Written evidence from the Urology Trade
Association (COM 96)
EXECUTIVE SUMMARY
Currently, there are significant weaknesses
in the commissioning of services and provision of products for
patients suffering from urology incontinence, many of whom have
long term conditions and complex clinical needs. This is despite
the existence of a National Drug Tariff that provides information
on products which have been assessed as safe, effective and provide
value for money.
The UTA has found in its contact with NHS commissioners
and procurement agencies that commissioners have tended to focus
on short term cost savings by restricting access to urology products;
however, this often leads to higher costs in the long term if
patients are forced to use products which are unsuitable for their
needs.
The following recommendations could help improve
the quality of commissioning for continence services:
— The Drug Tariff should be maintained
once the new commissioning arrangements are in place, as it provides
assurances on cost, safety and clinical outcomes.
— Steps should also be taken to ensure
that all those who are to be involved in commissioning decisions,
as well as patients, are aware of the role of the Drug Tariff.
— When commissioning and procuring continence
products, there is a need to ensure that commissioners have a
rounded view of the costs associated with particular products.
— GP Consortia need to ensure that there
is enough specialist clinical knowledge within their ranks for
all the various services and products that will be commissioned.
— The Department of Health needs to provide
assurances that patients will be fully informed about the products
to which they are entitled under Part IX of the Drug Tariff, that
decisions about which products to use are made in conjunction
with patients and that patients individual needs are respected.
— When making decisions about patient care,
commissioners should not only ensure that they take into account
the short term costs associated with a particular product, but
also the potential long term costs should their choices lead to
less than optimal patient outcomes.
THE UROLOGY
TRADE ASSOCIATION
The Urology Trade Association (UTA) represents
up to 95% of manufacturers and service providers who supply the
urology appliance market.
An estimated 6 million people in the UK are
affected by continence problems. High quality urology appliances
allow users to manage their conditions, maintaining their quality
of life and independence and avoiding repeated medical consultations.
The UTA welcomes this opportunity to respond
to this inquiry on commissioning. We submitted a response to the
inquiry into Commissioning carried out by this Committee before
the general election, and our concerns about the lack of clinical
knowledge among commissioners were explicitly acknowledged in
the final report. Since then, the new Government has announced
an overhaul of the way in which commissioning is carried out in
the NHS. While this could potentially address some of the issues
we raised in our original submission, there is still a large amount
of uncertainty as to exactly how the system will work. This submission
aims to highlight some of the key questions still to be answered
and to make recommendations as to how the new system can ensure
adequate commissioning for urology services.
HOW WILL
COMMISSIONERS ADDRESS
CLINICAL PRACTICE
VARIATION?
The importance of the Drug Tariff
In September 2010, the Royal College of Physicians
published the National Audit of Continence Care, which
examined the quality of continence services in England, Wales
and Northern Ireland. It identified a number of significant weaknesses
in the care offered to patients and found that there is an unacceptable
variation amongst NHS Trusts in the type, quality and quantity
of continence supplies made available to patients. However, there
is no reason for this to be the case.
In 2009, after their review of the previous
arrangements and over three years of consultation, the Department
of Health (DH) published The new arrangements under Part IX
of the Drug Tariff for the provision of stoma and urology appliances—and
related services—in primary care.
The new arrangements approved by the Secretary
of State endorse the products for stoma care and urology that
are listed in the Drug Tariff and determine the prices that the
NHS should pay for each of the products.
One important benefit of these arrangements
is that they prohibit a postcode lottery for stoma and urology
appliances—no matter where a person is in the country, they
should be able to use any of these products prescribed by their
GP, Nurse Independent Prescriber or Pharmacist Independent Prescriber.
This provides important protection for patients
who use continence devices, many of whom rely on specific products
for their comfort and wellbeing. While two urology appliances
may seem very similar, for the people who use them—many
of whom have complex, long-term conditions that seriously impede
their independence and mobility—slight variations can cause
serious discomfort and impede their ability to live relatively
independent lives. A less than optimum product can create further
respite care needs causing over reliance on carers. This neither
delivers effective commissioning of quality care nor enhanced
patient outcomes.
The Part IX arrangements also provide
protection for the NHS by setting a defined fair price for each
product, ensuring that the NHS is never over-charged for products
and that each PCT can purchase them for the same price. This also
protects the manufacturers of the products, who can rely on getting
a fair price for their products and can plan accordingly.
For items to be included on the Drug Tariff,
they must meet three criteria:
— The products are safe and of good quality;
— They are appropriate for GP and, if relevant,
nurse prescribing;
— They are cost effective.
This means that PCTs can purchase these products
in the knowledge that they have been found to be safe, of good
quality and cost effective. By adhering to the national arrangements,
PCTs provide necessary patient choice, ensure safety and quality
and pay a fair price for a cost-effective product.
Despite the fact that national arrangements
have been developed and despite the obvious benefits of these
arrangements, some PCTs have disregarded the national policy and
formulated their own local arrangements. These local arrangements
limit the number of products available to patients in the area,
producing a postcode lottery for these devices—something
that the national arrangements were specifically designed to stop.
PCTs have often chosen to develop their own
local arrangements with the aim of ensuring quality, value for
money and the best clinical outcomes. However, it is simply not
necessary for them to do this because this is the purpose of the
Drug Tariff. Hence these actions have only served to restrict
patient choice for no good reason. Although patients should have
the right to access any product on the Drug Tariff, the amount
of bureaucracy involved in accessing products which are not included
in local formularies is prohibitive, and many patients are not
aware of their rights. Furthermore, there is a general lack of
knowledge among commissioners as to what the Drug Tariff is.
Patients have also found difficulty in accessing
the number of products which they need. Provision of continence
products should be decided according to clinical need. However,
according to the National Audit of Continence Care, "66%
of PCTs impose a limit on provision".
These local arrangements put patients at risk
by limiting access to products that could improve their lives
and keep them healthy. Due to the invasive nature of many continence
products, any difficulties experienced can result in a need for
hospital treatment meaning that the local arrangements actually
run the risk of raising the cost of treating people who use continence
devices.
The average cost for the admission of emergency
urethral catheterisation resulting from infection, is estimated
in the region of £1,500 per patient, per visit. In addition,
if patients are forced to change products, they must first be
clinically assessed before being prescribed with alternatives.
In specialist care, the associated and potential costs of such
procurement initiatives are a considerable expense for PCTs and
could potentially far outweigh any initial savings.
While the NHS White Paper Equity and Excellent:
Liberating the NHS outlines a new system of GP-led commissioning
for the NHS, there are many details which are still in need of
clarification. There is likely to be some uncertainty while the
new arrangements settle down. Once PCTs are replaced with GP commissioning
consortia, there will be even greater scope for local variation
in provision and for a postcode lottery to develop. Therefore,
a National Drug Tariff which ensures consistency, quality and
value for money is of significant benefit to the NHS at this time.
RECOMMENDATIONS:
— The National Drug Tariff should be maintained
once the new commissioning arrangements are in place, as it performs
a useful function in identifying products which are safe, clinically
effective, provide value for money and are suitable for prescribing.
As well as ensuing patient choice, this is a useful tool for commissioners.
— As part of the preparation for the new
arrangements, steps should also be taken to ensure that all those
who are to be involved in commissioning decisions, as well as
patients, are aware of the role of the Drug Tariff, and the fact
that patients are entitled to access products which are included
in the Tariff.
— When commissioning and procuring continence
products, there is a need to ensure that commissioners have a
rounded view of the costs associated with particular products.
This should recognise that lower-price and lower-quality products
can precipitate longer-term costs if patients are forced to use
products which turn out not to be suitable for their particular
needs.
WHAT ARRANGEMENTS
ARE PROPOSED
FOR SPECIALIST
COMMISSIONING?
Urological care and continence management not
only requires clinical prescription of medical devices but also
the provision of related care services and support, including
access to advice and help with specific products and appliances
as well as the opportunity to provide feedback to the manufacturer.
Over 6 million people, both children and adults,
are affected by continence problems resulting from a wide range
of complex medical diagnoses including cancer, stroke, spinal
cord injury, multiple sclerosis, spina bifida, CVA and other neurological
conditions such as Parkinson's disease.
Medical diagnoses which require continence management
are therefore often long term conditions that require specialist
commissioning services. This is essential for urology patients
to not only improve their clinical health but also support their
independence, dignity and quality of life. These patients rely
on effective continence management in order to ensure that they
remain free from infection, lead independent lives and are able
to work.
In order to deliver effective specialist commissioning
for urology care, commissioners must recognise the complexity
of the wide range of medical conditions which require continence
management, and commission services which provide for an individual
patient's specific condition and needs. This entails ensuring
that patients can access the full range of products and services
which are listed on Part IX of the Drug Tariff.
The previous Government had a number of initiatives
to improve the quality of specialist commissioning. A key principle
of the World Class Commissioning framework was to offer patients
choice and control over which services they use to manage their
own conditions. This stance was widely reiterated in numerous
policy statements from the Department for Health and most notably
is now enshrined as a core patient right in the NHS Constitution.
It was also a strong theme in Lord Darzi's NHS Review that effective
commissioning would demonstrate improved patient outcomes, placing
quality at the heart of all NHS activity. However, the previous
report on commissioning by the Health Select Committee acknowledged
concerns over the lack of necessary clinical expertise to deliver
good quality commissioning, including those concerns expressed
by the UTA.
Recommendation: GP Consortia need to
ensure that there is enough specialist clinical knowledge within
their ranks for all the various services and products that will
be commissioned—for example, by having a commissioning lead
for urology products and services and a commissioning lead for
respiratory products and services. Where this is not possible,
the GP consortium should be encouraged to bring in specialist
advice or consultation. This specialist advice could come from
other GP consortia, from clinical specialists, from user groups
and representatives or from the independent sector.
HOW WILL
VULNERABLE GROUPS
OF PATIENTS
BE PROVIDED
FOR UNDER
THIS SYSTEM?
Many patients with urinary incontinence are
vulnerable patients with complex long term conditions. To ensure
that their needs are provided for, commissioners should ensure
that they have access to the full range of products which are
included under Part IX of the Drug Tariff, in order that they
can use the product which is most comfortable for them and best
meets their clinical needs.
The NHS White Paper states that patient choice
will be key within the new commissioning system: "Shared
decision-making will become the norm: no decision about me
without me." Providing patients with access to a restricted
range of products removes a patient's sense of ownership over
their own care. It also relies on patients to be fully knowledgeable
of the whole range of care items, devices and services which should
be available to them under the Part IX Drug Tariff arrangements
and feel confident challenging medical guidance.
Recommendation: the Department of Health
needs to provide assurances that patients will be fully informed
about the products which they are entitled to under Part IX of
the Drug Tariff; that decisions about product use are made in
conjunction with patients, by clinicians who fully understand
their needs, and that a patient's individual needs are respected.
HOW WILL
RESOURCES BE
ALLOCATED BETWEEN
COMMISSIONERS?
NHS reforms have long failed to address the
issue of silo budgeting and the perverse incentives that it causes.
In urology, this might be the associated costs of providing nurses
to visit people in their homes and assess the suitability of the
products they are using. This can help prevent complications which
could require expensive treatment further down the line, but it
is often not provided due to the initial cost. There is a need
for integrated patient care which takes account of more than just
the costs of individual products or services, and considers how
this can affect the overall amount of money spent on an individual
patient. This also links into the point we have made above about
the need to ensure that commissioners do not provide patients
with low quality products which do not meet their needs, and which
end up costing the NHS more money in the long run. We stated above
that the average cost for the admission of emergency urethral
catheterisation resulting from infection, is estimated in the
region of £1,500 per patient, per visit.
This is also important when bearing in mind
the fact that, under the new arrangements and the NHS Outcomes
Framework, GP consortia will be judged on the clinical outcomes
which they achieve. There is a need for commissioners to be aware
that driving down costs will not always lead to the best clinical
outcomes. Sufficient incentives and penalties should be in place
to encourage commissioners to make decisions in the best interests
of the overall treatment and care pathway for patients.
Recommendation: When making decisions
about patient care, commissioners should ensure that they take
into account not only the short term costs associated with a particular
product, but also the potential long term costs which will be
seen should their choices lead to less than optimal patient outcomes.
Incentives and penalties should be put in place to encourage them
to do this.
CONCLUSION
This submission has highlighted some of the
key problems currently experience in the commissioning of urology
services. Some of the reforms proposed in the NHS White Paper
could potentially lead to improvements in the quality of commissioning.
However, they key point that we would like to empathise is that
the national Drug Tariff is essential for ensuring that urology
patients have access to a full range of products so that they
can chose the one which best meets their clinical needs. This
will also avoid the danger of a postcode lottery which is present
when care decisions are devolved to the local level.
October 2010
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