Written evidence from London Specialised
Commissioning Group (COM 41)
INTRODUCTION
1. This response concentrates on the commissioning
of specialised services, where the low number of patients with
each condition requires the commissioning to be based on a planning
population of more than a million people.
2. The response is made in the light of
the White Paper proposals for the commissioning of specialised
services (White Paper, Equity and Excellence: Liberating the
NHS). These suggest that services within the Specialised Services
National Definition Set are to be commissioned by the NHS Commissioning
Board in the future.
3. London Specialised Commissioning Group
(SCG) effectively commissions a range of 23 services, eight on
behalf of PCTs in three SHA areas, from many of the largest Trusts
in England. London SCG has won awards for commissioning and performed
well in last year's world class commissioning assurance process.
4. Specialised commissioning has developed
considerably since the Carter (2006) review recommendations began
to be implemented. In London this has led to the concentration
of specialised commissioners from all parts of the capital into
a single team. This model might be seen as a forerunner of the
changes which will come if the White Paper proposals are agreed.
5. London SCG has a track record of involving
clinicians and patient and public representatives in both the
commissioning of services and in the monitoring of patient experience.
Patient experience in this paper is directly gathered from our
regular contacts.
EXECUTIVE SUMMARY
6. The national definition set for specialised
services (SSNDS) contains 38 categories of service, some are clearly
defined, others merge into secondary care services. Agreeing the
funding for specialised services is not straightforward because
of inconsistencies in coding. A method is proposed.
7. Specialised commissioning funding could
either be retained by the NHS Commissioning Board prior to allocation,
or routed through GP commissioning consortia and blocked back.
Both methods have positive and negative attributes. London SCG
favours retention by the NHS Commissioning Board.
8. While GP commissioning consortia will
have the responsibility for commissioning services outside the
SSNDS there may be circumstances where it might make sense for
this to be done by the NHS Commissioning Board. This might apply
where the ideal planning population for a service is larger than
GP consortia or there are other factors such as "open access"
that require collaborative commissioning across a large population
base.
9. Patients with rare or specialised conditions
can experience difficulty with co-ordination of services at primary
and secondary level. In addition there are conditions which manifest
in specialised services where the prevention solution is in primary
care, for instance morbid obesity. It is important that GP commissioners
are required to collaborate with commissioners of specialised
services on patient pathways.
10. There are a particular set of circumstances
in London caused by the historical distribution of services. Change
is required to respond to modern service standards and treatments.
Specialised services can be the catalyst for change.
11. National standards for specialised services
will be a great advantage for access to equitable treatment. Specifications
for the local application of those standards into contracts with
providers require a local knowledge and commissioning relationship.
There needs to be a local commissioning approach to most specialised
services.
12. The inclusion of maternity services
in the scope of the NHS Commissioning Board will allow the whole
pathway of care to be commissioned as a single care pathway including
Special Care Baby Unit (SCBU) and Neonatal Intensive Care (NIC).
There are 244 birthing units in England (source Birthchoice UK),
together with all the community maternity services. Since it is
a high risk service there needs to be adequate commissioning capacity,
nationally and locally.
EVIDENCE TO
SUPPORT RECOMMENDATIONS
ISSUES AROUND
THE SPECIALISED
SERVICES NATIONAL
DEFINITION SET
(SSNDS)
13. Like most SCGs across the country the
London SCG does not currently commission the whole national definition
set. The current governance model for SCGs is as a joint committee
of PCTs, and consequently all SCGs vary in their scope of work
depending on the policies and priorities of their PCTs. If the
NHS Commissioning Board is to commission the whole SSNDS, this
will mean that during the shadow year 2011-12 the 10 SCGs need
to get as close to commissioning the entire definition set as
possible. There are two main reasons for this:
— Continuity for patient services—the
sort of conditions covered by the SSNDS are uncommon and services
and their patients are therefore vulnerable if the expertise commissioning
them is lost.
— Whichever method of funding specialised
services is chosen (see below), the amount required needs to be
as accurately assessed as possible. As much of the finance connected
with the definition set should be in SCGs as possible, to ease
the transition to funding the NHS Commissioning Board. It will
be less easy to shift allocations between GP commissioning budgets
and the NHS Commissioning Board once budgets have been committed.
14. The funding calculation is of particular
importance. Funding the commissioning of the whole definition
set will include current spending by SCGs, excluding services
outside the definition set currently commissioned by SCGs, for
instance HIV outpatient services in London. Where PCTs know they
currently fund services in the definition set, this is also easy
to identify. Unfortunately the edges of the definition set are
unclear, data from providers is often inconsistently coded making
the accurate assignment of activity inconsistent. If the NHS Commissioning
Board is to commission the entire definition set from 2012-13
it will need more than the known spend in both SCGs and PCTs.
Recommendation 1
The allocation of funding to specialised commissioning
needs an accurate financial model based on patient level activity
information appropriately coded by providers. This must include
known SCG and PCT spend on the definition set services and a calculation
for the less well defined areas of the definition set where accurate
information is unavailable.
WHAT IS
THE BEST
FUNDING ROUTE
FOR SPECIALISED
COMMISSIONING?
15. The allocation of funding could either
be routed through GP commissioning groups, and blocked back, or
retained prior to allocation. Both methods have positive and negative
attributes.
16. One of the successes of the current
system in London is the sense of ownership of specialised commissioning
by the PCTs and Sectors. There is vigorous debate at the SCG Board
and clear oversight by the PCT Chief Executives who sit on it.
This means that the boundary between specialised services and
the rest of the care pathway for each condition is easy to manage.
For some services like HIV or child mental health, the key to
managing spend in specialised services is in prevention or early
detection in the patients care pathway.
17. Engaging a larger number of GP commissioning
groups with this sort of service would be easier if they had a
greater knowledge of specialised services, and giving them the
allocation and then blocking it back to the NHS Commissioning
Board would help connect the whole care pathway.
18. The counter argument to this is that
the cost of each patient can be significant, £4-500k per
annum is not unusual, and therefore all these services are risk
shared. The connection to GP commissioning groups could seem either
academic if they are in effect paying an insurance type fee, or
risk budget overspend if actual costs were attributed. Added to
this, it might seem unimportant to GP consortia to be paying into
a risk share fund for a condition the practices have never or
rarely seen.
Recommendation 2
The funding allocation for specialised commissioning
should be retained by the NHS Commissioning Board before the allocation
to GP Commissioning Consortia is made.
COMMISSIONING SERVICES
OUTSIDE THE
DEFINITION SET
19. The major thrust of the White Paper
is to devolve commissioning to GP consortia, as close to clinical
decision making as possible. The patient care pathways for most
common conditions are therefore managed as locally as possible.
At the other end of the commissioning scale, specialised services
will be commissioned on a whole England basis. There are however
a group of services that are in the middle where a collaborative
approach may be needed.
20. In London's case there are services
outside the definition set currently commissioned by the London
SCG where all the London PCTs have agreed a pan London approach
is beneficial. The number of patients with HIV in London is 48%
(2008) of the national total and London SCG commissions the entire
service. This allows it to have extremely close links with the
groups representing patients, as well as commission an equitable,
high quality service. Similarly, there has been a recent service
review of major trauma services in London, and the newly commissioned
service fast streams the most seriously ill patients to four major
trauma centres. This is already showing improvements in services.
Both these services are outside the SSNDS.
21. London SCG also commissions specialist
pharmacy services across 4 SHAs (Pharmacy in England—Building
on Strengths, 2008 White Paper) and plays a major role in pharmaceutical
safety and value for money. This is also outside the definition
set.
22. The aim is to seek GP consortia arrangements
to resolve commissioning arrangements for services where the critical
mass of the service requires a very large planning population
but are outside the national definition set. There is a danger
that the transactional costs may go up if there is too complex
a set of differing commissioning arrangements. It would be sensible
for there to be a permissive clause in the establishment of the
NHS Commissioning Board, which will allow the commissioning of
services outside the national definition set where GP Consortia
arrangements are found to be complex or unwieldy to put in place.
Recommendation 3
The NHS Commissioning Board should have the
discretion to be able to commission services outside the definition
set where the ideal planning population for a service is larger
than GP consortia or there are other factors such as "open
access" that require collaborative commissioning across a
large population base.
THE RELATIONSHIP
BETWEEN SPECIALISED
AND GENERAL
SERVICES
23. Many of the services in the definition
set are quite discrete, for instance gender dysphoria or cleft
lip and palate surgery, but others have a clear pathway with primary
and secondary services. Child and Adolescent Mental Health (CAMHs)
tier 4 services are a good example, where the interplay between
all parts of the patient pathway is vital to a good outcome.
24. Because of the rare nature of specialised
conditions the patient representatives who advise London SCG have
commented on a number of occasions, on the lack of understanding
of their needs in primary care. The planning for these services
therefore requires collaboration and being outside the GP Consortia's
main responsibilities, they may not receive focussed attention.
25. It is also true that in the future it
is probable that services will transfer, either into or out of
the national definition set. Because most specialised services
commissioned in London operate on a risk share, GP Consortia with
no experience of the condition may resist having to contribute.
26. All these factors lead to the need for
levers in the system to set out the expectation of collaboration.
Recommendation 4
GP commissioners should have a requirement to
collaborate with specialised services on patient pathways.
SERVICE CHANGE
AND "DESIGNATION"
27. A more vibrant provider market with
all sorts of new entrants will cause competition in London between
providers to become greater, in an already crowded market. For
specialised services where markets are small and niche, this represents
a potential risk to safe and sustainable services. An example
in London is the recent review of Haemophilia services, resulting
in two managed networks for adults and children.
28. The distribution of providers in London
is a product of the historical growth of services. Change is required
to respond to modern service standards and treatments.
29. Specialised services have moved toward
"designation" of services which meet nationally agreed
clinical standards. Designation may cause substantial service
change for providers who do not meet the standards, and once one
service is lost it can cause a domino effect since many services
are interdependent. Commissioners are also seeking the best value
for money through the QIPP agenda.
30. Once a service is designated it may
be difficult for new entrants to move into some specialised services
markets because of high capital costs, start up costs and the
range of interdependent services usually required. This means
there is even greater need for the commissioner to hold the designated
service to account, for quality and value for money.
31. The point to make is that specialised
services can be the key and the catalyst for change. The impact
of modern service standards in specialised services will have
an effect far beyond the immediate service change and consequences
for hospital development in London. This process will need to
be managed to avoid unintended consequences.
Recommendation 5
Specialised services may need to lead service
and consequential provider change in health economies.
A NATIONAL OR
LOCAL APPROACH
TO SPECIALISED
COMMISSIONING?
32. A comprehensive set of national specifications
for services in the definition set has not yet been developed.
Each of the 10 SCGs has a different scope depending on the local
circumstances of their constituent PCTs, and the White Paper proposal
of a single national commissioning board will promote a consistent
approach across the country. This could go hand in hand with a
designation process.
33. A series of meetings is currently underway
bringing together the QIPP agenda and quality development, held
jointly with the Specialised Healthcare Alliance. This has brought
together patients, clinicians and commissioners from across the
country to propose standards and quality markers in HIV and other
specialised services. From this work, together with national bodies
like NICE, it will be possible to create nationally consistent
specifications and benchmarks for each service.
34. At local commissioning level however
there will continue to be a strong need to contract with providers
according to local circumstance. The commissioners need to manage
their contracts in detail and if commissioners are remote this
will not happen. A local approach from the NHS Commissioning Board
would solve this potential problem. If the local approach is accepted,
each locality could take the lead commissioning role for the providers
in their area, and liaison with GP Commissioning Consortia using
these providers.
35. The capacity needed to contract with
providers will depend, as now, on the level of knowledge of the
commissioner and the time devoted to each contract. A detailed
knowledge of the provider allows the relationship to tackle difficult
issues like the changes needed for QIPP. Commissioning will be
carried out on an increasingly higher level if there is insufficient
capacity.
Recommendation 6
There needs to be a local approach to the commissioning
of most specialised services, as well as the national approach
for consistency of standards and equity of access.
COMMISSIONING CAPACITY
AND MATERNITY
SERVICES
36. While maternity services are outside
the scope of the SSNDS the proposals will bring their commissioning
into the same organisation and presents both opportunities and
threats. The principle opportunity is to bring the commissioning
of the whole maternity pathway together including SCBU and NIC.
37. Maternity commissioning is however a
very different proposition, being integrally networked into each
local health economy, at hospital, community and primary care
level. It presents a high risk and SHAs have maintained close
scrutiny. The commissioning will need local knowledge and enough
capacity to manage a comprehensive national service.
Recommendation 7
The high risk and widely distributed nature
of maternity services will require adequate commissioning capacity,
nationally and locally.
RECOMMENDATIONS
1. The allocation of funding to specialised
commissioning needs an accurate financial model based on patient
level activity information appropriately coded by providers. This
must include known SCG and PCT spend on the definition set services
and a calculation for the less well defined areas of the definition
set where accurate information is unavailable.
2. The funding allocation for specialised
commissioning should be retained by the NHS Commissioning Board
before the allocation to GP Commissioning Consortia is made.
3. The NHS Commissioning Board should have
the discretion to be able to commission services outside the definition
set where the ideal planning population for a service is larger
than GP consortia or there are other factors such as "open
access" that require collaborative commissioning across a
large population base.
4. GP commissioners should have a requirement
to collaborate with specialised services on patient pathways.
5. Specialised services may need to lead
service and consequential provider change in health economies.
6. There needs to be a local approach to
the commissioning of most specialised services, as well as the
national approach for consistency of standards and equity of access.
7. The high risk and widely distributed
nature of maternity services will require adequate commissioning
capacity, nationally and locally.
October 2010
| 
