Written evidence from Allied Health Professions
Federation (COM 35)
This submission is provided by Richard Evans,
Chief Executive Officer, The Society and College of Radiographers
on behalf of the Allied Health Professions Federation (AHPF).
1. SUMMARY
1.1 The White Paper proposals on commissioning
represent a high-risk strategy.
1.2 The existing system has been slow to
implement and achieve high standards but that does not imply failure
of the system or the need for radical change.
1.3 There is a lack of evidence that the
proposed system will provide improvement.
1.4 There are concerns that effective workforce
planning including education for professions will be further damaged
by the proposals.
1.5 GP consortia will require considerable
input from a number of clinical professional groups if they are
fully to grasp the breadth of issues of service provision.
1.6 Contestibility has not increased quality
or innovation in health care delivery.
1.7 The current proposals provide no reassurance
that there will be more robust attention paid to clinical quality
or workforce standards in the plural provider system.
1.8 Consortia of General Practitioners may
have difficulty in accepting the role to ration health care provision.
1.9 It is difficult to see how effective
patient/public advocacy will be promoted in practice.
1.10 It is difficult to see how integration
of health and social care is facilitated through the proposals.
1.11 There is a lack of clarity over how
small scale and highly specialised clinical services will be assured.
2. COMMISSIONING
2.1 In common with other groups of healthcare
professionals, the AHPF believes that the white paper proposals
for change in the model of commissioning predict severe disruption
to the delivery of health care, are likely to introduce additional
costs at a time of financial constraint and are uncertain to deliver
improvement to care provision.
2.2 We agree that there are imperfections
in the current system and understand frustration that the separattion
of purchase from provision in the NHS has not produced a stronger
commissioning model. However, the current pressures to continue
to expand capacity within fixed financial provision are placing
services under unprecedented strain. We are very concerned that
experimenting with commissioning at the present time is unnecessary
and risks severe damage to patient services.
2.3 There is a lack of evidence that the
model of GP consortia operating an "any willing provider"approach
will succeed in raising standards of health care and in achieving
the admirable objective of improving health outcomes. The proposals
do not apparently allow for testing of the model or indicate a
process for actively supervising the project to spot failure and
allow for intervention to change direction.
2.4 We are concerned that the proposals
are motivated by political dogma rather than by a genuine concern
to improve health care delivery in England.
2.5 The challenges of workforce planning
to ensure sustainability of services and to support innovation
and change in delivery are very significant and are another feature
of the commissioning task that is yet to become clear.
3. CLINICAL ENGAGEMENT
3.1 The AHPF supports the involvement of
clinical professionals in the commissioning process.
3.2 General Practitioners and their teams
in primary care have a unique role and perspective on the healthcare
needs of the population. However, it is clear that, even through
a consortium this does not translate into management expertise
to embrace the complexity of commissioning. Neither does it confer
expertise in depth about the services that will be required to
be provided through the commissioning process.
3.3 Experience has shown that clinical engagement
across the purchaser-provider relationship has been problematic.
This must be overcome in future and in particular, if the white
paper proposals go ahead, must inform a consortium based commissioning
model from the outset.
3.4 The requirement to adopt a plural approach
to provision challenges clinical team working and places pressure
on commissioners to ensure quality and sustainability in services
they cannot hope fully to understand. Commissioners require advice
and support from and dialogue with clinical experts if they are
to avoid some of the commissioning errors that were made, even
by the Department of Health and SHAs during the last decade.
4. COMPETITION
4.1 Plurality of provision of services has
been shown to work in some parts of the NHS over recent years.
There have also been some spectacular and costly failures, within
established NHS providers and within the independent sector that
demonstrate that the assumption that competition drives up standards
and innovation is insecure.
4.2 The "any willing provider"
ethic would perhaps be less worrying if it were "any suitable
provider" or "any capable provider". It is necessary
for there to be much more reassurance ove r service quality and
how this will be guaranteed.
4.3 Experience has shown that the ability
of small independent providers to "cherry pick" non-complex
procedures and deliver them cheaply and quickly can damage secondary
care providers that are left with a less flexible workforce and
a case load of more complex, resource-intensive work. It will
be important that commissioners see the "bigger picture"
and understand the full implications of their commissioning decisions.
4.4 Under any circumstances, commissioners
must be able to satisfy themselves that providers will be able
and willing to work together to provide the integrated high quality
services that are required in any care pathway. Continuity of
the medical records, pathology and PACS systems are obvious requirements
but so too are clinical team working and accountability.
4.5 The success of multidisciplinary clinical
team working in delivering improved care and outcomes and in reducing
costs must not be lost. However, it is self evident that preserving
this excellent practice will be more challenging within a context
of multiple providers. The AHPF fears that fragmentation of provision
is potentially damaging to care pathways and that commissioners
will require particular focus and expertise in ensuring overall
service quality across multiple providers in the face of strict
financial constraint.
4.6 There is an impressive record of development
of advanced and consultant practice amongst AHPs in recent years.
This has delivered very high quality services at low cost. It
is true to say that this sort of service innovation is not generally
seen within independent sector provision. We are concerned that
the drive towards further plurality will stifle professional development
and innovation, marking a return to less efficient, labour intensive
and costly models of provision.
4.7 Examples of innovation amongst AHPs
that have improved care for patients but that have challenged
traditional hierarchies include self-referral to AHP services,
supplementary prescribing and image interpretation. All are well
evidenced and make a massive contribution to efficient and effective
care. The AHPF is concerned that, because of conservatism in the
independent sector and the inherent medical bias in the commissioning
model, plural provision may not support these innovations. This
will be a detriment to patient care, restrict patient choice and
introduce serious challenges to the development, recruitment and
retention of the workforce.
4.8 The AHPF is glad to see reference to
the expectation that all providers will take part in funding the
education and training of the healthcare workforce. Commissioners
will have an important role in ensuring that the workforce within
their area is appropriately educated, trained and developed. This
is a feature of the commissioning role that is currently missing
from the white paper proposals but that cannot be overlooked.
Diversity of provision will make the task even more complex.
4.9 Plural provision of services brings
issues of workforce supply that are of concern to the AHPF. The
movement of healthcare professionals between different employers
is likely to become much more widespread. Whilst this might bring
opportunities for professionals to develop their careers in innovative
ways, there are also dangers. These include breaking of lines
of clinical supervision, developmental support and professional
networks. It is also clear that the process of local, regional
and national workforce planning will be made much more complex
in a plural system of provision. It is not at all clear how commissioning
consortia can possibly get to grips with this vital activity sufficiently
quickly and comprehensively so as to avoid calamitous workforce
deficits in the (relatively) near future.
5. ACCOUNTABILITY
5.1 The expectation that GP consortia will
be able to handle the large financial responsibility that is implied
in the proposals is fundamental to the success of the model.
5.2 Experience with the "fund-holding"
experiment in the past demonstrated that individual GPs responded
very differently and whilst there is clearly no expectation that
all GPs will become involved in the commissioning activity of
a consortium, there is an implication that the GP community will
work together effectively to manage the budget. The role as rationers
of care is a different perspective for many GPs.
5.3 The proposals seem to struggle with
the basic concept that a medically—led commissioning model
is ideal for the NHS as against a desire to control primary care
itself. As commissioning for primary care is to be centrally conducted,
it is not at all clear how consortia will deal with influencing
quality or outcomes at what is the entry level for the majority
of patients. As it is inconceivable that all GPs will be fully
supportive of the new arrangements, this weakness in the ability
of commissioners to affect outcomes could be a serious challenge.
5.4 Although patient choice remains clearly
evident in the white paper and receives some reference in connection
with commissioning, there is little within the proposals to indicate
how consortia will be able to demonstrate their responsibilities
to patients and the public as the key stakeholders in health and
social care.
5.5 A culture and mechanisms are required
to promote listening to patients, public, a range of professionals
and professional bodies as well as social care service commissioners
and providers.
5.6 Consortia must be clearly accountable
to patients and the public with demonstrable penalties for failure
to deliver agreed outcomes.
6. INTEGRATION
OF HEALTH
AND SOCIAL
CARE
6.1 Although integrated working across the
health and social care boundary is a clear objective within the
health white paper, there is little detail in the commissioning
proposals that indicates that any consideration has been given
to how this will work in practice.
6.2 Experience in health over the past ten
years has shown that a competitive market has tended to drive
providers apart and introduce tension between commissioner and
provider. The already (in many cases) uneasy relationship between
the health and social cate sectors requires particular attention,
encouraging a spirit of collaboration. This should not be absent
from the commissioning proposals and we are concerned that individuals
whose care is organised across boundaries will suffer a deficit
through implementation.
7. SPECIALIST
SERVICES
7.1 Some AHP groups are particularly concerned
with the delivery of low-volume specialist services.The proposal
that consortia should have the "freedom and responsibility
to decide for themselves" about levels of commissioning will
effectively allow these services, and the patients who rely on
them, to fall through the commissioning net.
7.2 In the context of immense complexity
that will be facing consortia, low-volume services are very likely
to be categorised as "too difficult" or just be overlooked
entirely.
7.3 The National Commissioning Board could
take responsibility for nominating lead consortia to deal with
these services on a regional or supra-regional basis and should
call on the expertise of professional bodies and patient groups
to inform the criteria for service provision, workforce and educational
planning that will be required.
7.4 There is a clear indication that some
very specialised services will be commissioned at national level.
Clarity over which services will be included is required and is
of interest to the AHPF.
7.5 Cancer services in particular receive
no reference within the commissioning proposals but are of enormous
public interest.
October 2010
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