Written evidence from North West Specialised
Commissioning Group (COM 90)
INTRODUCTION
1. This document sets out the key messages
that commissioners of specialised services have following the
proposals set out in the White Paper: Equity and excellence:
Liberating the NHS (and its four underpinning consultation
documents).
CONTEXT
2. Liberating the NHS indicates
that the commissioning of specialised services, that is services
that require a planning population of at least one million and
defined within the Specialised Services National Definition Set
(SSNDS), should be undertaken by the National Commissioning Board
"at the appropriate level".
3. Commissioning for Patients goes
further and both references and recommends the "more effective
implementation of Sir David Carter's 2007 review of specialised
commissioning".
4. This approach is also endorsed by the
Health select committee report on commissioning within the NHS
(HC 268-I) which recognised the significant improvements to the
commissioning of specialised services over the past four years.
However this report also suggested that in some parts of the country
these arrangements had not gone far enough.
5. Specialised services include those currently
commissioned at a National and Regional Level and are typically
low volume, high cost services that are provided in fewer than
50 centres across the country. In the case of some national services,
there may only be one or two centres in the UK. High Secure mental
health commissioning operates within a ministerial "line
of sight" as set out in the 1977 NHS Act so "special"
arrangements are in place to oversee the planning and performance
of these services. Within this context it should also be noted
that the National Definition Set includes all levels of secure
mental health commissioning.
HISTORY OF
SPECIALISED COMMISSIONING
6. Specialised Commissioning Groups (SCGs)
were established in April 2007 in response to the recommendations
made in the Carter Review.[152]
Arrangements for commissioning specialised services on a regional
basis had been in place in some areas of the country since 1999,
as set out in HSC 1998/198. The Carter Review also recommended
that the National Commissioning Group (NCG) be established to
advise Ministers on commissioning services on a national
basis. Whilst the NCG has now been superseded by the Advisory
Group for National Specialised Services (AGNSS), arrangements
for commissioning services on a national basis have been in place
in some form since 1983.
COMMISSIONING OF
SPECIALISED SERVICES
7. In summary, specialised commissioners
protect the interests of patients with rare conditions. They promote
their voice but also designate providers, a process that
ensures centres treat a sufficient critical mass of patients to
maintain clinical expertise, thereby maximising clinical safety
and quality through the maintenance of clinical expertise required
to meet minimum standards. Specialised commissioners also take
a strategic service-based view that means they can ensure
value for money in specialised services.
8. Whilst commissioners of specialised services
share much in common with their commissioning colleagues in PCTs,
there are a number of critical factors that set them apart. These
include:
(a) Acquired knowledge and expertise in the specific
services themselves, key to driving strategic configurations and
in negotiating change and improved value for money.
(b) Service-specific expertise leads to credibility
with providers and with other partners such as patient and professional
groups. In order to maintain this credibility, the multi-disciplinary
team approach as defined in the Carter Review will need to be
maintained, with teams comprising commissioning, finance, public
health, information and pharmacy.
(c) Operating a strong relationship model across
multiple organisations such as:
— Other Commissioners (Primary Care Trust
and Specialised Commissioners working collaboratively).
— Providers (NHS and Independent).
— Clinical Networks and Care Pathways.
— Criminal Justice System and Ministry
of Justice (Secure services).
(d) This has evolved because of the necessary
collaborative commissioning arrangements required by the current
model. This relationship management will need to be enhanced if
the interface between the National Commissioning Board and GP
Consortia is to be successful. This interface is also vital because
of the inter-relationships between specialised and non-specialised
services.
(e) The control and entry of innovation thus
preventing creep and the proliferation of inexpert centres.
(f) Expertise in managing the various types of
risk that are a component of specialised services, including political,
financial, policy, resources and clinical.
(g) Management of bespoke public and patient
engagement processes, which are essential with vocal and effective
patient groups who have a high level of understanding of the services
that they use.
(h) They are a vehicle for change through strategic
planning, co-ordination and management across multiple organisations.
(i) The need to manage the overall patient pathway
through explicit inter-relationships between specialised and non-specialised
services aspects of care.
LIBERATING THE
NHS
9. The proposal in the White Paper that
specialised services should be commissioned by the NHS Commissioning
Board would help to address some of the concerns raised by the
Health Select Committee.
10. Coordination, management and implementation
of this would need to ensure that the right incentives are in
place so promoting more integrated care pathways. This is most
pertinent at the interface between GP Consortia Commissioning
and the NHS Commissioning Board.
11. To make sure that there continues to
be sufficient focus on services for people with very rare conditions,
it is recommended that the distinction between national and regional
specialised services is maintained in legislation, whilst acknowledging
that this is a continuum with opportunities for greater synergy.
12. There should be advisory mechanisms
for determining what comes into or out of the definition set.
13. The NHS Commissioning Board will need
to continue the focus on commissioning high secure services since
Ministers are likely to want to continue to have a line of sight
to this politically sensitive service.
14. The success of commissioning specialised
services in the new regime will rely on three elements:
Setting Directions: NHS Commissioning Board
— Developing Service Specifications.
— Finance and procurement.
— Communications and social marketing.
— Informatics and Data Collection/Validations.
— Research, development and innovation.
Making it happen: "Area" Market and
System Management
— Pathway-based approach.
— Integration of local joint needs analysis
with Specialised Services.
— Delivery of Quality, Innovation, Productivity
and Prevention at a Regional Level and as a component part of
the National Commissioning Board.
— Challenging clinical practice in respect
of Better Care Better Value Indicators and changes in Clinical
Threshold's.
Delivering: Relationship Management
— Forecasting and Predictive Modelling
in order to inform and control budgets.
— Performance management.
— Quality and Audit (CQUINS).
— Assurance processes—Compliance
and Outcome Measures.
— Systems Management across the pathways.
15. There are both benefits and risks to
the White Paper proposals and whilst we believe that these counteract
each other the risks are not insignificant and will need to be
managed carefully. This will be a key requirement for any transition
plans.
16. Minimising risk will depend on getting
the right balance between undertaking tasks once at a national
level where possible, whilst maintaining an appropriate level
of resource at a local level to undertake effective relationship
and contract management, partner engagement and integrated care
pathway development.
Benefits include:
— Greater equity through consistent commissioning
of the definition set common strategies, priorities, policies,
specifications, outcome measures, standards/commissioning criteria,
communications, political oversight, prioritisation, data warehousing.
Appropriate measures of equity will need to be developed. It will
be through this transparent approach that true patient choice
can be achieved for specialised services.
— National information systems to support
comparative analysis (including international benchmarking); needs
assessment; contract management and service currencies and costs.
— Opportunities for teams (public health,
commissioning, finance, information and pharmacy) to lead on specific
programmes of care, for example, neurosciences, mental health,
renal, cardiac, cancer, etc. Functions could be undertaken just
once with sharing of knowledge and analysis on a national basis.
This would include needs assessment, clinical development and
central contract reporting.
— Economies of scale by undertaking tasks
just once rather than ten times over. This is critical given mandated
reductions in the number of staff. There may also be economies
of scale in working with the other service areas for which the
NHS Commissioning Board has responsibility, for example, maternity
services, offender health.
— Easier liaison between programme teams
and national functions/organisations; national clinical directors;
Monitor; Care Quality Commission, Health watch; NICE; national
patient groups; Royal Colleges; national teams on clinical currencies
for tariff.
Risks include:
— The challenge of determining the appropriate
level of resource to support consistent commissioning of the definition
set.
— The coding and financial systems (over
60% services outside tariff) for specialised services are weak.
However, difficulties in data collection should not determine
that a service is not considered specialised when there is a strong
clinical case, for example, childhood rheumatoid arthritis. To
minimise risk, information systems and shadow monitoring arrangements
would need to be put swiftly into place.
— Convergence of policy across the 10 SCGs
by summer 2012 to enable consistent commissioning by the time
PCTs are proposed to cease at end of March 2013. "Levelling
up" will carry financial risks; "levelling down"
will potentially put at risk the reputation of the NHS Commissioning
Board with the well-organised patient groups and the All Parliamentary
Party structures/Select Committees.
— Insufficient capacity to support convergence
if the workforce is considerably reduced at an early stage.
CONCLUSION
In response to the vision set out in the White
paper, Directors of Specialised Commissioning have met in order
to support and influence, through the development of this paper,
the consultation process.
This paper, along with the development of a
transitional plan has been developed to ensure continuity of the
current work steams and effectively manage the transfer of the
current specialised commissioning functions to the new arrangements
as the structural changes of the reform become clearer.
This transition plan will build on the collaboration
already in existence between the English Specialised Commissioning
Teams (both regional and national teams) and ensure effective
communication at all tiers across the specialised commissioning
architecture and with key partners.
Directors have considered what functions can
be undertaken once and what function are needed at a more "local
level" assuming the need for specialised services to be commissioned
"at the appropriate level".
On behalf of the 10 Directors of Specialised
Commissioning Groups
October 2010
152 Review of Commissioning Arrangements for Specialised
Services, May 2006, chaired by Sir David Carter Back
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