Written evidence from National Voices
(COM 139)
SUMMARY
1. Commissioning is about securing health
and well being outcomes. It needs to be multi-disciplinary, to
focus on care pathways and to cross the boundaries of health,
social care and public health. It needs to fully involve patients
and citizens.
2. National Voices advocates a unified health
and well being outcomes framework, as a driver of integrated working.
3. Commissioning has yet to mature in England.
The Government's proposed reforms provide an opportunity to make
commissioning more holistic and responsive to patient needs. They
also present risks, in particular the risks of fragmentation and
loss of existing expertise.
4. We welcome the opportunity to open health
and social care to new commissioning models, in which there is
a big potential role for the voluntary sector.
5. General practitioners are well-placed
to take a pivotal role in commissioning. But the interests of
GPs and patients are not identical.
6. There must be patient and lay participation
in the governance of consortia on terms of equality. Commissioning
decisions need to involve patients and local communities, including
HealthWatch, and reflect patient and service user experience.
Patient and lay involvement need to be backed by statute.
7. Hard choices will be inevitable to maintain
an effective health service in conditions of austerity. It is
not clear that the White Paper posits sufficiently robust mechanisms
for making these choices. It is important that patients and citizens
are not left out in the cold as these decisions are taken. They
need to be partners in the decisions, for example on the reconfiguration
of services.
8. There needs to be an explicit focus in
the remit of the National Commissioning Board on the needs of
patients and service users who are vulnerable by virtue of their
health condition or demographic characteristics.
INTRODUCTION
9. National Voices welcomes the opportunity
to submit evidence to the Health Select Committee inquiry on commissioning.
We are the coalition of national voluntary organisations with
a mission to strengthen the voice of patients and citizens at
all levels in health and social care. This submission represents
the collective views of National Voices members, and is consistent
with our response to the Government's consultations on its NHS
White Paper "Equity and Excellence".
10. We have structured our submission as
follows:
(a) A general observations section and (b) specific
responses to the questions set out in the Committee's terms of
reference.
GENERAL OBSERVATIONS
Context
11. There has been considerable progress
in the last decade in improving health and care in England, but
more needs to be done. We need a service that is equipped to cope
with growing demand, to ensure greater consistency of quality
and to make care more tailored to the diverse needs of individuals
and communities.
12. We know that there are large variations
in quality, that death rates for several cancers lag those in
other advanced countries, and that health inequalities have remained
wide and, in the case of the life expectancy gap between rich
and poor, have widened. The care of people with long term conditions,
to which the majority of NHS resources are devoted, does not systematically
follow good practice. More needs to be done to take unnecessary
activity out of hospital settings and to provide people with the
support and information they need to be in control of their health
and their conditions and be fully involved in decisions about
their care. The provision of adult social care is patchy and inequitable.
The health and social care systems are often difficult and confusing
to navigate. There is frequently poor coordination across the
boundaries between NHS and local authority services and between
primary, community and secondary care.
13. More needs to be done to ensure that
patient and citizen voices become powerful drivers of change in
the NHS.
14. We know from our members that care systems
struggle to respond effectively to the needs of particular people
and groups, for example: frail elderly people; people with mental
health conditions, learning disabilities and physical disabilities;
some minority groups; chronically excluded groups, such as homeless
people, sex workers, and asylum seekers; and people with rare
conditions or with those which the NHS does not generally prioritise,
such as musculo-skeletal conditions. Even for the most articulate
and health-literate, the experience of care can sometimes be disempowering,
frightening and lacking in respect and compassion.
15. National Voices members are therefore
not complacent about the status quo, which can be seen among other
things to reflect a continued immaturity in the state of commissioning.
Commissioning still manifests itself too much as a series of incrementally
evolving buying decisions, and not enough as the strategic design
of care pathways which ensure that services are joined up, and
that, for example, self-supported patients with long term conditions
have a better and cheaper option than A&E when they are unwell.
16. We believe that the Government's proposed
reforms offer an opportunity to rethink the way health and social
care are delivered in England and to make significant improvements.
In particular, we strongly support the emphasis on quality and
outcomes, and on empowering patients and citizens. We welcome
the commitment to build on the work of Lord Darzi on quality and
to maintain the NHS Constitution. We applaud the vision of an
NHS built around the principles of shared decision making, including
better information and choice, and of "no decision about
me without me". We believe that general practice commissioning,
if carefully introduced and supported, has the potential to make
the design of local services more responsive to need. We welcome
the proposed new role for local authorities in promoting integrated
commissioning across health and social care and in public health.
17. Our members have also highlighted risks
associated with implementing the Government's reforms. A number
of major changes are happening in parallel:
— an NHS change programme of unprecedented
scale and pace, which is already underway;
— an efficiency programme designed to release
up to £20 billion of savings for reinvestment within the
NHS;
— the drive to achieve significant savings
in the NHS management overhead; and
— cuts to benefits, local authority services
and support to the voluntary sector, a set out in the comprehensive
spending review.
18. In combination these factors risk undermining
the intent of the NHS White Paper through:
— professionals losing focus on safety,
clinical effectiveness and the experience for patients;
— a loss of skills and expertise, especially
in commissioning;
— disruption of models of care that are
working well;
— short termist cuts in service provision
with long lasting consequences; and
— a widening of health inequalities and
harm to the health and wellbeing of poor and marginalized communities.
Commissioning
19. The new commissioning arrangements need
to respond effectively to diverse needs at local, regional and
national level. In the transition to the new arrangements it will
be vital to guard against the risk of fragmentation and growing
inequity as between consortia areas, and the unwitting loss of
services and good practice. The leadership role of the emerging
NHS Commissioning Board will be of vital importance, in particular
to guide the development of services at geographical levels beyond
that of individual consortia. Patient, service-user, carer and
community organizations need to be closely involved in supporting
the transitional arrangements.
20. Commissioning consortia will need skills
and infrastructure to support their work. GPs are well placed
to understand the needs of their patients, but also need to understand
the diverse needs of their populations, not all of which are manifest
in the consulting room. GPs' interests are not identical to those
of patients and communities and GPs are not proxies for patients.
General practice commissioning will need to draw on the expertise
provided by a range of health and social care professionals and
on the expertise about particular conditions that lies with patient
organizations and with patients themselves.
21. GP consortia will be publicly funded
and accountable bodies. They need to feel very firmly accountable
to local communities. Consistent with the Government's commitment
to shared decision making and meaningful public involvement, we
consider it vital that there is equal lay participation in the
governance of consortia, and that their meetings are held in public.
They need to involve local communities in their work. A significant
lay involvement is also needed in the governance of the NHS Commissioning
Board.
RESPONSES TO
THE COMMITTEE'S
QUESTIONS
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?
— How will commissioners address issues
of clinical practice variation?
— How will GPs engage with their colleagues
within a consortium and how will consortia engage with the wider
clinical community?
22. We support a multi-disciplinary approach
to commissioning which makes full use of comparative data on clinical
outcomes, patient reported outcomes and patient experience. It
is vital that existing skills, for example those lying within
specialist heart, stroke and cancer networks, are not lost as
the PCTs and SHAs wind up.
How open will the system be to new entrants?
— Will care providers be free to offer
new solutions which offer higher clinical quality, better patient
experience or better value?
— Will commissioners be free to access
new commissioning expertise?
— Will potential new entrants be free to
offer alternative commissioning models?
— What arrangements will be made to encourage
the Third Sector both as commissioners and providers?
23. We support a system which is open to
new entrants and which can make full use of alternative commissioning
models, including those which involve voluntary sector organizations
as commissioners and providers.
24. It is important in the interests of
accountability that there is maximum transparency about the arrangements
for supporting commissioning in each consortium area.
25. We envisage the risk of support for
commissioning becoming dominated by a small number of large organizations,
in which case a level playing field for competition will not apply.
Accountability for commissioning decisions
— How will patients make their voice heard
or their choice effective?
— What will be the role of the NHS Commissioning
Board?
— What legal framework will be required
to underpin commissioning consortia?
— How will commissioning interface with
the Public Health Service?
— How will commissioning interface with
Health Watch?
— Where will the "buck stop"
when commissioners face hard choices?
26. We support patient and lay participation
in the governance of consortia on terms of equality, along the
lines demonstrated by the practice based commissioning consortium
Principia in Nottinghamshire.
27. Commissioning decisions need to involve
patients and local communities and reflect patient and service
user experience. We think Experience Led Commissioning[57]
is a good example of an approach which seeks to achieve this.
28. We support a legal duty on consortia
to involve patients and local communities in commissioning decisions.
This needs to be supported by guidance from the NHS Commissioning
Board. The aspiration should be co-design of services, achieved
through meaningful involvement of local people, and including
a strong role for local HealthWatch. Current practice in the realm
of patient and public involvement often remains too tokenistic
and formulaic.
29. We should be commissioning for health
and quality of life, not illness. Commissioning needs to promote
a strong connection between health, social care and public health
and there is an important role here for the new health and well
being boards.
30. We believe that local accountability
is better served by maintaining the separate scrutiny functions
of the health Overview and Scrutiny Committees.
31. Hard choices will be inevitable to maintain
an effective health service in conditions of austerity. It is
not clear that the White Paper posits sufficiently robust mechanisms
for making these choices. It is important that patients and citizens
are not left out in the cold as these decisions are taken. They
need to be partners in the decisions.
Integration of health and social care
— How will any new structures promote the
integration of health and social care?
— What arrangements are proposed for shared
health and social care budgets?
32. Analysis by the Audit Commission, Nuffield
Trust, Integrated Care Network and Turning Point has suggested
that joint working is most effective when focused, not on administrative
structures and the process of joining up (sharing management,
pooling budgets, etc) but on the outcomes for patients and service
users.
33. National Voices advocates a unified
health and well being outcomes framework, as a driver of integrated
working.
34. The executive role of health and well
being boards, and the accountability provided by OSCs and HealthWatch
will be important.
35. It is important that the new reforms
do not undermine instances of joint working (eg Care Trusts) which
are working well now.
What will be the role of local authorities in
public health and commissioning decisions?
How will the new arrangements strengthen commissioners
against provider interests?
36. A disaggregation of commissioning arrangements,
alongside the proposed increase in powers and freedoms for providers,
creates the risk of weakening, rather than strengthening commissioners
against provider interests.
How will vulnerable groups of patients be provided
for under this system?
— How will the proposed system facilitate
service reconfiguration?
— Will the new arrangements safeguard current
examples of good practice?
— Who will drive innovation during the
transitional period?
— How will transitional costs (redundancy
etc) be minimized?
37. There needs to be an explicit focus
in the remit of the National Commissioning Board on the needs
of patients and service users who are vulnerable by virtue of
their health condition or demographic characteristics.
38. Service reconfiguration will be difficult
to achieve without an approach will allows decision making at
the right geographical level (such as the recent work to reconfigure
acute stroke services in London) and which involves patients and
citizens in an honest and meaningful way.
39. There is an opportunity to drive innovation
through a "pathfinder" process that encourages, publicises
and carefully evaluates a diversity of approaches.
Resource Allocation
— How will resources be allocated between
commissioners?
— What arrangements are proposed for risk
sharing between commissioners?
— What arrangements will be made to safeguard
patient care if a commissioner gets into difficulty?
40. National Voices favours maximum clarity
and transparency about the arrangements that will pertain.
Specialist Services
— What arrangements are proposed for commissioning
of specialist services?
— How will these arrangements interface
with the rest of the system?
41. National specialist commissioning arrangements
need to continue.
December 2010
57 http://www.networks.nhs.uk/nhs-networks/healthcare-professionals-commissioning-network/documents/section-useful-resources/Putting%20people%20at%20the%20centre%20of%20GP%20commissioning%20ELC%20report%20161110.pdf Back
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