Commissioning - Health Committee Contents


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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