Commissioning - Health Committee Contents


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 injury—including commissioning, public health, finance, information and administrative staff—be 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 injury—including commissioning, public health, finance, information and administrative staff—be 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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