR COMMISSIONING
DECISIONS
4.1 How will patients make their voice heard
or their choice effective?
4.1.1 The consortia will need to be open
and transparent in their decision making processes, and ensure
that full and adequate consultation is undertaken with local communities,
including patient organisations and participation groups, faith
groups and other local representative bodies, when awarding, reviewing
or de-commissioning services.
4.1.2 A system for patient engagement and
feedback is also needed to enable effective monitoring and managing
of NHS performance, as well as to ensure that the views of patients
are recorded. Improved patient experience and satisfaction must
be an important element in assessing the quality of care and services
provided. The RCN recognises that there are already systems for
patient engagement and feedback in primary care, which can be
supplemented by local approaches.
4.1.3 Nurses play an integral role in supporting
patients in making choices about their healthcare options and
in playing an advocacy role for their patients, not least via
initiatives such as information prescriptions and care-planning.
In a system with increasing emphasis on the patient choice, appropriate
support for nursing staff in advocacy and support roles will be
needed.
4.2 What will be the role of the NHS Commissioning
Board?
4.2.1 The RCN believes that the role of
the NHS Commissioning Board should be to:
— take on a coordinating role, share examples
of best practice and coordinate evidence-based research so all
consortia can learn from its findings, rather than commission
individual projects. This is particularly important in areas where
staff will have little or no current expertise (ie managing financial
risk)
— set up an appropriate payment system
for consortia and practices that supports efficient and effective
local commissioning. Support and encouragement must be offered
when problems arise, rather then punitive action which is likely
to only deter people from being honest about how their local commissioning
is progressing. For consortia to succeed, commissioners must feel
confident to take their problems to the board, not simply stories
of success and how budgets are being well controlled. More broadly,
the RCN also has an interest in how general practice nurses and
healthcare support workers/healthcare assistants are rewarded
for their work within general practice, and how they contribute
to the quality of services provided by the practice. The RCN would
be keen to discuss this further with stakeholders
— make full use of current the expertise
and knowledge that PCT and SHA staff have about commissioning
where it exists.
4.2.2 The Government has already made a
commitment to providing consortia with resources to fund management
costs. In addition to this, the RCN would ask that the Board also
provide resources to support learning and development for members
and staff of consortia. Learning and development should include
an understanding of the commissioning cycle (including issues
around contract compliance); financial management; constitutional
and governance issues; consortia responsibilities within their
public sector duties and training on equality impact assessments;
and workforce planning.
4.2.3 The RCN acknowledges that workforce
planning is complex and not an exact science. However, in order
to prevent a repeat of the boom and bust patterns of the past,
there must be national oversight of workforce planning. If workforce
planning is relegated solely to local organisations (who do not
have experience of undertaking this role) there is a risk that,
in the future, there will not be a nursing workforce fit for purpose
and able to meet the needs of the population. This will require
concerted action and responsibility at a national level and should
therefore be looked at by the NHS Commissioning Board.
4.2.4 The NHS Commissioning Board should
also oversee workforce training and education. The vital contribution
of nursing to delivering the ambitions for improved patient outcomes
underlines the importance of supporting nursing clinical practice.
The Boorman Review demonstrates the link between staff wellbeing
and motivation and patient outcomes. The RCN recognises the legitimate
role for employer organisations in the education and training
of the nursing workforce. However, the RCN believes there must
be a national oversight function to ensure that current and future
nurses have the right skills and competencies to continually deliver
the highest quality and most efficient patient care. Ensuring
that the workforce is fit for purpose requires the explicit acknowledgment
and involvement of key professional bodies such as the Nursing
and Midwifery Council and Council of Deans alongside employers
and professional representative organisations.
4.2.5 The RCN believes that the responsibility
of assessing consortia commissioning is also a role the NHS Commissioning
Board could take on. This would enable a country-wide approach
to assessment, enabling benchmarking, and the monitoring and correction
of any significant unequal service provision or patient outcomes.
4.3 What legal framework will be required
to underpin commissioning consortia?
4.3.1 There must be clear mechanisms in
place for how the consortia will conduct their business and how
they will engage with and be accountable to the communities they
serve locally and to the tax payer nationally.
4.4 How will commissioning interface with
the Public Health Service?
4.4.1 Robust mechanisms to ensure the Public
Health Service and the NHS work together are vital. It is important
for commissioning to integrate with the public health service
if health inequalities are to diminish and public health improve.
Healthcare professionals, often nurses, deliver and understand
public health. For example, health visitors, midwives and school
nurses are an excellent public health resource and should be used
to inform commissioning and to work closely with local public
health teams.
4.5 How will commissioning interface with
Health Watch?
4.5.1 As Health Watch will be set up to
compile data on performance, consortia must use the findings of
the new body to base, in part, its commissioning decisions. The
RCN also believes that the relationship between Local Health Watch
and GP patient participation groups (PPGs) needs to be one of
respect and mutual support. PPGs and Health Watch should be brought
together when fairly radical decisions on the redesign of certain
services are being explored by commissioners. The RCN would like
to be consulted further about the creation of Health Watch England
and the local Health Watch bodies.
4.6 Where will the "buck" stop when
commissioners face hard choices?
4.6.1 The RCN maintains that it is important
that national political accountability is not lost in the new
system. There will be possible conflicts of interest between the
consortia's role of providing personal clinical care to patients
and their new remit, which may require them to take difficult
decisions ie to decommission services. Consortia will need support
in making such decisions and the Government must acknowledge its
role in such changes.
5.0 INTEGRATION
OF HEALTH
AND SOCIAL
CARE
5.1 How will any new structures promote the
integration of health and social care?
5.1.1 The RCN believes that the key to improving
integration of the two systems is in the reform of the social
care system, and crucially the way in which it is funded, so that
it is transparent, simple, and fair, and enables equity of access.
In light of the role nurses play in delivering social care and
in dealing with its impact on the NHS, the RCN carried out a survey
with 1,500 members on social care and long term trends. Members
told of how the current system prevents integrated health and
social care delivery and leaves many social care needs unmet.
On a daily basis our members have to deal with issues like bed-blocking,
whilst NHS demand rises in the face of inadequate social care
provision. Members were also concerned by the complexity of the
current social care funding system, by the postcode care lottery
and resulting inequalities across England.
5.1.2 The RCN welcomes the Government's
aim to improve integration of the health and social care systems
and will be contributing evidence to the Government's Commission
on the Funding of Care and Support, when requested.
5.2 What arrangements are proposed for health
and social care budgets?
5.2.1 The NHS budget will receive inflationary
increases in this Parliament but this is in the face of significant
rising demand, which the proposed increases will not meet. Social
care is funded through local authorities who are tasked with making
25% cuts to their overall budget. Since social care is not ring-fenced,
the RCN is concerned that the service, which is currently underfunded
and leaves many social care needs unmet, could be a target for
cuts. Failure to meet social care needs appropriately places greater
pressure on the NHS. Both the NHS and social care systems are
stretched financially, with both requiring adequate resources
of their own to provide high quality care.
5.2.2 This question may also refer to the
use of personal budgets in health and social care. The RCN believes
that the principle of patient empowerment should be welcomed.
Social care individual budgets have been empowering for some groups
of service users (especially young people). However, this was
not the case for other groups (older people). The RCN therefore
believes that such budgets should be optional.
5.2.3 The RCN also has concerns and questions
over the use of personal budgets in a health setting including:
what happens if an individual's budget runs out but care is still
required, and how will this affect the NHS principle of "free
at the point of use"? The RCN maintains that Government must
await the findings from the piloting of personal health budgets,
and apply its learning, before rolling them out.
5.3 What will be the role of local authorities
in public health and commissioning decisions?
5.3.1 The role of local authorities in public
health and commissioning decisions will be focused on prevention.
The work they carry out under the new system must be used to fund
progammes that prevent the need for healthcare and promote well
being. Nurses play pivotal roles in delivering public health and
prevention and the RCN would want to see that nursing expertise
and knowledge about public health delivery and promotion is transferred
and utilised in the new structures.
5.3.2 The RCN maintains that with the aim
of providing the most effective commissioning, there would seem
to be merit in aligning consortia with local authority boundaries
or their ward boundaries (depending on the size of GP consortia).
Local authorities have significant insight about their populations,
which they use to inform local public service provision, and it
seems sensible to utilise this existing knowledge.
5.4 How will the new arrangements strengthen
commissioners against provider interests?
5.4.1 The proposals set out in the White
Paper to increase the scope for competition within healthcare
delivery are untested in the UK context and introduce substantial
elements of risk to the core operations of NHS funded health and
social care. The Government must set out a blueprint for a system
of effective checks and balances designed to provide for a level
playing field for providers and commissioners, and prevent the
fragmentation of healthcare in England. The system must be developed
to work for the whole country, providing guaranteed standards
of sustainable, safe, high quality and efficient healthcare for
all patients throughout the country.
5.5 How will vulnerable groups of patients
be provided for under this system?
5.5.1 The RCN believes there is considerable
risk attached to insisting on flexible local implementation of
the White Paper reforms proposed, including that it could result
in the development of local variations in access to service or
service quality, which could exacerbate health inequalities.
5.5.2 The nursing profession is well placed
to ensure that vulnerable patients' needs are provided for. Nurses
often advocate for, work with and understand the needs of different
patient groups and their input into the commissioning process
will be essential.
5.5.3 The RCN has identified a number of
different measures the Government can take to ensure that no-one
is disadvantaged by the proposals:
— There should be an identified accountable
officer in the consortia for equity and equality issues, thus
ensuring that they underpin all decisions made on service provision.
— It is important that the system provides
for effective advocacy for people with severe and enduring mental
health illness and other complex health problems.
— All opportunities must be taken to ensure
that communication is effective and encourages people to speak
up and let their views be known.
— Current good practice must be allowed
to continue and where PCT commissioners are making progress, this
must be encouraged to continue within the new arrangements.
— The Government must be careful to ensure
that there are no perverse incentives or disincentives for GP
consortia or practitioners to work in particular areas or particular
patient groups.
5.6 How will the proposed system facilitate
service reconfiguration?
5.6.1 It is possible that, as has been seen
at a national level, consortia will prefer not to make the hard
decisions about, for instance, closing hospitals and moving care
into the community. Due to the popularity of such services with
the general public, consortia will need support in making such
decisions and the Government must acknowledge its role in such
changes.
6.0 TRANSITIONAL
ARRANGEMENTS
6.1 Will the new arrangements safeguard current
examples of good practice?
6.1.1 The NHS Commissioning Board should
make full use of the current knowledge and expertise that PCT
and SHA staff have about commissioning. Commissioning requires
analytical thinking, public health knowledge and intellectual
rigour. Such talent must be identified within existing PCTs and
local authorities, and the RCN strongly recommends that existing
expertise is effectively employed in the new consortia.
6.1.2 In addition, many of the arms-length
organisations facing significant change have been instrumental
in protecting and promoting good health. The Government must ensure
that the key functions they perform, particularly with regards
to improving quality, are not lost in a re-organised system.
6.2 Who will drive innovation during the transitional
period?
6.2.1 The RCN's Frontline First campaign
has uncovered a range of nurse-led innovations taking place across
the country that are protecting services, finding efficiency savings
and improving care. As the NHS faces significant reorganisation
whilst also having to find £20 billion in efficiency savings
and cut management costs by 45%, nurse involvement on the NHS
Commissioning Board and GP consortia is essential to ensure that
their expertise is best utilised to continue to drive innovation.
6.3 How will transitional costs (redundancy
etc) be minimised?
6.3.1 Given the investment needed to train
registered nurses with the appropriate skills to deliver effective
patient care, the RCN believes that this knowledge and expertise
should be retained wherever possible. The RCN would want to see
arrangements put in place, where necessary, for the redeployment
of nursing staff to minimise the loss of jobs and nursing expertise
from the healthcare service. For example, systems will need to
be created to help nurses make the shift from acute care to working
in the community as the provision of care moves closer to home.
7.0 RESOURCE
ALLOCATION
7.1 How will resources be allocated between
commissioners?
7.1.1 At present, it is not clear how resources
will be allocated. However, the RCN believes that any resource
allocation approach must be balanced, representative of need and
demography, and sustainable in the long term. It should also seek
to address health inequalities. When decisions of funding are
made then it is vital that they are made with the long term in
mind. A welcome approach would be not to judge allocation and
commissioning simply upon costs but upon the sustainability and
long term impact of resource allocation.
7.2 What arrangements are proposed for risk
sharing between commissioners?
7.2.1 In its White Paper response, the RCN
maintains that consortia will have to take part in risk-pooling
arrangements, whilst Government will need to ensure mechanisms
are in place to ensure it does not lose financial control in the
new structures.
7.3 What arrangements will be made to safeguard
patient care if a commissioner gets in difficulty?
7.3.1 The RCN notes that the Government
has said that it will not bail out failing providers and commissioners.
However, the RCN believes that failing services or consortia will
require support from Government, as services cannot simply stop
overnight. The Government must ensure mechanisms are put in place
to ensure services are sustainable and demonstrate how it will
manage the risks associated with system reform.
8.0 SPECIALIST
SERVICES
8.1 What arrangements are in place for commissioning
of specialist services?
8.1.1 Nurses have established expertise
on how best to deliver some specialist services, such as cancer
services. They provide much of the specialist care and advice
patients receive and have a unique perspective on understanding
their needs. Nurses should therefore have a significant role in
the commissioning of these services through involvement with the
NHS Commissioning Board and GP consortia.
8.2 How will these arrangements interface
with the rest of the system?
8.2.1 It is too early to be able to suggest
if any specialised services might be better commissioned by GP
consortia in the future: not enough is known about how the proposed
reforms will work and how they might affect commissioning in practice.
Such services will have to be identified following a period of
learning and development.
October 2010
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