Written evidence from Neurological Commissioning
Support (COM 120)
1. INTRODUCTION
1.1 Neurological Commissioning Support (NCS)
is a unique consultancy organisation developed by three leading
charities; the Multiple Sclerosis (MS) Society, Motor Neurone
Disease (MND) Association, and Parkinson's UK. We work alongside
all those planning for, and providing, health and social care
services: commissioners from Primary Care, Social Services, and
GP consortia, in order to improve the way that neurological services
are commissioned. This is done through a service user focus on
the key elements of commissioning and, in particular, the planning
component.
We liaise with service commissioners on a regular
basis and have representation on many Primary Care Trust (PCT)
and Local Authority commissioning groups through regional staff
and members. Additionally, all of our three founder organisations
support a comprehensive branch structure and have contact with
thousands of people affected by neurological conditions, which
provides a unique perspective on the experiences these people
have of their local health and social care services.
2. EXECUTIVE
SUMMARY
2.1 NCS believes that neurology should be part
of specialised commissioning in the future, a view mirrored by
the third sector neurology organisations that we represent.
2.2 Patients and carers have not been given
the consideration they deserve in this White paper. They play
a huge role in delivering health and social care and need to have
a central place in the new system.
2.2.1 NCS feels that more detail is needed
on how patients and carers will be included in GP consortia. Their
place in commissioning is an essential part of the new system
and should not be tokenistic. NCS would like to see patient and
carer representation on the boards of both the GP consortia and
the NHS Commissioning Board.
2.3 Workforce planning is not addressed
in the White Paper. As this was previously part of the Strategic
Health Authority's role, we recommend that the NHS Commissioning
Board takes over this responsibility.
2.4 NCS believes that the Government should
use the term "GP led" rather than "GP commissioning"
to reflect the multi-disciplinary nature of general practice today.
IT also feels that the whole multidisciplinary team (MDT) should
be involved in GP-led commissioning including designated MDT and
service user posts on the NHS Commissioning Board and "GP
consortia".
2.5 NCS feels there is a need to pilot "GP
consortia commissioning". Given the significant reorganisation
proposed, there is a need to build on and transfer existing capacity
and knowledge from World Class Commissioning which demonstrated
that knowledge and experience of commissioning was developing.
2.6 Commissioning requires a wide range
of skills and it is important that accountability is retained
especially when services are decommissioned so that the implications
of service loss and risk management in relation to this loss are
fully understood.
3. 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 GP-led commissioning could bring clinical
expertise right to the forefront of commissioning and is to be
welcomed. Traditionally, commissioners have focussed on programmes,
whereas providers and clinicians' focus has been on systems, but
these two developments now need to take place in an integrated
way. This has implications for clinicians: for GP's who need to
develop commissioning skills but also for hospital clinicians
who will need to also have clinical engagement in commissioning
for the whole population of patients for which they can make a
specialised input and not solely the referred population. The
value and skills of the multidisciplinary team in providing this
clinical expertise should not be forgotten, and in particular
the nursing professional which has been involved in commissioning
in recent years. It is essential that this continues, with nurses
involved both within GP consortia and on the NHS Commissioning
Board.
3.1.2 Service users have demonstrated their
expertise in the development of commissioning strategies and shared
decision-making for prioritisation of services and the contribution
that these individuals can bring should not be underestimated.
3.1.3 Clinical networks, care pathways and resources
such as Map of Medicine can ensure high quality decisions are
made by proving the relevant information is available whilst also
keeping the workforce up to date on condition-management issues.
3.1.4 NCS also feels strongly that clinical
services should be equally relevant to the prevention of condition
deterioration and the promotion of health; there needs to be greater
focus for long term conditions' commissioning on the public health
aspect of clinical services.
3.2 How will commissioners address issues of clinical
practice variation?
3.2.1 To prevent health inequality NCS feels
there must be a national system in place to monitor and address
clinical practice variation. This would be possible, for example,
through using standards for general practice accreditation potentially
through the Royal College of General Practitioners. Regular audit
using a common audit tool would indicate if variations were resulting.
3.2.2 Monitoring commissioning practice through
tools like Neuronavigator, (the Year of Care tool developed by
NCS for motor neurone disease, Parkinson's and multiple sclerosis),
would also be possible once this tool is rolled out nationally.
The process for creating this tool is easily transferrable, and
could be replicated in similar tools for other conditions.
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 NCS believes that the Government should
use the term "GP led" rather than "GP commissioning"
which reflects the multi-disciplinary nature of general practice.
Commissioning requires an appropriate range of health and social
care professionals and if these are not involved in the commissioning
process then new models will fail. Engagement could be undertaken
through local clinical networks if these are in place, and if
not currently established, they should be encouraged to facilitate
communication. It is also vital that the clinical skills of practitioners
in secondary care are utilised and there must be ways in which
this essential expertise is utilised. Mechanisms to facilitate
this need to be developed.
3.3.2 The third sector and service users have
a key role to play in commissioning and engagement with the wider
clinical community, and they have a unique perspective on understanding
those services which are required. For example NCS has demonstrated
in both Gloucestershire and Wandsworth the valuable insight into
health and social care service delivery which people affected
by neurological conditions have had. This has included contributing
to changes that have delivered better value for money, more efficient,
and effective services, and a higher quality of care provision.
This same way of working can be easily replicated for the services
needed by those living with other conditions; the expertise that
those living with any given condition have about that same condition
should be recognised and utilised accordingly.
3.4 How open will the new system be?
3.4.1 The proposed reforms are radical. For
this reason, NCS feels that there should be an appropriate piloting
and phasing programme in place to move to GP consortia commissioning.
It would be wise to develop the system in a range of pilot areas
before full implementation is undertaken. It would also be advised
to ensure that open lines of communication are established between
all of the commissioning bodies across the country, particularly
between health and social care. It is also highly necessary that
strong networks between GP-led consortia be created to allow for
the sharing of best practice, the coordination of care across
wider areas, and a level of peer support and accountability.
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 It is imperative that the move to GP consortia
is appropriately managed and moved forward through a pilot phase.
NCS is concerned that the timeframe for this change alongside
the need to make efficiency savings will not result in better
care for service users as consortia may not be in a position to
assess which solutions offer best care and value. There is a danger
that the inexperience of new GP commissioners combined with a
real drive to make efficiency savings could see essential services
cut without full understanding of the implications that this will
have further down the line of both quality of care and a later
detrimental impact on finances. As an example, in one area NCS
discovered that two patients had been refused non invasive positive
pressure ventilation (NIPPV) because of the cost for this, totalling
£12,000. Both patients were subsequently admitted into hospital
in respiratory crisis and had to be ventilated which later resulted
in a bill of almost £1 million pounds, both patients subsequently
having lengthy stays in an intensive care unit.
The expertise in current commissioning models
should also not be lost and there should a way identified that
will help to retain the skills of the current commissioners which
will assist with this. The third sector could have an increased
role in identifying best practice in market provision.
3.6 Will commissioners be free to access new commissioning
expertise?
3.6.1 It is obvious that the new GP consortia
will not be able to develop commissioning expertise quickly. The
Kings Fund has indicated that commissioners will need to utilise
commissioning expertise from commissioning support organisations
such as Neurological Commissioning Support. NCS feels that in
the near future other third sector organisations could also take
on the role of commissioning support for specific conditions.
NCS believes that it, and organisations like it, will be able
to assist in making the right commissioning decisions whilst helping
to develop the expertise within GP consortia.
3.7 What arrangements will be made to encourage
the Third Sector both as commissioners and providers?
3.7.1 NCS firmly believes that the third sector should
work closely with commissioning consortia staff to explore options
for future service improvement and in some cases could take over
commissioning for specific areas, such as neurology. The third
sector is able to provide the expertise required to develop quality
services from a service user perspective and in this tight financial
climate can often highlight what would be best value services
for a particular client group. Additionally, smaller third sector
organisations like NCS provide competition to larger profit-making
commissioning support agencies.
4. ACCOUNTABILITY
FOR COMMISSIONING
DECISIONS
4.1 How will patients make their voice heard or
their choice effective?
4.1.1 Consortia will need to ensure that
full and adequate consultation is undertaken with service users
and citizens when making commissioning decisions. The third sector
and organisations like NCS can ensure this occurs in a transparent
way.
Methods of consultation will need to be wide
ranging to meet the needs of a diverse population. Employing new
technology and modern communications will be required to ensure
full consultation across the entire demographic, including age
and ethnicity. NCS has successfully used artistry, social networking
such as Facebook and Twitter, local media, websites, flyering
and posters in local community centres and leisure areas, in order
to reach as diverse a population as possible. Graphic artistry
and social networking specifically, targeted service users with
communication difficulties and those of a younger age with good
results.
4.1.2 There will also need to be in place
systems to ensure effective monitoring and managing of NHS performance
to ensure that the views of patients are recorded and acted upon
accordingly.
4.2. What will be the role of the NHS Commissioning
Board?
4.2.1 NCS believes that the role of the NHS
Commissioning Board should be to:
— Adopt a coordinating role, sharing
examples of best practice and coordinating evidence-based research
so that all consortia can learn from its findings and act on these,
rather than each commissioning on an individual consortia basis.
— Provide support and encouragement
for consortia so that commissioners can feel confident about
their new roles. NCS do not feel that the Board should adopt a
"policing" model seeking out commissioning "failures"
as this will not be constructive to development.
— Make full use of the current expertise
and knowledge that PCT and SHA staff have about commissioning.
4.2.2 A commitment has already been made
to provide consortia with resources to fund management costs.
Additionally, NCS feels that further resources should be provided
to support commissioning education programmes which should help
the new commissioners to understand such things as the commissioning
cycle; financial management; constitutional and governance issues,
and workforce planning.
4.2.3 Workforce planning should also fall
under the remit of the Board as should training and education,
to ensure that there is a workforce fit for purpose to meet commissioning
need. For example, in its' report: Halfway through: are we
halfway there? (NCS 2010), Neurological Commissioning Support
has discovered that there are insufficient numbers of health and
social care staff with specialist training and understanding in
neurology who are competent to manage the needs of the 8 million
people living with a neurological condition in England (and 10
million in the UK). The lack of understanding of the needs of
these people has led to excessive and costly length of stays in
hospital or inappropriate emergency admission where preventative
treatment would have been more cost effective as well as enhancing
the individual's quality of life.
4.2.4 NCS also believes the NHS Commissioning
Board could take on a role to monitor and correct inequity of
service provision. This would then enable a universal approach
to assessment, 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 Mechanisms must be in place to detail
how the business of consortia will be conducted and how they will
engage with, and be accountable to, both their local communities
and the tax payer.
4.4. How will commissioning interface with the
Public Health Service?
4.4.1 There needs to be a greater focus on public
health for long term conditions, with a recognition of neurology
as an area of health which falls within this bracket, but should
not be subsumed by it. There needs to be a system in place that
will ensure the Public Health Service and the NHS work together
seamlessly. People with long term conditions can remain independent
for longer if adequate information and health promotion strategies
are employed to keep them well, and many more expensive treatments
and emergency admissions can be avoided if appropriate preventative
treatments are provided in a timely fashion. Commissioning to
date has not universally taken this into account and greater emphasis
on this important issue needs to be undertaken.
4.5 How will commissioning interface with Health
Watch?
4.5.1 It is important that Health Watch works
closely with existing patient participation groups (PPGS). NCS
and its third sector partners would like to be further involved
in developments with Health Watch as we feel many of our existing
networks would be of benefit to this new and important entity.
4.6 Where will the "buck" stop when
commissioners face hard choices?
4.6.1 NCS has experienced the conflicts of interest
that can ensue when difficult decisions need to be made about
decommissioning services where there is a need to provide clinical
care whilst achieving the best outcomes—both financially
and for the patient. It is vital that national political accountability
is not lost in the new system and thought must be given as to
how consortia receive support to make hard choices about service
provision. The Government must acknowledge its role in such changes.
4.6.2 There are challenges relating to unbundling
health spend and difficulties in understanding all of the costs
associated with care; commissioners in the future need to estimate
current costs and spend for services and any quality improvements
made. Poor quality services are unfortunately both common and
costly.
4.6.3 There needs to be greater flexibility
across the different payment systems and across agencies which
could release money (from hospital admissions) in order to fund
services. The overall health and social care must be seen as such,
rather than individual agencies unnecessarily keeping hold of
their "pot" of money to the detriment of health and
social care in general, as may be the case at times.
5. 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 key to this will be reform of
the social care system. The care needs of people living with a
long-term neurological condition span health and social care,
but these services are not, on the whole, integrated. Information
is key to integrated working but commissioning knowledge about
the totality of needs of service users is not known. For example
record sharing (which could facilitate integration between social,
primary and secondary care) is not commonplace. Issues such as
bed blocking are often found with service users needing to stay
in expensive hospital beds because of inadequate social care provision.
In the same way, it is not uncommon for someone discharged from
hospital to be readmitted shortly afterwards due to a lack of
social care provision on discharge, leaving the patient vulnerable
and with inadequate support. We are also concerned about the complexity
of the funding system and care lottery that results in huge inequalities.
5.1.2 NCS has developed a Year of Care tool
(called Neuronavigator) for the health and social care of people
with motor neurone disease, Parkinson's disease and multiple sclerosis
which can help consortia to understand the totality of need for
these conditions and promote integration of thoughts around commissioning.
Tools such as this should be available to consortia
to assist with integration, further supported by the development
of integrated care pathways, with each care pathway reflecting
the holistic needs of individuals.
5.2 What arrangements are proposed for health
and social care budgets?
5.2.1 Both health and social care are required
to make significant cuts to their overall budget. NCS is concerned
these cuts, such as in social care, are being made in a service
that is already underfunded and this will leave many social care
needs unmet. Failure to meet social care needs places greater
pressure on health care and deprives the individual of core services.
5.2.2 The principles of patient empowerment
and personal budgets are to be welcomed but NCS feels that these
budgets many not be suitable for everyone and the Government should
await findings from the piloting of personal health budgets, and
apply its learning, before rolling them out. NCS also feels that,
whilst the principle of personal choice is entirely correct, there
needs to be a readiness of clear and concise information on services,
and on people's right to access these services, before this element
of choice can be realistically given. The third sector could assist
with advocacy and brokerage when personal budgets are used, as
well as information provision, if requested.
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.
Insufficient work to date has been done on this important aspect
of living with long-term neurological conditions and NCS would
expect to see a greater emphasis on the delivery of public health
initiatives and promotion in the new structures.
5.3.2 NCS feels that it would seem sensible
to align GP consortia with current Local Authority boundaries
(this would, however, have to depend on the size of the individual
GP consortium). Local authorities already have significant information
about their populations, which they use to inform local public
service provision and aligning the two could ensure better service
provision.
5.4 How will the new arrangements strengthen commissioners
against provider interests?
5.4.1 The proposals set out in the White Paper
increase the scope for competition within healthcare delivery.
As yet this is largely untested in the UK health system and may
introduce substantial elements of risk to the core operations
of NHS funded health and social care. The Government should outline
a system to provide effective checks so that there is a level
playing field for providers and commissioners, thus preventing
fragmentation of healthcare. The system must ensure guaranteed
standards of safe, high quality and efficient healthcare for all
service users, and carers, across England.
5.5 How will vulnerable groups of patients be
provided for under this system?
5.5.1 NCS feels that there are significant risks
in the development of local systems which could exacerbate health
inequalities. Strategies must be put into place to ensure this
does not arise. Suggestions for addressing this include a sharing
of best practice and specialist information by those consortia
who have specific specialists amongst their number.
5.5.2 An additional safeguard that NCS suggest
is that there should be an identified accountable officer in each
consortia for equity and equality issues, thus ensuring that they
underpin all decisions made on service provision.
5.5.3 It is important that the system provides
for effective advocacy for people with severe and enduring mental
health illness and other complex health problems.
5.5.4 All opportunities must be taken to
ensure that communication is effective and encourages people to
speak up and let their views be known.
5.5.5 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. Current
work and objectives within PCTs which have strong measurement
systems and research behind them should be considered for continued
action under the new consortia.
5.5.6 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 patient
groups.
5.6 How will the proposed system facilitate service
reconfiguration?
5.6.1 Where difficult decision have to be made
for example on decommissioning hospitals because of local opinion
about services. NCS has experienced this in one of the PCT areas
it worked with. Consortia will need support when making unpopular
changes and the Government must acknowledge this and offer solutions
to provide support.
6. TRANSITIONAL
ARRANGEMENTS
6.1 Will the new arrangements safeguard current
examples of good practice?
6.1.1 All current knowledge and expertise in
commissioning should be noted and utilised. The skills required
to commission are very different from clinical skills and will
take time to acquire. NCS recommends that existing expertise is
employed within the new consortia. The value of commissioning
support agencies in particular areas of commissioning should also
be highlighted by the Government.
6.2 Who will drive innovation during the transitional
period?
6.2.1 There are many models of good practice
across the country and these should be highlighted. NHS Innovations
holds information on a plethora of outstanding practice initiatives
across the country, and as a resource should be called on to inform
future plans. The third sector, where it has supported commissioning,
has often done so in innovative and unique ways, and this should
be noted. Continued partnerships of this nature will spur on innovation
under the new systems coming into place.
In this time of finding efficiency savings it
is essential that innovation is not stifled, but given space to
flourish even more widely. In times of newness and uncertainty,
innovation can help to build and strengthen systems coming into
place, However, NCS fears that this may not be the case, and steps
should be taken to protect current, and encourage further, innovative
working.
6.3 How will transitional costs (redundancy etc)
be minimised?
6.3.1 NCS feels that expertise should be
retained wherever possible and there is a danger that a wealth
of experience and knowledge will be lost from the health service
during this reform. Arrangements should be put in place, where
necessary, for the redeployment of staff to minimise the loss
of jobs and expertise from the healthcare service. Systems need
to be established and implemented to assist staff in moving from
the acute sector to working in the community, for example.
7. RESOURCE ALLOCATION
7.1 How will resources be allocated between commissioners?
7.1.1 NCS believes that any resource allocation
must be representative of need and demography. It should also
seek to address health inequalities.
7.2 What arrangements are proposed for risk sharing
between commissioners?
7.2.1 Consortia will have to take part in risk-sharing
arrangements but Government needs to ensure mechanisms are in
place for its overall financial control in the new structures.
7.3 What arrangements will be made to safeguard
patient care if a commissioner gets into difficulty?
7.3.1 The Government must ensure that mechanisms
are in set up and put into place to ensure services are sustainable.
NCS believes that the Government also need to demonstrate how
it will manage the risks associated with system reform, something
which, as yet, does not seem to have had a great deal of though
given to it.
8. SPECIALIST
SERVICES
8.1 What arrangements are in place for commissioning
of specialist services?
8.1.1 NCS has concern for neurology services
in the move towards GP-led commissioning consortia and this is
mirrored by the third sector. We therefore feel that neurology
would be better considered under specialist services.
October 2010
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