Written evidence from the National Spinal
Cord Injury Board (COM 82)
This response is submitted on behalf of the
National Spinal Cord Injury Strategy Board (NSCISB) following
a discussion at a meeting of the NSCISB in August 2010.
The NSCISB was established in 2010 under the
aegis of the National Specialised Commissioning Group, with representation
from all 10 Specialised Commissioning Groups and all eight Spinal
Cord Injury Centres in England. The purpose is:
1. To agree a co-ordinated and common approach
across England to the delivery and commissioning of services for
people with a spinal cord injury (SCI).
2. To ensure improved health outcomes for people
with spinal cord injury in England by effective commissioning
of appropriate high quality and cost effective services.
There are two parts to this Response.
Part 2 contains the responses in full.
Part 1 is the summary requested.
PART 1: SUMMARY
OF NSCISB RESPONSE
1. Clinical Engagement
The NSCISB structure fits well with the plan
to transfer specialized commissioning to the NHS Commissioning
Board and could be replicated for other specialized services.
In planning the transfer of specialized commissioning
to the NHS Commissioning Board, provision needs to be made for
focused Public Health expertise to be provided and developed for
each service. Ideally the public health expertise contained within
SCGs would transfer directly to the NHS Commissioning Board and
would not have to be contracted for from the proposed Public Health
Service, which would have other important priorities such as health
protection.
2. Information/Data
As part of the forthcoming NHS Information Strategy
that there needs to be a particular focus on the information needs
of Specialised Commissioning to enable this area of commissioning
to operate in a data rich environment in the future.
A national information system is essential to
enable consistent commissioning of the SSNDS and needs to be in
place by April 2012. It is needed to support comparative analysis
(including international benchmarking); needs assessment; contract
management, service currencies and costs, and outcome-based commissioning.
This could be provided by a single specialised
services database, or a set of service-based databases, several
of which exist or are in development.
Arrangements need to be in place for the support,
specification and development of national commissioning databases
for specialised services.
3. How will patients make their voice heard
or their choice effective?
The NSCISB structure fits well with the plan
to transfer specialized commissioning to the NHS Commissioning
Board and it could be replicated for other specialized services.
4. What will be the role of the NHS Commissioning
Board?
Specialised Commissioning already has a national
structure in place and there is considerable sharing of the work
between the SCGs. It could therefore be transferred into the NHS
Commissioning Board without too much disruption to work programmes.
5. Will the new arrangements safeguard current
examples of good practice?
There is a risk that that knowledge and expertise
about rare services , and good work being implemented and planned,
will be diluted or lost in the transition of Specialised Commissioning
from SCGs to the NHS Commissioning Board, especially if reductions
on staffing are imposed.
Continuity in Specialised Commissioning is essential
in the interests of efficiency and good outcomes. Consideration
should be given as to how the learning and development needs of
the next and future generations of commissioning staff can be
provided for and assured in order to ensure the effectiveness
of the reforms outlined in the White Paper.
6. How will resources be allocated between
commissioners?
When the NHS CB commissioning budgets are set,
experienced specialised commissioners should be consulted about
the most appropriate basis/methodology for each service.
Clarity about the scope of funding is essential.
Steps will be needed to prevent "cost-shunting".
Flexibility is needed to permit movement of
funds between commissioners where there is evidence that this
will improve services.
7. What arrangements are proposed for commissioning
of specialist services?
The transfer of Specialised Commissioning to
the NHS Commissioning Board could work well for specialised spinal
cord injury services, and fits well with the National Spinal Cord
Injury Strategy Board structure and the planned change to national
commissioning classifications (currencies).
It provides the opportunity to solve some of
the problems currently facing specialized commissioners in implementing
QIPP and outcome-based commissioning, such as information flows
and commissioning database.
It was a particular concern that an experienced
and dedicated team of commissioners for spinal cord injuryincluding
commissioning, public health, finance, information and administrative
staffbe in place to maintain the momentum of the substantial
work programme.
It was considered important to ensure that the
special needs of Spinal Cord Injured people continue to be recognised
as distinct, and they should not be grouped with other services
under the general heading of "Specialised Spinal" as
sometimes occurs.
8. How will these arrangements interface
with the rest of the system?
Perverse incentives and unforeseen consequences
must be avoided when services are specified and budgets set.
PART 2: DETAILED
RESPONSES BY
THE NSCISB TO
SPECIFIC QUESTIONS
ASKED IN
THE CONSULTATION
Clinical engagement in commissioning
How will commissioners access
the information and clinical expertise required to make high quality
decisions about the shape of clinical services?
NSCISB response
Clinical Engagement
The National Spinal Cord Injury Strategy Board,
established early in 2010, has a line of accountability to the
National Specialised Commissioning Directors. It has seats for
service users, commissioners and other stakeholders. Each specialized
centre has a seat, and most are represented by a lead clinician.
Additional there are sub-groups in which clinicians are involved.
The Currencies Group, which has been running for several years,
has been notable for the high level of clinical engagement throughout.
The professional organization BASCIS has an e-mail clinical group
which is useful when a view is required at short notice.
The NSCISB structure fits well with the plan
to transfer specialized commissioning to the NHS Commissioning
Board and could be replicated for other specialized services.
Public Health professionals are a scarce resource
in Specialised Commissioning. Those supporting SCGs have found
it difficult to provide an input to every service in the national
definition set.
In planning the transfer of specialized commissioning
to the NHS Commissioning Board, provision needs to be made for
focused Public Health expertise to be provided and developed for
each service. Ideally the public health expertise contained within
SCGs would transfer directly to the NHS Commissioning Board and
would not have to be contracted for from the proposed Public Health
Service, which would have other important priorities such as health
protection.
Information/Data
The NSCISB supports the proposal to commission
on the basis of outcomes. This has a real potential to improve
the quality of healthcare, but if this is to be fully realised
in specialised services the outcome measures need to be specific
and tailored to the needs of the patients.
Urgent work is needed to develop systems that
allow the extraction of specialised services activity from standard
information systems such as HES.
The intent that the Government intends to bring
about an NHS information revolution is to be welcomed. There are
particular challenges facing commissioners of specialised services
from an information perspective.
The current classification systems used in the
third edition are the International Classification of Diseases,
version 10 and the OPCS Classification of Interventions and Procedures,
version 4.5. Many areas of Specialised Commissioning are hampered
by inadequate information, particularly Spinal Cord Injury Services.
The problems result from the underlying coding (as a result of
lack of specificity in terms of OPCS Surgical Codes and ICD-10
Medical Codes) and problems with the integration of necessary
bespoke datasets to support specialised services with mainstream
healthcare informatics systems (such as the Secondary Uses Service
of the NHS Spine).
Basing Specialised Commissioning Groups within
a "host" PCT has hampered their ability to view data
for the populations for which they commission, due to Information
Governance restrictions.
Example: The South of England Spinal Cord Board
carries out strategic planning for five SCGs, and the South of
England Consortium carries out procurement and risk sharing for
four SCGs. Information sharing protocols are in place for only
a small proportion of the PCTs in the Consortium. The Consortium
is dependent on reports in the form of spreadsheets supplied by
the specialised centres.
In the case of long-term conditions, such as
spinal cord injury, the need to view data for planning purposes
extends to patients living with spinal cord injury who are being
treated in non-specialised settings, where the activity is classed
under the specialty treating the patient (eg urology). The National
Spinal Cord Injury Strategy Board has highlighted this need in
its information strategy.
Many specialized services including Spinal Cord
Injury are currently outside the scope of PbR because of the complexity
of defining and measuring them. For spinal cord injury the DH
has supported the development by commissioners and providers of
National Commissioning Classifications ("currencies")
but has concluded that because of the complexity of the classifications
they will have to remain outside formal PbR for the immediate
future. There is therefore an urgent requirement for a national
web-based database to provide a platform for spinal cord injury
"grouper" software, to classify activity to the new
currencies, which will be shadowed in 2011-12.
To overcome these problems, there is a need
for national commissioning databases in several specialized services,
to record activity and support planning and procurement. These
databases need to be adequately structured and supported, and
capable of providing both commissioners and providers with information
supporting the full range of commissioning activities, including
outcome metrics. This need was recognized in the Carter Report.
These problems will need to be addressed in
order to deliver the information required to support the Governments
intent to better care, better outcomes and reduced costs. We would
suggest that as part of the forthcoming NHS Information Strategy
that there needs to be a particular focus on the information needs
of Specialised Commissioning to enable this area of commissioning
to operate in a data rich environment in the future.
A national information system is essential to
enable consistent commissioning of the SSNDS and needs to be in
place by April 2012. It is needed to support comparative analysis
(including international benchmarking); needs assessment; contract
management, service currencies and costs, and outcome-based commissioning.
This could be provided by a single specialised
services database, or a set of service-based databases, several
of which exist or are in development.
Arrangements needs to be in place for the support,
specification and development of national commissioning databases,
where there is a demonstrable need.
How will commissioners address issues of clinical
practice variation?
The NSCISB has not commented specifically on
this question.
How will GPs engage with their colleagues within
a consortium and how will consortia engage with the wider clinical
community?
The NSCISB has not commented specifically on
this question.
How open will the system be to new entrants?
The NSCISB has not commented specifically on
this question.
Will care providers be free to offer new solutions
which offer higher clinical quality, better patient experience
or better value?
The NSCISB has not commented specifically on
this question.
Will commissioners be free to access new commissioning
expertise?
The NSCISB has not commented specifically on
this question.
Will potential new entrants be free to offer alternative
commissioning models?
The NSCISB has not commented specifically on
this question.
What arrangements will be made to encourage the
Third Sector both as commissioners and providers?
The NSCISB has not commented specifically on
this question.
Accountability for commissioning decisions
How will patients make their
voice heard or their choice effective?
NSCISB Response
Specialised services commissioners have a well-established
track record of involving patients and patient groups in their
activities.
The National Spinal Cord Injury Strategy Board,
established early in 2010, has a line of accountability to the
National Specialised Commissioning Directors. It has seats for
service users, commissioners, service providers and other stakeholders.
Additionally there are sub-groups in which patient organizations
are involved. The NSCISB reports directly on progress to the All
Party Parliamentary Group for Spinal Cord Injury.
The NSCISB structure fits well with the plan
to transfer specialized commissioning to the NHS Commissioning
Board and it could be replicated for other specialized services.
What will be the role of the NHS Commissioning
Board?
NSCISB Response
The NHS Commissioning Board will have a wide
range of tasks, currently undertaken in different parts of the
NHS.
Specialised Commissioning already has a national
structure in place and there is considerable sharing of the work
between the SCGs. It could therefore be transferred into the NHS
Commissioning Board without too much disruption to work programmes.
What legal framework will be required to underpin
commissioning consortia?
The NSCISB has not commented specifically on
this question.
How will commissioning interface with the Public
Health Service?
The NSCISB has not commented specifically on
this question.
How will commissioning interface with Health Watch?
The NSCISB has not commented specifically on
this question.
Where will the "buck stop" when commissioners
face hard choices?
The NSCISB has not commented specifically on
this question.
Integration of health and social care
The NSCISB has not commented specifically on
this question.
How will any new structures promote the integration
of health and social care?
The NSCISB has not commented specifically on
this question.
What arrangements are proposed for shared health
and social care budgets?
The NSCISB has not commented specifically on
this question.
What will be the role of local authorities in
public health and commissioning decisions?
The NSCISB has not commented specifically on
this question.
How will the new arrangements strengthen commissioners
against provider interests?
The NSCISB has not commented specifically on
this question.
How will vulnerable groups of patients be provided
for under this system?
The NSCISB has not commented specifically on
this question.
How will the proposed system facilitate service
reconfiguration?
The NSCISB has not commented specifically on
this question.
Transitional arrangements
The NSCISB has not commented specifically on
this question.
Will the new arrangements safeguard current examples
of good practice?
NSCISB Response
The White Paper outlines a need for the NHS
to achieve unprecedented efficiency gains, with savings reinvested
in front-line services, to meet the current financial challenge
and the future costs of demographic and technological change.
It is therefore extremely important that any
reform maintains the grip within the system to ensure that the
Quality, Innovation, Prevention, and Productivity (QIPP) initiative
is kept on track to deliver efficiency gains.
It is stated that the Government will reduce
NHS management costs by more than 45% over the next four years,
freeing up further resources for frontline care. We understand
that this target reduction is largely based on growth in NHS management
costs in recent years to a level that is now viewed as being unsustainable.
However this recent increase in expenditure
on management was not experienced universally across the commissioning
landscape and as such there are potential risks in applying a
blanket reduction of 45% in the transfer of functions to the NHS
Commissioning Board from SCGs which are already under-resourced
and not able to effectively discharge their current responsibilities
it has.
Example: none of the 10 SCGs are currently commissioning
the full portfolio of 34 Specialised Services National Definitions.
There is a risk that that knowledge and expertise
about rare services , and good work being implemented and planned,
will be diluted or lost in the transition of Specialised Commissioning
from SCGs to the NHS Commissioning Board, especially if reductions
on staffing are imposed.
Continuity in Specialised Commissioning is essential
in the interests of efficiency and good outcomes. Consideration
should be given as to how the learning and development needs of
the next and future generations of commissioning staff can be
provided for and assured in order to ensure the effectiveness
of the reforms outlined in the White Paper.
Who will drive innovation during the transitional
period?
The NSCISB has not commented specifically on
this question.
How will transitional costs (redundancy etc) be
minimized?
The NSCISB has not commented specifically on
this question.
Resource Allocation
How will resources be allocated
between commissioners?
NSCISB Response
It will be important to identify any specialised
services activity not currently commissioned by SCGs together
with the associated budget and to ensure that this is transferred
to the NHS Commissioning Board.
Example: In the case of Spinal Cord Injury,
existing contracts for the specialized centres in some cases do
not cover important parts of the patient pathway, which remain
in local contracts for historic reasons.
New currencies are being costed in 2010; these
will ensure a common definition of the components of the service,
and a common approach to costing; this work will therefore provide
a more appropriate basis for budgets than existing contract or
outturn values.
When the NHS CB commissioning budgets are set,
experienced specialised commissioners should be consulted about
the most appropriate basis/methodology for each service.
It is essential that when resource allocations
are made, barriers are not inadvertently put in place which prevent
funds moving flexibly between GP Commissioning and Specialised
Commissioning (in either direction) where there is evidence that
overall improvements in quality, efficiency, cost and outcomes
can be achieved.
For example: there is evidence that some newly-injured
patients are ventilated in critical care in the receiving hospital,
when with investment in a spinal cord injury outreach scheme,
they could be weaned off ventilation.
Conversely care will be needed to ensure that
GP Consortia do not perceive Specialised Services as "cost-free"
or as a tax on their income, and that perverse incentives are
not put in place which encourage "cost-shunting".
Example: Spinal Cord Injury Centres frequently
experience bed blocking when local services are reluctant to provide
equipment or care which the patient will require in the community.
The result is that the patient cannot go home after rehabilitation,
and the specialised bed is not available for a newly injured patient.
Frequently the cost of the specialised bed is higher than the
local saving, but the local budget-holder does not have responsibility
for funding the specialised service.
This can be avoided if the NHS Commissioning
Board clearly specifies the coverage of specialised contracts
and sets out the responsibilities of GP Consortia.
Clarity about the scope of funding is essential.
Steps will be needed to prevent "cost-shunting".
Flexibility is needed to permit movement of
funds between commissioners where there is evidence that this
will improve services.
What arrangements are proposed for risk sharing
between commissioners?
The NSCISB has not commented specifically on
this question.
What arrangements will be made to safeguard patient
care if a commissioner gets into difficulty?
The NSCISB has not commented specifically on
this question.
Specialist Services
What arrangements are proposed
for commissioning of specialist services?
NSCISB Response
There was general consensus at the NSCISB meeting
in August 2010 that the transfer of Specialised Commissioning
to the NHS Commissioning Board could work well for specialised
spinal cord injury services, and fits well with the National Spinal
Cord Injury Strategy Board structure and the planned change to
national commissioning classifications (currencies).
As noted above, it provides the opportunity
to solve some of the problems currently facing specialized commissioners
in implementing QIPP and outcome-based commissioning, such as
information flows and commissioning database.
It was a particular concern that an experienced
and dedicated team of commissioners for spinal cord injuryincluding
commissioning, public health, finance, information and administrative
staffbe in place to maintain the momentum of the substantial
work programme.
It was considered important to ensure that the
special needs of Spinal Cord Injured people continue to be recognised
as distinct, and they should not be grouped with other services
under the general heading of "Specialised Spinal" as
sometimes occurs.
How will these arrangements interface with the
rest of the system?
NSCISB Response
It is essential that when resource allocations
are made, barriers are not inadvertently put in place which prevent
funds moving flexibly between GP Commissioning and Specialised
Commissioning (in either direction) where there is evidence that
overall improvements in quality, efficiency, cost and outcomes
can be achieved.
For example: there is evidence that some newly-injured
patients are ventilated in critical care in the receiving hospital,
when with investment in a spinal cord injury outreach scheme,
they could be weaned off ventilation.
Conversely care will be needed to ensure that
GP Consortia do not perceive Specialised Services as "cost-free"
or as a tax on their income, and that perverse incentives are
not put in place which encourage "cost-shunting".
Example: Spinal Cord Injury Centres frequently
experience bed blocking when local services are reluctant to provide
equipment or care which the patient will require in the community.
The result is that the patient cannot go home after rehabilitation,
and the specialised bed is not available for a newly injured patient.
Frequently the cost of the specialised bed is higher than the
local saving, but the local budget-holder does not have responsibility
for funding the specialised service.
This can be avoided if the NHS Commissioning
Board clearly specifies the coverage of specialised contracts
and sets out the responsibilities of GP Consortia.
Concerns were expressed by the NSCISB the current
financial environment will impact adversely on Spinal Cord Injury
Services, through the lack of adapted housing. This could result
in more patients blocking NHS beds.
Perverse incentives and unforeseen consequences
must be avoided when services are specified and budgets set.
October 2010
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