Written evidence from the Royal College
of Physicians (COM 89)
The Royal College of Physicians (RCP) plays
a leading role in the delivery of high quality patient care by
setting standards of medical practice and promoting clinical excellence.
We provide physicians in the United Kingdom and overseas with
education, training and support throughout their careers. As an
independent body representing over 20,000 Fellows and Members
worldwide, we advise and work with government, the public, patients
and other professions to improve health and healthcare.
1. SUMMARY
The RCP supports the decision to put commissioning
in the hands of clinicians but there is little mention in the
formal consultation documents of the role that specialist physicians
could play in this process. We support a model of commissioning
based on more effective dialogue and partnership between GPs and
hospital specialists. Without specialist engagement there is a
risk of compounding the separation between primary and secondary
care, making it consequently more difficult to produce effective
outcomes for patients.
We also note that many GPs are coming to commissioning
with little or no experience and that among some, there is reluctance
to take on the role. This has several risks; first, GP consortia
may decide to offer differentiated services. While a local approach
is welcome, it is vital that differentiation in this sense lead
to services that are genuinely tailored to meeting the local population's
health needs and does not simply engender unacceptably wide variations
in access. Secondly, depending on the eventual size of consortia
it may become harder to introduce new district wide services that
require a critical mass of patients to be sustainable. Thirdly,
we must guard against GPs and consultant engaging in "bidding
wars", rather than working cooperatively as colleagues with
different areas of complementary skills.
Finally we note the opportunity for challenging
conflicts of interest to arise where a GP is caring for an individual
patient, while simultaneously having to consider the effects of
spending decisions on the local health economy as a whole.
To mitigate these risks we propose that consortia
would be explicitly required to include specialist clinical advice
on commissioning services and that clear commissioning guidance
are developed with their input. In particular:
— Specialists must be involved in the planning
and commissioning of all services, especially for specialist services
and those with complex and long-term conditions.
— Specialists and public health doctors
should hold positions within the governance structures of GP consortia
so that they can contribute their knowledge and expertise to commissioning
care.
— Consortia should use best practice protocols
for commissioning services developed by the Royal Colleges, in
addition to existing guidance and the proposed NICE quality standards.
— Consortia should have access to networks
of specialist physicians such as currently takes place in cancer
and cardiac networks.
— Commissioning will need to be coordinated
closely with local authorities in order to include social care
services.
2. CLINICAL ENGAGEMENT
IN COMMISSIONING
How will GPs engage with their colleagues within
a consortium and how will consortia engage with the wider clinical
community?
We support the move to clinically led commissioning
but new structures and mechanisms must be developed so that local
specialists become fully involved with the planning and commissioning
of specialist health services. Physicians report a disconnection
between the remoteness of PCT-led commissioning process and the
clinical specialists who have the relevant expertise in providing
care and are also responsible for and leading the service delivery.
Examples such as the cancer and cardiac networks provide models
from which best practice can be drawn. Additionally, the RCP and
other professional bodies have a wide experience of developing
guidelines and pathways of care which can be used to build effective
commissioning.
Commissioning groups/consortia should talk to
their specialist and secondary care partners in order to better
understand local referral flows and ways they might be managed
more effectively. We believe that the best outcomes for patients
will be achieved by GPs and consultants working in partnership,
designing pathways and guidelines for patients' needs that are
sensitive to individuals and localities. Effective working will
require productive engagement between them that should be purposely
designed into the system rather than left to naturally occur.
Without purposeful design productive relationships will develop
in some places and not in others. For commissioning to be completely
effective strong relationships will be needed in all parts of
the country.
3. HOW OPEN
WILL THE
SYSTEM BE
TO NEW
ENTRANTS?
Besides the third sector and social enterprises
the reforms open a door to increased involvement of the for-profit
private sector in the NHS. There is some concern that private
providers will focus more on driving down costs and less on establishing
effective pathways that makes the best use of existing assets
within the local health economy. The RCP believes that quality
of services and not cost should be what drives external providers
of commissioning support.
4. ACCOUNTABILITY
FOR COMMISSIONING
DECISIONS
GP consortia will need specialist input into
integrated commissioning decisions. New ways of ensuring that
GPs and specialists routinely talk with one another to plan pathways
across primary and secondary care and are needed to improve the
quality of care. Each GP consortia will need formal arrangements
to ensure they receive advice on from specialists. These arrangements
need to be purposefully designed into the system. For cardiac
and cancer services the clinical networks have a proven track
record for providing commissioning oversight of services and their
expertise should be used.
The pre-eminent driver of commissioning should
be robust governance arrangements emphasising the quality of care
rather that its locus of delivery. There must be safeguards against
any bias towards primary care provision over secondary care provision
that cannot be justified on strict quality grounds. Clinical governance
arrangements should include a statutory requirement for external
scrutiny.
The size right of a consortium is essential
for effective commissioning and for strategic planning, especially
in relation to commissioning pathways of care. How this is determined
will depend on careful assessment of the commissioning population
taking into account the local hospitals, the local health economy
and the social demographic of the area and current local authority
boundaries. Experience from the past has illustrated that to pool
risk, to create economies of scale and to communicate on an equal
level with large Trusts and external bodies consortia will need
to be of sufficient size.
A key challenge in addressing health inequalities
is that the most disadvantaged and marginalised are often the
last in society to seek medical help. GP consortia and specialists
need to engage with their local communities and work to widen
access to services and connect with hard-to-reach sections of
society. When GP consortia are commissioning individual services
thought should be given to empowering the public to take increased
control of their health.
Not all GPs are used to thinking about the health
needs of a population rather than on their practice lists, so
they will need training in a whole population approach. Clinicians
will need to work collaboratively to develop systems to promote
equality for all patients and staff.
5. INTEGRATION
OF HEALTH
AND SOCIAL
CARE
In some parts of the country there has been
considerable fragmentation of local health services due to an
overly inflexible interpretation of the purchaser/provider split.
This has been a real barrier to integrating health and social
care. Too often, those with complex and long-term conditions are
either unnecessarily readmitted to hospital because of lack of
timely access to specialist care, or have an unnecessarily prolonged
hospital stay because of practical difficulties with accessing
supportive community services. This leads to poor outcomes and
is wasteful of resources. We wish to see fully integrated care
pathways that bring together a comprehensive range of specialists
and services for older people and those with complex and long-term
conditions.
The local authority already commissions social
care services, which have a large and direct impact on healthcare
services. Within current proposals the local authority will be
the lead on all joint and single commissioning areas, such as
mental health and care for people with learning difficulties,
and will also play a pivotal role in public health. Given this
expanded role, local authorities must be held to account in the
same way as PCTs, GP consortia, acute and specialist providers
will also be held to account.
How will vulnerable groups be provided for under
the new arrangements?
Service commissioning must be equitable nationwide.
Many patients and carers find it difficult to access the GP of
choice. It is vital to provide user-friendly and accessible information
and advice on health issues to socially disadvantaged groups,
and in particular younger people. Engagement programmes should
go hand-in-hand with a broader restructuring of services, where
healthcare providers are more closely integrated with social services,
education and childcare provision and employment services. In
addition, there should be increased peer review and the sharing
of best practice across boundaries and nation-wide, where appropriate,
to ensure that equitable approaches and standards are met.
How will commissioning interface with HealthWatch?
The RCP and its patient and carer network support
the strengthening of the patient voice and in principle the creation
of Health Watch. We have always advocated that involving patients
in decisions about their care and in partnership with doctors
is the only way to achieve quality of care. However, in order
to strengthen the patient and carer voice current systems need
to be evaluated. If properly constituted and genuinely representative
then a Local Healthwatch should be the first domain and sometimes
the only stop for public consultation in terms of influencing
commissioning decisions and engaging with GP consortia. But it
is important that Local Healthwatch is not just composed of people
with chronic health conditions. There must be space for non healthcare
users to express their views.
6. TRANSITIONAL
ARRANGEMENTS
The RCP welcomes the transfer of resources from
unnecessary management and bureaucracy to clinical care, as long
as standards of care are maintained or improved and there are
strong arrangements to manage the changes and ensure the expertise
and best practice held in PCTS and SHAs is not lost in the transition.
There is real concern that ground will be lost on quality improvements
as staff leave organisations that have been designated for closure
before the new arrangements are in place. Health trusts are already
inviting voluntary redundancy and early retirement applications.
A high quality health service cannot be delivered and retained
without its valued staff.
A particular area that needs to be preserved
and expanded is national clinical audit. Data from audit can be
a mechanism to ensure that appropriate national guidance is followed,
quality is maintained and that patients get good care. The new
commissioning arrangements must ensure the appropriate participation
in national audits by provider units, and the NHS Commissioning
Board should ensure appropriate national funding for the infrastructure
needed to support them. This should include mechanisms for the
feedback of data to the commissioners to inform their monitoring
functions.
As well as national audits there is the need
to develop local quality assurance processes. If some services
are out-sourced there should be a commitment to ongoing review
of quality. There are already examples of networks that are well
placed to provide such reviews of services. If concerns arise
the Royal Colleges could be mandated to be the appropriate source
of multi-professional external scrutiny. We already have experience
of this through our "invited service review" function.
7. RESOURCE ALLOCATION
What arrangements are proposed for risk sharing
between commissioners?
The RCP is sceptical of the ability of many
of the GP consortia to enter complicated negotiations with hospitals
and this risks consortia failing manage their budgets. Evidence
from the US suggests that failures are likely if a full risk-bearing
model is adopted. This will mean defining failure and developing
the mechanisms to prompt improvement or trigger the tendering
of new contracts. It is important that there is clarity about
what happens if a group overspends and/or fails to meet health
outcome or patient experience targets. The extent, to which this
risk would be carried by GPs as individuals, by practices, or
by the collective group, needs to be.
What arrangements will be made to safeguard patient
care if commissioners get into difficult?
There should be mechanisms in place where by
health professionals who are not happy with commissioning decisions
can raise their concerns. The NHS Commissioning Board will be
working to develop "criteria or triggers for intervention"
with the DH when consortia are not performing well. This seems
to be aimed at consortia's overall performance, but consortia
may do well overall but performing badly in a particular area.
There must be a process by which concerns and problems can be
flanked in relation to specific areas of commissioning. Professional
bodies (including those of the allied professions) could be mandated
to be appropriate source of multi-professional external scrutiny.
We believe that physicians acting as groups, with the support
of local professional networks, backed up by central standard
setting from the College, would be in a strong position to recognise
problems early and to alert the regulator to inefficient areas
of poor performance before any major impact on patient care.
8. SPECIALIST
SERVICES
What are the arrangements proposed for commissioning
of specialist services?
To ensure that specialists are fully engaged
in the commissioning of specialised services the NHS Commissioning
Board should develop sub-groups of clinicians to look at specialised
commissioning in the different specialties. In addition the relevant
National Clinical Director could sit on the group. GP consortia
could also have leads for regional commissioning that engage with
their secondary care colleagues with input from public health
and other sources of expertise.
The range of services that are selected as needing
commissioning beyond the level of consortia will need to be reviewed
and potentially increased. It may require NHS Board to commission
them. Such combined commissioning will be needed for many small
volume procedures to assure patients that the necessary clinical
governance arrangements can be provided. A uniform approach to
the designation of services requiring beyond consortia level commissioning
will be needed to prevent greatly differing approaches to the
provision of services across the country (post-code lotteries).
For services that need to be commissioned beyond consortia each
of the constituent consortia must be obliged to liaise with their
providers to make sure they have the necessary information to
enable evidence-based regional planning decisions. Such information
should conform to a national framework for assessing quality standards
of service provision.
October 2010
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