List of recommendations
1. The
Committee believes that effective commissioning is a precondition
to the successful delivery of the requirement for the NHS to achieve
an efficiency gain of 4% per annum over the four years from 2011-12
("the Nicholson Challenge"). Failure to deliver this
requirement would undermine either the quality or the availability
of care for patients—which would in turn lead to pressure
for extra resources. (Paragraph 2)
2. As in our first
report on this issue, we remain convinced that meeting increasing
demand for high quality health care while delivering 4% efficiency
gains year on year remains the biggest challenge that faces the
NHS. Effective commissioning is key to that target being achieved.
(Paragraph 3)
Commissioning
accountability
3. The
Committee welcomes the stated intention of decentralising power
within the NHS and loosening political control of day-to-day decision
making. Voters will, however, rightly continue to regard the Secretary
of State as accountable for the development of the NHS—there
can and should be no doubt that ultimate responsibility rests
with him. The Government must therefore put in place structures
which enable the Secretary of State to respond to this political
reality. (Paragraph 8)
4. Although the Committee
endorses the need for clear national accountability of commissioners
to the Commissioning Board, it agrees with the Government that
NHS structures should aim to reinforce responsible devolution
of authority. It is, however, concerned that this objective is
unlikely to be delivered by the provisions of the Health and Social
Care Bill. (Paragraph 16)
5. The Committee believes
that these influences create the danger of an overcentralised
service and it believes that, although they will always remain
strong, the most effective counterbalance to the pressures for
centralisation is a strong local voice in the commissioning system.
To be effective, however, this voice needs to be able to speak
authoritatively for local stakeholders; the Committee is concerned
that the proposed structure of GP Commissioning Consortia does
not achieve this objective. The proposals in this report are intended,
among other things, to address this weakness. (Paragraph 18)
Local
Commissioning governance
6. The
local commissioning bodies proposed by the Bill will be public
authorities responsible for more than half of the largest of all
public service expenditures. Voters and taxpayers are entitled
to expect that the legislation which establishes them reflects
standards of good public sector governance. (Paragraph 19)
7. Although the Committee
acknowledges the view that the detailed operating arrangements
for local commissioning are not best dealt with in primary legislation,
it does not believe that the arrangements for governance of NHS
commissioning authorities should be delegated to NHS management.
It therefore believes that the Bill should place a duty on the
Secretary of State to bring forward secondary legislation which
prescribes structures for local commissioning bodies which meet
the objectives set out in the following paragraphs, the principles
of which should be set out in the Health and Social Care Bill.
(Paragraph 22)
8. The Committee does
not agree that it would be "over-prescriptive" to require
local commissioning bodies to adopt governance structures which
meet basic standards of good governance. As statutory NHS bodies,
spending large sums of taxpayers' money, they should be legally
required to have a governance structure (including a formal Board)
which complies with minimum requirements set out by the Secretary
of State in secondary legislation. (Paragraph 24)
9. The Committee therefore
recommends that the statutory governance arrangements for local
commissioning bodies should prescribe that GPs should be a majority
of the members of the Board, but that other places should be preserved
to reflect the range of other (clinical and non-clinical) considerations
which impact on effective commissioning. (Paragraph 36)
10. The Committee
also recommends that the statutory governance arrangements for
local commissioning bodies should prescribe that the membership
of the Board should include representatives of nurses and of secondary
care doctors. (Paragraph 37)
11. The Committee
recommends that the statutory governance arrangements for local
commissioning bodies should prescribe that Directors of Public
Health or a public health professional nominated by them should
sit on the boards of Commissioning Authorities. (Paragraph 41)
12. The Committee
therefore recommends:
i. The proposal to establish Health and Wellbeing
Boards separate from both NHS commissioning and local authority
structures should be dropped.
ii. Responsibility for preparing Joint Strategic
Needs Assessments and Joint Health and Wellbeing Strategies, and
for promoting integrated working between commissioners, should
be shared jointly by the Commissioning Authorities, local authorities
and Public Health England.
iii. The statutory governance arrangements for
local commissioning bodies should prescribe that the membership
of the Board should include:
- a professional Social Care
representative;
- an elected member nominated
by the local authority.
(Paragraph 48)
13. The Committee
believes that the local authority scrutiny function has become
established and supports its continued development. The Committee
welcomes the extension of the health scrutiny powers of Local
Authorities to private sector providers of NHS care and independent
practitioners in primary care. (Paragraph 51)
14. Although Local
Healthwatch can demand information from healthcare providers,
the Bill does not provide for Local Healthwatch to demand information
from commissioning consortia. This effectively continues current
arrangements in respect of LINks, whose power to request information
relates only to services-providers. The Committee regards the
lack of power on the part of Local Healthwatch to request information
from commissioners as a deficiency which should be corrected.
Local commissioning bodies should be under a duty to consult Healthwatch
when making decisions about service provision. (Paragraph 55)
15. The Committee
believes that good governance demands that a public authority
has an identified Chief Executive and an identified Finance Director,
and that both officials are full members of the Board. (Paragraph
58)
16. The Committee
therefore recommends that there should be an independent Chair
of the Board of each local commissioning body and that these individuals
should be appointed by the NHS Commissioning Board. (Paragraph
60)
17. The statutory
governance arrangements for local commissioning bodies should
prescribe that Boards have a duty to meet in public and their
papers should be available to the public. (Paragraph 66)
18. The Committee proposes that local commissioning
bodies should be required to adopt procedures for dealing with
conflicts of interest of Board members which comply with the standards
laid down by the Committee on Standards in Public Life. In particular
all relevant private interests of Board members should be declared
on a public record; no Board member should be present when decisions
are made which affect their private interests, and all decisions
of the Board should be made in public on the basis of papers which
are available to the public. (Paragraph 68)
19. The Committee,
therefore, proposes that the new local commissioning bodies to
be created by the Health and Social Care Bill should be referred
to as NHS Commissioning Authorities. (Paragraph 69)
Primary
care commissioning
20. With
local commissioning bodies being under the exclusive control of
GPs, the Government has found itself having to devise a system
that separates the commissioning of and provision of primary care
services. The cited rationale for this is to protect GPs from
allegations of conflict of interest. However, the Government has
established that the NHS Commissioning Board will rely on GP-led
local commissioning bodies to undertake the most significant task—that
of improving primary care provision. Given the complexity of this
proposal, the Committee has reviewed the Government's proposals
for primary care commissioning. (Paragraph 74)
21. The Committee
finds that the evidence provided by the Secretary of State and
officials runs counter to the direction of policy. If integration
of primary and secondary care commissioning is important, then
separating them in order to support the proposed system architecture
may cause significant harm to the commissioning system as a whole,
and should be reconsidered. (Paragraph 79)
22. The Committee
agrees that confidence in the governance arrangements of local
commissioning bodies is key to them taking on greater responsibility
for primary care commissioning. The Committee considers that arguments
for the complex arrangements set out by the Government fall away
if our proposals for significantly strengthened governance in
NHS Commissioning Authorities are accepted. Given this, the Committee
recommends that NHS Commissioning Authorities should assume responsibility
for commissioning the full range of primary care—including
services such as pharmacy and dentistry as well as general practice—alongside
their other responsibilities. (Paragraph 80)
Authorisation
and assurance of commissioning authorities
23. The
Committee notes that Dame Barbara anticipates that it is likely
that authorisation will be a process rather an event, with the
result that there will be a phased implementation of the changes
to NHS commissioning, rather than a big bang. The Committee strongly
endorses this approach. (Paragraph 84)
24. This answer implies
that the NHS Commissioning Board will have a wide range of discretion
about the pace and extent of authorisation of individual local
commissioning bodies. It is important that there are powers in
the Health and Social Care Bill to allow the NHS Commissioning
Board to manage this process effectively. (Paragraph 87)
25. The Committee
supports this change from the principle of "assumed liberty"
to one where commissioners will earn autonomy, and are only authorised
to commission once the NHS Commissioning Board is satisfied that
they are competent and capable. (Paragraph 89)
26. The Committee
welcomes Sir David's commitment to consult all stakeholders during
the authorisation process. (Paragraph 92)
27. The Committee
acknowledges the need for authorisation and assurance processes
for local commissioning bodies, and for intervention by the NHS
Commissioning Board when things are going wrong. However, these
processes will be resource-intensive and require local knowledge
that a national body may not possess. We recommend that when the
PCT clusters become outposts of the Board in 2013 that their resources
be directed towards authorisation, assurance and support of commissioning
bodies. (Paragraph 100)
28. Given their role
in authorising and assessing local commissioning bodies, and their
powers of intervention when commissioners are failing or likely
to fail, the outposts of the Board have all of the characteristics
of performance managers. The Committee welcomes the presence of
performance management in the commissioning process and believes
its role should be strengthened by requiring local commissioners
to have regard to Support and Improvement Plans developed by or
with the outposts of the Board. (Paragraph 101)
Service
reconfigurations
29. The
Committee believes that the ability to manage service reconfiguration
(i.e. keep service delivery up to date and in line with current
best value and best practice) is fundamental to good stewardship
of public funds and the delivery of high quality, good value healthcare.
In particular it believes it is essential that local commissioning
bodies are able to introduce changes to clinical care in their
communities which reflect the changing needs of their patient
populations. (Paragraph 110)
30. The Committee
also believes that the unprecedented scale of efficiency gain
required by the Nicholson Challenge puts a particular emphasis
on the ability of commissioners to facilitate necessary service
reconfigurations. (Paragraph111)
31. The Committee
is mindful that this unprecedented requirement to manage a process
of change in the clinical model of the NHS will require effort
and commitment from NHS managers whose work we believe should
be valued, alongside the work of the clinical staff of the NHS.
The Committee regrets the fact that the work of NHS management
is sometimes the subject of unjustified populist criticism. (Paragraph
112)
32. The Committee
believes the recommendations it has made elsewhere in this report
for broader clinical and non-clinical engagement in the commissioning
process are fundamental to the delivery of necessary service reconfigurations.
(Paragraph 113)
Interface
between health and social care
33. Against
this background the Committee urges the NHS Commissioning Board
to work closely with local commissioning bodies to facilitate
budget pooling and service integration to reflect patient
priorities. (Paragraph 116)
34. Health and social care commissioning can
also become fully integrated into one body, as in the example
of the Torbay Care Trust, from who we took evidence in our previous
commissioning inquiry.
35. The Committee believes it is essential
that these "Health Act flexibilities" are retained and
developed within the future structures of health and social care.
(Paragraph 118)
36. The Committee
welcomes these proposals and encourages the NHS Commissioning
Board to promote their widespread use. (Paragraph 119)
37. The Committee
believes it is important to promote the integration of health
and social care commissioning, and develop coordinated packages
of care for patients. It recommends that the Government should
ensure that the proposed assurance regime for local NHS commissioning
bodies is developed in association with Local Authority stakeholders
and is capable of assessing joint commissioned services. (Paragraph
120)
38. Aligning geographic
boundaries between local NHS commissioning bodies and social care
authorities has often been found to promote efficient working
between the two agencies. There will in the first instance be
more local NHS commissioning bodies than social care authorities;
the Committee therefore encourages NHS commissioning bodies to
form groups which reflect local social care boundaries for the
purpose of promoting close working across the institutional boundary.
History suggests that some such groups will find the opportunities
created by co-terminosity encourage more extensive integration
of their activities. (Paragraph 121)
Local
Commissioning finances
39. The
Department says that a new NHS funding formula is to be tested
by local commissioning bodies in 2012-13. To make this a meaningful
exercise, the geographic boundaries and constituent practices
of all local commissioning bodies will need to have been established
during 2011-12. The evidence we have heard suggests that this
will be difficult to achieve. The Committee recommends that the
Government should publish a detailed timetable for the implementation
of the new resource allocation formula as soon as possible. (Paragraph
129)
40. Although there
are arguments both for and against consortia being able to carry
forward surpluses, the Committee considers that greater clarity
is needed on commissioners' financial procedures and risk pooling
arrangements. The Department and HM Treasury must publish the
arrangements for effective risk pooling and any plans for rolling
surpluses or deficits forward. (Paragraph 135)
41. The Government
has asked PCT clusters and the emerging GP commissioning bodies
to eliminate their structural deficits over the next two years.
The Committee recognises that had consortia been promised that
the slate would be wiped entirely clean when they take over commissioning
from 2013, this would have sent the wrong message to local commissioners—at
a time when substantial efficiency savings urgently need to be
made. (Paragraph 145)
42. However, we are
concerned that this is just one of many demands being made on
local commissioners (present and future) as they seek to accomplish
the complex transition in a relatively short period. They face
a daunting list of tasks—just as the resources available
for administration are substantially reduced, leading to significant
administrative job losses. (Paragraph 146)
43. We are also concerned
at the apparent lack of robust data on the true underlying financial
position in each PCT (as opposed to the in-year position). Without
this information, it is impossible to know the true scale of the
task that confronts PCT clusters and consortia. (Paragraph 147)
Choice
and competition
44. The
Committee has made clear its view that voters will continue to
regard the Government in the person of the Secretary of State
as responsible for the development of the NHS. It has also made
clear its view that the most effective instrument available to
the Secretary of State to deliver voters' objectives for the NHS
is the development of effective commissioning. It believes it
is important that this objective is not undermined by parallel
policies on the development of choice and competition in the NHS.
(Paragraph 149)
45. The Committee
does not find this comparison between healthcare and the privatised
utilities either accurate or helpful. Competition in the privatised
utilities helps to create a balanced relationship between individual
customers and the utility; the government is not directly involved
in the relationship. In the NHS, the position is fundamentally
different because the government is directly involved as the commissioner.
(Paragraph 155)
46. The Committee
believes that Commissioners should determine the shape of service
provision. It follows the extent of choice, the extent of application
of Any Willing Provider, and the method of determination of entry
into the AWP market all have to be consistent with that core
principle. (Paragraph 162)
47. Monitor told us
that providers operating under Any Willing Provider "are
not being commissioned by the GP consortia". The Department
needs to explain how it will ensure that commissioners are not
simply bill payers where Any Willing Provider applies. (Paragraph
163)
48. The Committee
regards it as essential that NHS commissioners are able to choose
the pattern of service delivery which reflects their clinical
and financial priorities. (Paragraph 167)
49. As part of the
process of strengthening NHS commissioning, the Committee welcomes
the continued development (initiated by the previous government),
firstly, of the culture of open-minded consideration by commissioners
of all options to meet their objectives, and, secondly, of engagement
with patients to reflect their individual needs and priorities.
(Paragraph 168)
50. Although there
has been much discussion of this issue during the passage of the
Bill, the statements made to the Committee by the Secretary of
State, the Chief Executive Designate, and the Chairman of Monitor
have been consistent and clear, and bear only one interpretation:
commissioners will have the power necessary to design, commission
and monitor integrated pathways of care. We regard this as a vital
commitment of principle which must not be prejudiced and which
should be written into the Bill to avoid further ambiguity. (Paragraph
175)
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