Written evidence from the Royal College
of Paediatrics and Child Health (CFI 22)
1. The RCPCH is pleased to submit a response to the
Health Select Committee follow-up inquiry into Commissioning,
building on our submission in October. As a professional body
seeking to ensure the best outcomes for children, we want to highlight
the particular implications for children and young people in the
areas being specifically examined by the Committee. We have laid
out our evidence against the specific sections of the Bill that
the Committee is addressing in this follow-up.
2. The 11.78 million children in England comprise
over 22% of the population and it is essential that the changes
envisaged to the NHS and public health result in improvements
to their health and wellbeing rather than worsening outcomes and
increased complexity of provision
3. (para 81) Examining the assurance regime around
consortia so that NHSCB has authority to deliver outcomes as set
out in the Commissioning Outcomes framework.
4. Commissioning for children's services is difficult
and complex. They are not "little adults" and need services
that reflect their age, maturity and that link closely with the
other influences on their lives, such as education, housing, and
social care, including family support. In particular children
with specialist requirements or complex needs, such as those with
long term and/or rare conditions, need to be confident that their
care will be joined up, and aligned with other public sector provision.
For example, children with autism or ADHD (not defined conditions
for the outcomes framework) will require a package of commissioned
care that links to education and (possibly) social care.
5. Compliance with statutory and professional guidance
is likely to be effectively monitored for provider services through
Monitor and CQC, but if inadequate services are commissioned,
particularly for conditions that are not part of the outcomes
framework measures, then those particularly vulnerable children
and families expecting support from the health service may suffer
extremely poor care resulting in increased care needs in future.
6. Responsibility for effective joint commissioning
for the health and wellbeing of children who are looked after
and/or placed away from home requires clarification within the
new arrangements, as expertise within commissioning consortia
is likely to be diluted in transition from PCT commissioners,
and it is not clear that Health and Wellbeing Boards will have
sufficient capacity or "traction" to ensure health needs
are met.
7. It is not yet clear how the outcomes and incentive
arrangements will be implemented, but controls are needed to ensure
that those whose condition does not fall into the 150 for which
quality standards are being developed do not receive poorer care.
8. (para 91) Lines of accountability between the
NHS Commissioning Board, Department of Health and Secretary of
State to prevent potential future conflicts
9. We have no specific comment on this theme, save
seeking assurance that links with the Department of Education
and relevant Ministers relating to interventions and responsibilities
for children's health and wellbeing are clear. Relationships at
all levels must be open and constructive, focussing at all times
on the child and their family.
10. (para 96) It is essential for clinical engagement
in commissioning to draw from as wide a pool of practitioners
as possible...GPs should be generalists drawing on specialists
when required. Review the arrangements for integrating clinical
expertise into commissioning.
11 We welcome this focus on ensuring that specialist
clinical input is sought and valued, and that this should not
be considered to compromise a market-led system. There is an increasing
amount of detailed, evidence based, guidance for children's healthcare
which can helpfully inform commissioning decisions by setting
minimum standards of care and in some case, providing "checklists"
for service provision. But guidance cannot be used alone; skilled
commissioning requires contextual judgements, needs assessment,
understanding of staffing skills and competencies, liaison across
specialities, availability of alternate or tertiary provision,
and audit/monitoring arrangements to be effective. Children's
services are specialist, with many conditions benefitting from
networked arrangements and it is imperative that commissioners
have an understanding (through using expert clinical advice) of
the benefits and consequences of their proposals for children.
12. It is also important to consider the skills of
local acute and community consultants in engaging with GPs to
provide clinical advice. The College is keen to work with partners
in supporting its members to develop their skills in this arena.
13. Designated doctors and nurses currently provide
an oversight and expert function within the PCT commissioner and
to the (coterminous) LSCB Board, ensuring that provider-unit clinicians
are properly supported in a range of specialist activities. Designated
professionals provide support for child protection practice, but
there are also appointees for looked after children's health,
Special educational needs and child death panels. Designated doctors
and nurses and should be consulted for input to commissioning
contracts, information sharing, training, supervision and policy
relating to children, young people and families using services.
These clinicians contribute extensively in many areas to the work
of LSCBs and sub committees, bringing a health perspective to
local authority planning and training. Whilst the Bill states
that the responsibilities will transfer to consortia, there is
uncertainty as to whether the roles, particularly for child protection,
will be supported and how links with the LSCB and authority will
be maintained. There must be a clear duty on Commissioning Consortia
to include advice from designated nurses and doctors within their
commissioning plans.
14. (para 102) Risks to purchaser/ provider split
must not affect high quality care
15. For those children with rare or complex needs[60],
the proposals expose potential difficulties in maintaining continuity
and integration of care, where a number of agencies and services
are involved. For example, the removal of boundary restrictions
for GPs and absence of a co-terminosity requirement between consortia
and authorities could result in complicated cross-charging arrangements
for children requiring complex packages of care, and less opportunity
for clinical, therapy and social care staff to build constructive
professional teams around the child and family.
16. Any delays in developing an alternative secure
system of information sharing poses a risk to those children who
have a range of professionals involved in their care, across several
provider organisations. It is not clear where the "lead professional"
oversight of the child's package of care will lie; if it is with
the GP then patient information systems within individual practices
may be insufficiently developed to deal with complex contractual
arrangements to best meet the health and social care needs of
children and young people
17 (para 104) arrangements for commissioning primary
care services
18. We have no separate comment to make regarding
this issue
19. (para 107) Effectiveness of structures proposed
in the Bill to safeguard co-operative arrangements and promote
the development of new ones.
20. We very much welcome the focus of the follow-on
review on these issues - we had serious concerns that the Committee's
initial considerations may not have fully explored the implications
for protecting children from harm with the new commissioning arrangements.
Much stronger systems need to be in place around joint working
and information sharing to ensure that the responsibilities of
consortia and health partners for protecting children from harm
are explicitly identified. Close and accountable joint working
with Local Authorities, commitment to Local Safeguarding Children
Boards and compliance with statutory guidance in this area are
fundamental principles that should be overt in commissioning duties
and contracts.
21. The links between health and with other agencies
(children's social care, the police and the judiciary) needs much
greater recognition and clarity over responsibilities particularly
during transition and once the new reforms are in place. Specifically
the Joint Strategic Needs Assessment and Joint Health and Wellbeing
Strategy must include core sections on child protection arrangements
across organisations and pathways of services, with contributions
from expert designated clinicians
22. Under the proposals, commissioning consortia
may span more than one Authority, and there will probably be two
or more consortia in each LSCB catchment area. Managing LSCB business
with this plurality of health organisations, including implementing
LSCB-wide procedures, delivering joint training and building strong
and trusting relationships between GPs and the relevant social
care teams will be an increased challenge, and there is a much
greater potential for children at risk to be missed, or confusion
over responsibility to occur. RCPCH is pressing for detailed modelling
and practical exploration with Local Authorities and LSCBs as
to what arrangements can mitigate this risk.
23. We need stronger assurances that Health and Well
Being Boards will work closely with GP Commissioning Consortia,
specialist professionals and the wider local community, with a
specific statutory remit to commission services together to raise
standards of care for all children based on need and impact. Whilst
recognising the strengthening of requirements on commissioning
consortia to take account of the joint strategy, the governance
appears underpowered with respect to commissioning across health/social
care boundaries.
24. A mechanism for reporting on effective joint
working and monitoring outcomes for all children across services
(linking health, public health, education and social care) should
be considered, particularly in relation to incentive payments
for commissioning
25. Splitting the commissioning of the healthy start
programme between consortia up to aged five years, and with local
authorities through health and wellbeing boards once children
have started school offers a potential risk to continuity and
family support if health visiting and school nursing are insufficiently
linked. There are no elements within the Bill that support mental
health and emotional well-being interventions for young children
and adolescents - two crucial points where input can demonstrably
improve outcomes.
26. (para 110) Arrangements to enable commissioning
consortia to collaborate in reconfiguring services. (Including
major service reconfiguration)
27. The College supports reconfiguration of services
where this improves standards and compliance with requirements
such as the EWTD. In December the College published a set of agreed
service standards for all acute care which, if taken to conclusion,
is likely to result in reconfiguration at a significant number
of units. Similarly the recent report on paediatric Cardiac Surgery
had the full support of clinicians in recommending cessation of
surgery and a number of smaller centres. There must be strong
controls in place within the NHSCB to facilitate major reconfigurations
for the ultimate benefit of all.
28. The Committee is urged to consider modelling
within the pathfinder consortia of pathways of care for disabled
children and those with complex health and social care needs so
that effective care, which is timely, consistent and cost effective,
is provided as close to home as feasible.
29. The impact of low-volume/high cost continuing
care packages for children with the most complex needs could drain
an individual commissioner's budget and there should be a risk-pooling
system to support these awards
30. Ensuring that children receive the best quality
evidence based care requires the introduction or maintenance of
clinical networks, for example for paediatric specialties. It
is not clear in the Bill how these networks will be sustained
in an open market to ensure appropriate investment in secondary
and tertiary services, which may require co-located ancillary
services. The College has published clear service standards for
paediatric care and is strengthening its guidance for managed
clinical networks for a range of specialist services. The bill
requires strengthening to ensure that expert clinical advice is
taken into account by the National Commissioning Board, Commissioning
Consortia and Monitor, and there is enthusiasm to support pathways
of care across services.
31. Accountability for outcomes in a networked arrangement
will also require consideration as the current measures tend to
be disease specific and may not work for rare and complex cases,
which may also be high cost. It is important that flexibility
for national commissioning by the NHSCB is maintained particularly
for high cost low volume paediatrics.
32. (para 115) Arrangements for consortia to reconcile
choice with clinical and financial priorities
33 The market concept where any willing provider
can be commissioned for specific services may improve service
responsiveness in some areas, but may also lead to a fragmentation
of staff culture, competition between providers across a pathway
of care, gaps in provision and information flows and a lack of
integration and co-ordination of appointments. This may result
in poorer quality of care and inequity of provision for children
together with significant increase in bureaucracy to commission
and performance manage effectively.
34. We have concerns about the risk to availability
and quality of medical training placements within small independent
providers - this is already proving a concern within acute mental
health and plastic surgery services
35. High quality commissioning will require access
to timely and relevant information to inform decision-making,
however there is a considerable gap between what is available
now and is needed. Given the problems with the National Programme
for IT, there is considerable concern with regard to how the relevant
information will be made available, captured and shared between
a rang e of providers.
36. Whilst welcoming the principles of choice and
competition to drive up quality we seek additional security within
the system to protect children's services. Market-based competition
in health however without expert collaborative commissioning will
undermine links between professionals, leach expertise, reduce
service availability and increase waits and there must be safeguards
in the Bill to ensure that services for children, which may not
be lucrative enough for competitive market improvement, do not
suffer.
37. Where services cannot be provided within the
market system more clarity in needed on the process of "designated"
services and how this process may affect children's healthcare
which may not be a lucrative investment for independent providers.
Depending upon the strength of the designated service arrangements,
there is a risk that assertive providers will convince commissioners
they can "cherry pick" the most lucrative services.
This could leave vulnerable families with more complex journeys,
poorer levels of care and the consequent risk of children missing
appointments and suffering poorer health outcomes
38. (para 118) Arrangements for local accountability.
39. Whilst provision of information and advice direct
from providers in a plural system can improve choice and quality
of care, navigation through the options for vulnerable patients
and carers will require careful commissioner support, to ensure
that children receive the care they need and appropriate safeguards
are in place. There are examples within the current "Choose
and Book" system of parents failing to make appointments
for their children, or failing to attend with consequent deterioration
of the child's condition. Increased competition amongst provider
services will require clear contractual safeguarding within commissioning
to ensure children's rights are protected.
40. (para 123) Formation of clear and credible
plans for debt eradication
41. We do not have any comment on this clause
42. We hope you find this submission useful and we
would be very happy to discuss any of these in further detail,
if required.
February 2011
60 For example, children with Downs' syndrome or cerebral
palsy need input from a range of health services (such as paediatricians,
physiotherapists, speech therapists, geneticists, and sometimes
a children's heart or glands specialist) which families usually
receive from one health centre or hospital, as well as educational,
social care and family
support provided by public and third sector services. Back
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