Written evidence from the Royal College
of Physicians (CFI 31)
SUMMARY
1. At a national level the
NHS Commissioning Board is responsible for setting the standards
for consortia. The medical royal colleges are well placed to offer
advice on these standards and should be central to the governance
of the commissioning board. The RCP is making the following recommendations
that we feel can maximise the best results for patients.
2. To enable clinician-led
commissioning that draws from the full variety of specialists
and wider health professionals the RCP is calling for:
— A tighter
requirement for consortia and the national NHS Commissioning Board
to involve practising specialists, public health and social care
professionals at the highest levels of commissioning decision
making. We believe this is crucial to the success of commissioning
that it should be on the face of the Bill.
— Guiding
principles for involvement should be laid out in accompanying
guidance documents. This would ensure all consortia adhere to
the same general principles for commissioning, without being too
prescriptive on consortia's ability to find locally appropriate
mechanisms. The RCP believes these guiding principles will promote
integrated care.
3. To enable competition
to be compatible with integrated working, collaboration and the
long-term sustainability of services we believe the following
measures need to be put in place.
4. Robust, evidence based
quality measures need to be identified to enable competition on
the basis of quality. RCP can help identify these measures.
— The
RCP believes that a robust analysis of whether the current arrangements
for the introduction and regulation of competition will block
collaboration between primary and secondary care. This should
be made public.
— Monitor
should be required to give due consideration to overriding principles
of collaboration, integration and sustainability when licensing
providers.
— Tariff
and pricing arrangements should be thoroughly examined to ensure
they drive quality, integration and investment, and support the
delivery of sustainable services.
— Safeguards
to ensure that "commercial sensitivities" do not block
information sharing, transparency, accountability and the development
of positive staff cultures (eg that enable whistleblowing) - common
standards and openness must apply across providers.
— The
Board and Consortia be given a duty to consider the longer-term
sustainability of services (including education and training)
when exercising their commissioning functions.
— More
detail to be provided outlining how service continuity and patient
health will be protected in the event of provider failure, ie
how the "designation" of services by Monitor will work
in practice.
5. To facilitate commissioning
of "uncommon conditions" we believe there needs to be:
The provision of a clear vision from the national Board outlining
how commissioning arrangements will work for "uncommon conditions",
which are neither rare (so are the responsibility of the NHS Commissioning
Board itself) or common, and so require economies of scale.
INTRODUCTION
6. The Royal College
of Physicians (RCP) welcomes the Health Select Committee's follow-up
inquiry into commissioning. We value the opportunity to provide
further evidence on how the new arrangements for commissioning,
laid out in Equality and Excellence, can maximise the best
results for patients. The RCP is in a powerful position to help
improve commissioning and standards overall. No other body offers
such a full range of evidence based quality guidance; we perform
audits, issue clinical guidance, conduct clinical effectiveness
studies, provide accreditation and write clinical pathways. The
medical royal colleges are so well placed to advise on quality
and standards that the RCP believes we should be at the heart
of national commissioning decisions, advising the NHS Commissioning
Board on how to raise quality throughout the NHS in England.
7. One of the underpinning
principles of the reforms to the health service is the aim to
put both patients and clinicians at the heart of commissioning.
The RCP fully supports this; we believe it will result in better
patient care. However, we are concerned that some of the arrangements
that are expected to deliver this remain too loose and there is
a danger this vision will not be achieved. In our evidence laid
out below, the RCP provides details on how we believe this risk
can be mitigated and the vision of effective commissioning can
be achieved. Further, the RCP has some concerns that under the
proposals as they stand, competition could be at the expense of
quality, collaboration and integration. We have proposed some
safeguards that should prevent this.
8. In outlining our evidence,
the RCP has chosen to focus on two questions posed by the Health
Select Committee:
— the
arrangements proposed for integrating the full range of clinical
expertise into the commissioning process, and
— the
effectiveness of the structures proposed in the Bill which are
designed to safeguard co-operative arrangements that already exist,
and promote the development of new ones.
INTEGRATING THE
FULL RANGE
OF CLINICAL
EXPERTISE INTO
COMMISSIONING
9. The government clearly
wants all healthcare professionals to work together to deliver
effective commissioning. The government's response to the Health
Select Committee's recent Commissioning Report[70]
states, "The GP practice and registered patient list will
be the building blocks of commissioning consortia, but successful
commissioning will clearly also be dependent on the wider involvement
of other health and care professionals." The RCP, along with
other medical royal colleges, supports "teams without
walls", an integrated model of care, where professionals
from primary and secondary care work together across traditional
health boundaries, to manage patients using care pathways designed
by local clinicians.[71]
Additionally, the BMA believes that successful commissioning can
only be achieved with GPs, secondary and tertiary care consultants
working together.[72]
We would all like to see "commissioning without walls"
and are therefore pleased to see that the government's intention
reflects a model of care that we have been advocating for some
time.
10. However, the RCP fears
that there may be some distance between rhetoric and reality,
which could threaten achieving the best outcomes for patients.
To achieve the best commissioning arrangements for patients, which
draws from the expertise of specialists and other healthcare professionals,
the RCP is calling for:
11. A TIGHTER
REQUIREMENT IN
THE BILL
FOR THE
NHS COMMISSIONING BOARD
AND CONSORTIA
TO INVOLVE
A FULL
RANGE OF
HEALTH PROFESSIONALS
There is much consensus that successful commissioning
involves the expertise of many healthcare professionals. At present,
however, the provisions in the Bill are too loose, meaning efficacy
will often depend upon local relationships. The RCP believes that
the current duty in the Bill for both consortia and the national
Board to obtain appropriate advice when commissioning should
be strengthened to be a duty to involve specialists. As
it stands, we fear that the duty to obtain appropriate advice
may become a tick box exercise, which has the potential to damage
patient care. The RCP will be submitting an amendment to the Bill
once it reaches Committee Stage in the House of Lords with the
aim of strengthening this clause. Specialists and public health
doctors must be involved at the highest level of governance in
consortia. In practice, we would like to see all consortia being
required to have a board where specialists sit to input into commissioning
decisions.
12. To achieve effective
commissioning across the country, the RCP believes that greater
responsibility could be placed on the NHS Commissioning Board
to promote specialist involvement and integrated working across
primary, secondary, tertiary and social care. This should be reflected
in the current Board's, "duty to encourage integrated working",
which currently references only consortia and local authorities.
13. Guiding principles for
effective clinician-led commissioning and integrated care.
In collaboration with the government, Health Select
Committee, BMA and other medical royal colleges, the RCP would
like to draft guiding principles to achieve effective commissioning.
The RCP expects local solutions to commissioning to evolve over
time. There are some principles for successful commissioning,
however, that are applicable across all localities. The RCP proposes
the following general principles for commissioning, which we believe
will help to achieve the vision of clinician led commissioning
promoting integrated care.
— There
should be greater transparency on how a full range of health professionals
will be involved in commissioning. We believe this will strengthen
accountability of consortia to their local populations. Each consortium
should publish information on how they will involve and have involved
specialists in their annual plan, annual report and constitution.
The Board should assess the extent to which consortia have collaborated
with other professionals and integrated primary, secondary and
social care and public health in their annual assessment.
— Strong
professional networks to further enable a wider range of specialists
to feed into commissioning decisions should be established and
developed. Existing cancer and cardiac networks provide models
from which best practice can be drawn.
— A network
of the appropriate specialists should always be involved in commissioning
decision that affects the services they provide.
— Patients
should be empowered and enabled to be fully involved in commissioning
decisions of both consortia and the national board. We are consulting
with our Patient and Carer Network on effective structures that
would enable meaningful involvement from these groups.
— Consortia
will be responsible for a significant amount of public money.
They should be accountable and transparent organisations, and
these principles should be embedded in their cultures and structures.
Further consideration needs to be given to how this can be achieved.
— Health
and Wellbeing Boards should involve specialists when assessing
needs via the Joint Strategic Needs Assessments, and when setting
priorities via the Health and Wellbeing Strategy.
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
14. The RCP has concerns
that under the current proposals, competition could be at the
expense of quality and integration. Although we welcome professional
competition as a means to drive up standards, we wish to ensure
that collaborative working is enshrined. To achieve this we are
calling for a range of safeguards that will ensure quality is
at the heart of all commissioning decisions, that collaboration
and integration of services are promoted, that common cultures
of accountability and transparency apply across all providers,
that service continuity is protected and that there are structures
to facilitate the commissioning of 'uncommon conditions.' More
detail on each of these recommendations is given below.
THE IMPORTANCE
OF QUALITY
15. The Royal College of
Physicians has a 500 year history of setting standards. Quality
is at the centre of RCP's mission and objectives. The RCP is concerned
that there is the potential for competition to trump quality.
We have heard some reassurance from evidence given by Sir David
Nicholson and the Secretary of State for Health to the Health
Bill Committee that competition in the NHS will be based on quality,
not price. However, we still have concerns, particularly in the
context of the £20 billion efficiency challenge,[73]
that quality could slip as providers are under pressure to offer
services at decreasing rates. This could result in low price at
the expense of value for money when making commissioning decisions.
The risk of this is exacerbated as there are no clear measures
for quality. We offer the RCP's services in identifying quality
measures, which have a strong evidence base that can be used to
drive up standards.
16. On listening to the Care
Quality Commission's evidence to the Health Bill Committee we
are further concerned that there will not be a body with a role
to drive up quality and share best practice. The Chief Executive
of the Care Quality Commission made it clear that CQC's role is
a safety net, monitoring only essential standards of quality and
safety. If competition is to be based on quality, it is unclear
who will be monitoring quality and awarding the quality indicators
that would allow comparison and competition. If there is no body
responsible for measuring and grading quality, it will be impossible
for competition to be based on this. To mitigate against this
risk, we suggest that Monitor be required to give due consideration
to the overriding principles of collaboration, integration and
sustainability when licensing providers.
PRICE
17. The RCP remains concerned
that if providers are able to undercut the tariff - eg by offering
"loss leaders" - this could have damaging long term
implications for sustainability, choice, quality and efficiency.
We recommend that tariff and pricing arrangements be thoroughly
examined to ensure they drive quality, integration and investment,
and support the delivery of sustainable services.
18. The RCP urges the Department
of Health to consider using a "best practice tariff".
This would not be an average tariff, but the cost of delivering
a good service, linked with quality and outcomes. This
should be designed by the NHS Commissioning Board, with support
from the medical Royal Colleges. The RCP envisages it as a mechanism
to promote integrated pathways, define quality and standards.
We would not expect it to threaten competition because it would
not stipulate preferred providers.
INTEGRATED CARE
19. The RCP still has some
concerns that collaboration and integration could be undermined
by the requirement on Monitor to promote competition. We strongly
believe that collaboration is more likely to improve patient outcomes
than competition. Monitor's role in regulating competition must
not prohibit the involvement of secondary and tertiary care specialists
in service planning. We would recommend that a robust
analysis of whether the current arrangements for the introduction
and regulation of competition will block collaboration between
primary and secondary care. This should be made public.
20. The RCP accepts that
there are potential conflicts of interests with a representative
of a "provider" contributing to and signing off consortia's'
commissioning plans. There are various other potential areas of
conflict of interest around the commissioner/provider role inherent
in the Bill. For example, GPs will be both providers and commissioners
and some providers will be required to join consortia because
they hold primary medical services contracts. We do not believe,
however, that these conflicts should be allowed to jeopardise
integrated care. We would welcome these issues being explored
further.
21. We remain concerned that
competition in a market of "willing providers" will
make it difficult for primary care and secondary care physicians
to collaborate without fear of legal challenge from "competitors".
We have heard mixed evidence that this could be a threat. It is
our understanding that if bodies within the NHS, such as foundation
trusts, are behaving like private companies, they will be treated
as such in law. However, the Secretary of State argued during
his oral evidence session to the Health Bill Committee that the
only circumstances where competition law applies is if the intention
is to restrict provider access to commissioning services. There
is still uncertainty in the sector over, where and when competition
law will apply under the reforms. We would like clarity on this
and to recommend that safeguards ensure that "commercial
sensitivities" do not block information sharing, transparency,
accountability and the development of positive staff cultures
(eg that enable whistleblowing) - common standards and openness
must apply across providers.
22. The RCP would like to
highlight the risk of destabilising foundation trusts if some
services are taken out of hospitals. For example, if a urology
service is removed from a large hospital, there could be no acute
urology provision left. This can also affect continuity of care
for patients, a particular issue for those with long term and/or
complex conditions. For example patients with diabetes may have
to travel to several different locations and providers to receive
a full range of care. To safeguard against this, the RCP would
like requirements on commissioners to give due regard to the integrity
of the range of a hospitals' services to ensure there is a comprehensive,
sustainable healthcare service for local populations.
LONG-TERM
SUSTAINABILITY
23. The RCP welcomes services
becoming more responsive to local needs. However, we would like
to recommend that strong safeguards against the potentially damaging
effects of service fragmentation be put in place. In particular,
integrated care pathways and integration across care pathways,
particularly for those with complex conditions and complex co-morbidities
need to be protected. To do this, we would recommend that the
Board and consortia be given a duty to consider the longer-term
sustainability of services, including education and training,
when exercising their commissioning functions. Further,
the RCP would like more detail on how service
continuity and patient health will be protected in the event of
provider failure, ie how the "designation" of services
by Monitor will work in practice. We believe that commissioning,
licensing of providers by Monitor and national tariff arrangements
must consider the long-term sustainability of health services
- e.g. provision of education and training and the use of "loss
leaders".
24. The RCP would also like
clarity on the mechanisms that local populations can use if a
reconfiguration is proposed in their area. The consultation process
for a reconfiguration needs to be made clear. Would local populations
appeal to the local authority scrutiny committee, Health and Wellbeing
Board, Monitor and/or the NHS Commissioning Board? How will complaints
be escalated? There should be accountability to the local population
for these decisions.
UNCOMMON CONDITIONS
25. Clarity is required on
the commissioning arrangements for "uncommon conditions".
Facilities such as a trauma centres, or severe burns units, and
conditions such as immunodeficiency, haematology, and haemophilia
require a critical mass to be cost effective and are therefore
currently commissioned on a regional basis. A clear vision
from the national Board on commissioning arrangements for "uncommon
conditions" is required. We would recommend that
these services are commissioned by the NHS Commissioning Board
and some form of sub-national structure is likely to be required.
26. The RCP stresses that
the impact of the reforms on workforce cannot be under estimated.
We will be responding to the Department of Health's workforce
consultation in due course. We seek clarity on the crossovers
between the proposals for the future of the healthcare workforce
and the wider structural reforms laid out in Equality and Excellence.
February 2011
70 2011 Government Response to the House of Commons
Health Select Committee Third Report of Session 2010-11: Commissioning.
Presented to Parliament by the Secretary of State for Health by
Command of Her Majesty. London Back
71
2008 RCP RCGP RCPCH Teams without Walls. The value of medical
innovation and leadership. London Back
72
2011 BMA Consultant involvement in commissioning - the implications
of the Health and Social Care Bill. Joint CCSC and GPC guidance.
London Back
73
The challenge, first articulated by the NHS Chief Executive, Sir
David Nicolson, in 2009 to achieve an efficiency gain of 4% per
annum from 2011-12 (also expressed as the need to make £15-20
billion in efficiency savings. Back
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