Written evidence from Lundbeck (CFI 18)
The commissioning of services that either work across
[health and social care] boundaries, or are intimately linked
is therefore an issue to which the Committee attaches great importance,
and we intend to review the effectiveness of the structures proposed
in the Bill which are designed to safeguard co-operative arrangements
which already exist and promote the development of new ones. (Paragraph
107)
SUMMARY
— The
Health and Social Care Bill must ensure that effective structures
are in place to ensure that GP consortia and local authorities
work together to commission services across the boundaries of
public health and health services. Lundbeck has two concerns regarding
the proposed structures for the commissioning of services across
boundaries.
— Firstly,
the White Paper, Liberating the NHS: Local democracy and legitimacy
makes a distinction between primary prevention and secondary prevention.
However, this distinction is complex; in relation to the prevention
of alcohol misuse, interventions cannot be clearly delineated
as primary and secondary prevention. For instance, brief intervention
is both a primary and secondary prevention.
— Secondly,
where there are multiple commissioners across one therapy area,
such as in alcohol misuse, there may be some uncertainty as to
who is responsible for funding and commissioning services which
can be considered both primary and secondary prevention. The current
consultation on public health funding and commissioning routes
adds to the uncertainty on who (GP consortia or local authorities)
should fund and commission to deliver public health outcomes.
— Finally,
where public health, health and social care outcomes overlap,
as with alcohol misuse, the Joint Strategic Needs Assessments
should be harnessed to enable collaborative commissioning between
local government and GPs.
1. Lundbeck are specialists in psychiatry and
pioneers in neurology, with an interest in alcohol policy.
2. The Health and Social Care Bill outlines the
designation of the majority of commissioning responsibilities
to GP consortia, whilst transferring local health improvement
(public health) commissioning to Directors of Public Health in
local authorities. It is vital that services are commissioned
collaboratively and effectively across the boundaries of public
health and GP consortia. The commissioning of public health primary
prevention services must be linked with secondary prevention and
treatment services in primary care.
3. The NHS White Paper, Liberating the NHS:
Local democracy and legitimacy sets out the distinction between
primary and secondary prevention commissioning in relation to
funding for smoking cessation services. Primary prevention (smoking
cessation services) will be commissioned and funded by Directors
of Public Health, whereas secondary prevention (treatment for
those with an impaired lung function due to smoking) will fall
under GP consortia commissioning. If the same distinctions are
made in alcohol, services around primary prevention with regards
to local -health improvement will be funded by Directors of Public
Health in local authorities, but treating the physical complications
related to alcohol dependence will be funded by GP consortia.
4. In the case of alcohol services, the distinction
between primary and secondary prevention is complex. Primary prevention
for alcohol misuse can include awareness and behavioural change
campaigns in a local area. But primary prevention can also include
providing patients with information about sensible drinking levels
and reducing alcohol consumption, which can be achieved through
a brief advice or brief intervention by a trained healthcare professional.
Brief advice is a short opportunistic intervention offering advice
on the risks of drinking too much. Brief intervention is a specific
structured interview by a trained Alcohol Health Worker for 20
to 30 minutes, setting goals and providing information for reducing
alcohol consumption, with a follow up in the community or by a
GP. Setting up the infrastructure for screening and brief intervention
would be seen as a secondary prevention measure and therefore
the responsibility of GPs.
5. Our concern is where there are multiple commissioners
across one therapy area, such as in alcohol misuse, there may
be some uncertainty as to who is responsible for commissioning
a service which can be considered both primary and secondary prevention.
This could result in one commissioner relying on the other to
achieve outcomes, when all commissioners should be working together.
For example, with Directors of Public Health responsible for primary
prevention of alcohol services, GPs could take the view that "alcohol
has already had decent investment through the Directors of Public
Health awareness programmes, so they should invest in other health
priorities as opposed to further investment in secondary prevention".
The worst case scenario is that neither Directors of Public Health
nor GP consortia commission secondary prevention services because
Directors of Public Health are focused on primary prevention (awareness
and information) and GPs are focused on treating the physical
complications and harms related to alcohol.
6. The Department of Health consultation, "Healthy
People, Healthy Lives: consultation on the commissioning and funding
routes for public health" further illustrates our concern
regarding multiple commissioners. The consultation document states
on prevention and treatment services for alcohol misuse should
be commissioned through local authorities, but proposes the example
of establishing Alcohol Health Workers in a variety of healthcare
settings. The healthcare settings could, presumably, include GPs
surgeries, A&E units and other primary care services. However,
this raises the question of who will take responsibility for ensuring
prevention and treatment services are in place between the local
authority and GP commissioners. The Health and Social Care Bill
must ensure there is clarity in defining which organisations have
accountability for public health outcomes.
7. The consultation on commissioning and funding
routes for public health also indicates that brief interventions
are to be funded from the NHS public health budget for drug misuse
and tobacco control, but are not listed for alcohol misuse despite
evidence that brief interventions for alcohol misuse are cost
effective.[54]
8. The Health and Social Care Bill must ensure
that effective structures and incentives are in place to ensure
GP consortia and local authorities coordinate activity across
the boundaries of public health and health. The consultation on
commissioning and funding routes indicates that where a health,
public health and social care outcome overlap, as set out in Department
of Health outcome framework documents, this should be a "focus
of Joint Strategic Needs Assessment" for joint working. Alcohol
misuse is included as an outcome in the frameworks for health,
public health and social care and should therefore be a priority
for the Joint Strategic Needs Assessment. The Health and Social
Care Bill should reflect the relationship between outcomes and
the Joint Strategic Needs Assessment in order to encourage coordination
between local authorities, GP consortia and other related organisations.
9. Joint approaches across public health and
GP commissioning are vital in therapy areas such as alcohol misuse.
If this collaborative working is not taken into account, the danger
is that this issue will fall even further behind other health
problems in the change to the commissioning structure. In England,
26% of the adult population, including 38% of men and 16% of women,
consumes alcohol in a way that is potentially or actually harmful
to their health, and 4% of adults in England are alcohol dependent.[55]
Under the current system only a small minority of dependent drinkers
currently receive treatment, estimated at one in 18 which is less
that 6%.[56]
If this were to fall any further it would have a devastating impact
on both individuals' health, society and the NHS, as treating
alcohol-related conditions already cost the NHS approximately
£2.7 billion a year.[57]
February 2011
54 Alcohol Concern (2011), Making alcohol a health
priority - opportunities to reduce alcohol harms and rising costs Back
55
NICE (2011) Alcohol-Use Disorders: Diagnosis, assessment and management
of harmful drinking and alcohol dependence CG115 Back
56
House of Commons Health Select Committee (2009) Alcohol: First
Report Session of 2009-10 Back
57
NHS Confederation (2010) Briefing No 193: Too much of the hard
stuff? Back
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