Commissioning: further issues - Health Committee Contents

Written evidence from the Royal College of Nursing (CFI 24)


With a membership of more than 410,000 registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world. RCN members work in a variety of hospital and community settings in the NHS and the independent sector. The RCN promotes patient and nursing interests on a wide range of issues by working closely with the Government, the UK parliaments and other national and European political institutions, trade unions, professional bodies and voluntary organisations.

The RCN responded to the Health Select Committee's initial call for evidence for its inquiry into Commissioning in October 2010. Following the publication of the Health and Social Bill, we welcome this opportunity to submit further evidence to the Committee.


  • The RCN welcomes the underlying principles of the Bill to place patients at the centre of care; to reduce inefficiency in the NHS; to involve clinicians in the commissioning of services; and to improve standards across all aspects of the health service. However, the RCN has repeatedly expressed major reservations that the policies set out in the Bill will actually deliver on these underlying principles.
  • The RCN is deeply concerned that the Bill does not make sufficient provisions for the role of nursing leadership within the new commissioning framework. This will be to the detriment of care and quality across the service. As the lead in the patient journey, nursing staff understand the holistic needs of patients, their carers and families.
  • The RCN does not believe that the Bill has sufficient detail around assurance and governance, particularly in light of the proposals to significantly increase private sector involvement in delivering services on behalf of the taxpayer. There is potential for significant variation in quality, scope and access across localities if commercial sensitivities and weak national governance prevent the appropriate sharing of service and patient level data.
  • In its submission to the Committee's initial inquiry into commissioning, the RCN highlighted the need to pilot the proposed changes. Although Commissioning Consortia pathfinders have now been established, there is concern that these will not undergo any formal evaluation. The RCN would like assurances that these pathfinders will undergo stringent evaluation to ensure best practice is shared across the country.
  • The RCN does not believe that the Bill delivers a consistent message around patient and public engagement. There is no requirement for the NHS Commissioning Board, Commissioning Consortia or HealthWatch England to have a public representative on their boards. In addition, the RCN is concerned that there is no provision in the Bill for Commissioning Consortia to make public annual financial reports or to hold open board meetings.


3.1  Will the assurance regime ensure that the NHS Commissioning Board has sufficient authority to deliver its objectives defined in its Commissioning Outcomes Framework?

3.1.1  The RCN supports an outcomes framework that is sufficiently flexible to allow for local responses. However, it must provide a robust national framework to allow for comparisons and bench-marking. It must also ensure populations across England are not disadvantaged through poor commissioning, poor delivery or inappropriate allocation of resources. Without this, areas that could potentially be disadvantaged include offender health, sexual health and public health services, as well as those groups who are hard to reach. Whilst the RCN supports a system allowing for some locally sensitive outcome measures, we have also stressed the need for consistency across England to prevent inequity of access or service quality developing for certain population groups or health needs.

3.1.2  It is important to note the vital and unique contribution that nursing plays to the delivery of health outcomes. There is a wealth of evidence on the role nurses, midwifes and health visitors play in improving outcomes by safeguarding patient safety, for instance, through infection control and preventing errors.

3.1.3  Nursing input is key to the development of a clinically meaningful outcomes framework, which incorporates insight and understanding of the patient experience and the delivery of high quality, safe care. It is important to recognise that outcomes are influenced by issues such as staffing and skill mix; internal processes such as team work; safety systems and supervision; and particular patterns of behaviour. It is therefore disappointing that there is so little detail on the role of nursing within the Government's wider vision for a future NHS.

3.1.4  The RCN sees a crucial role for regulators in the NHS as part of the system of checks and balances. The proposed changes that will give greater freedoms, and potentially more involvement from a plurality of providers, necessitate a very clear set of standards and credible checks and balances in the system. Regulators need to respond to a more diverse range of providers and plan for the longer term. If the number and type of providers increases, it is important to ensure that they operate in ways that deliver high quality, safe care. The Care Quality Commission (CQC) (and others) has a role to play in setting standards and monitoring providers. In particular, the CQC has a number of enforcement powers and can therefore bring to bear strong incentives for providers to ensure that they deliver high quality, safe care. It is essential that the CQC has effective powers and the resources required as a robust and effective regulator.


4.1  Will the arrangements proposed in the Bill for defining the lines of accountability prevent future conflicts arising?

4.1.1  It is imperative that there remains a clear line of political accountability between the general public and national politicians for NHS-funded services and outcomes. The NHS consumes significant public resources and will inevitably always be a political issue both at national and local level (for example, by local MPs campaigning to keep open their local hospital). Politicians should scrutinise the NHS and decisions made by the Secretary of State for Health on behalf of the public and patients. The RCN does not see removal of the political involvement as credible, realistic or desirable. There must be clear and transparent accountability for public funds and outcomes.

4.1.2 The RCN has a particular concern regarding accountability in terms of health inequalities. Clause 3 of the Bill states that the Secretary of State "must have regard to the need to reduce inequalities", but leaves this open-ended as to how the Secretary of State has to demonstrate this and how his progress will be held into account. The RCN believes that the NHS is currently well placed to take a strategic overview of health inequalities and identify need across a wide area. The RCN has concerns that the proposals as they stand will not allow for this strategic oversight.


5.1  Will the arrangements in the Bill ensure that the full range of clinical expertise is integrated into the commissioning process?

5.1.1  The RCN was disappointed to see that the Bill does not include any provisions for the important role of nurse leadership within the new commissioning framework. The RCN believes that this will be to the detriment of care and quality across the health service.

5.1.2  The Bill states that the NHS Commissioning Board and the Commissioning Consortia only have to "make arrangements with a view to securing that it obtains advice appropriate… from persons with professional expertise relating to physical and mental health of individuals". By leaving this option open for commissioning bodies, it does not go far enough in prescribing for the needs of patients as a whole. No single profession can have sole responsibility for commissioning services and if the appropriate range and mix of health and social care professionals are not involved in the commissioning process, the proposed new models will fail.

5.1.3  The RCN will be seeking amendments to the Bill, which will include designated nursing posts on the NHS Commissioning Board and the Commissioning Consortia. It is also important for there to be nursing input at the Department of Health. The RCN therefore calls for the Chief Nursing Officer to hold a prominent position in regard to national commissioning and oversight of this process.

5.1.4  The RCN believes that these amendments are vital, as nurses that sit on Primary Care Trusts (PCTs), Strategic Health Authorities (SHAs) and provider organisation boards, provide an invaluable insight into the practical issues of service delivery. They have a pivotal role in being able to stand back and view the whole care pathway, take a holistic perspective to look above the day to day clinical issues and effectively support commissioners in the decision making process. In addition, some solutions to commissioning will inevitably be nurse-led; modern healthcare services are increasingly nurse-led as a response to changing healthcare needs. These include specialist services, such as cancer services, and many public health initiatives.


6.1  Will the new arrangements reconcile conflicts?

6.1.1  Where competition is introduced, it is inevitable that there will be conflicts of interest. The most important factors in mitigating these conflicts are open and transparent processes and timely resolution by external parties.

6.1.2  It will be important for there to be significant investment in the leadership skills of the new commissioning consortia, who will not have existing expertise in conflict resolution at a strategic level. This investment in skills beyond the usual clinical expertise will be necessary to ensure the new commissioning consortia are able to work effectively, as has been shown in the USA.[23] It is also important that the boards of Commissioning Consortia contain a range of healthcare professionals, including nurses, to ensure different professional perspectives are taken into account when examining conflicts of interest.

6.1.3  The proposed reforms, if fully realised, will fragment the present service into many different and competing services. Bodies such as the National Patient Safety Agency and the NHS Institute for Innovation and Improvement, which helped to foster the sharing of information and good practice, have been abolished. The RCN is concerned how the sharing of information and best practice across an increasingly competitive health and social care market will be supported.


7.1  How does the Bill make arrangements to address the potential conflicts of interest between Commissioning Consortia and local care providers?

7.1.1   The RCN sees a crucial role for NHS regulators as part of the system of checks and balances. The proposed changes that will give greater freedoms, and potentially more involvement from a plurality of providers, necessitate a very clear set of standards and credible checks and balances in the system. The Commissioning Consortia will need to be open and transparent in their decision making processes, and ensure that full and adequate consultation is undertaken with local communities, patient organisations and other local representative bodies when awarding, reviewing, or decommissioning services from local care providers.


8.1  How effective are the structures proposed in the Bill, which are designed to safeguard existing co-operative arrangements and promote the development of new ones?

8.1.1  The RCN fully supports the Government's desire to better integrate health and social care services, but believes that there is a need to learn and take the best from current integrated programmes. The RCN also believes that cooperation is best achieved by good relationships between healthcare professionals.

8.1.2  The RCN believes that the development of better integration of health and social care would be significantly helped by nursing involvement at all parts of the commissioning process.

8.1.3  RCN members' experience shows that NHS staff are currently frustrated by the implications of unmet social care needs. A recent survey of RCN members highlighted a number of examples where they had cared for a patient, who left the surroundings of a ward offering social interaction, well-fed and in good health to be cared for in the community. However, the patient was soon readmitted due to inadequate social care provision and having developed health problems subsequently. The result is the "revolving door", where patients leave hospital time and time again only to be let down by the lack of social care at home.

8.1.4  Nursing involvement in the commissioning process in important in any reform of the social care system as they have to manage the many daily challenges of the current system. These include carrying out needs assessments, form-filling, and discharge planning, in addition to dealing with healthcare needs that result from unmet social care needs.

8.1.5  There has been a lack of integrated workforce planning across health and social care in the past. It is important the Government's proposals will ensure sufficient resources and infrastructure to provide national and regional oversight, as well as a multi-professional approach to workforce planning. This is particularly important as changes in the type of demand with regards to care take place, for example, a greater emphasis on moving care into the community. The RCN believes that there should be greater use of scenario-based planning[24] for health and social care workforce planning.

8.1.6  The lack of coterminosity in the new system between Commissioning Consortia and Local Authority boundaries may also hinder integration. The current pathfinder programmes, which cover 50% of the population, vary widely in size. They will not undergo parliamentary scrutiny and there will be no formal evaluation of the impact of not matching up to Local Authority boundaries. The RCN is concerned that the lack of coterminosity may lead to patients falling through potential cracks in services.


9.1  Do the new arrangements encourage Commissioning Consortia to cooperate in achieving the benefits to patients which may be available from major service reconfiguration?

9.1.1  The RCN is supportive of the reconfiguration of acute hospitals, where this will deliver better, more efficient services for patients. However, these decisions have proved difficult in the past for SHAs and PCTs, as well local MPs. Local hospital closures have become extremely political around local and national elections, which has consequently skewed local decision making on some occasions.

9.1.2  The Bill will not necessarily encourage Commissioning Consortia to look at undertaking these difficult decisions collaboratively. It is unclear how the new Commissioning Consortia will have the capacity to consider and consult on major configurations alongside their other new responsibilities. There will also be significant pressure from their individual populations. The RCN therefore believes that there should be regional boards, which can provide strategic oversight to better facilitate major reconfigurations, which will deliver benefits to patients.


10.1  How does the Bill enable Commissioning Consortia to enhance patient choice at the same time as delivering the Consortia's clinical and financial priorities?

10.1.1  The RCN welcomes greater focus on patient choice, where this is meaningful and there is sufficient provision and accessibility of information available.

10.1.2  However, it is important that national political accountability is not lost in the new system. There will be possible conflicts of interest between the Commissioning Consortia's role of providing personal clinical care to patients and their new remit, which may require them to take difficult decisions. For example, to decommission services due to either financial or clinical reasons.

10.1.3  There remain significant concerns that these reforms will put clinicians in a difficult position if and when cuts are made to those services and that they will be perceived as the rationers of patient care. Commissioning Consortia will need support in making such decisions as they will lack experience and take time to develop the necessary infrastructure and skills. Success will be strongly dependent on how effectively Commissioning Consortia control their finances and are prepared to make difficult decisions.

10.1.4  The RCN also has some concerns regarding the Commissioning Consortia's ability to manage public expectations. The Bill rightly highlights the importance of patient choice, but it will raise people's view that they have a right to demand. This will be particularly difficult for Commissioning Consortia, which cover a more informed community. It may put pressure on how the Commissioning Consortia can demonstrate enhanced patient choice whilst also delivering clinical and financial priorities.

10.1.5  Another area of concern regarding patient choice is that the public will be able to register with any GP they choose, whilst also being able to change as frequently as they want to. If a patient can change to a GP outside of their geographical area, the GP is no longer responsible for just their local community, but also those who may use the practice for convenience. For example, those working in London, but living outside and commuting in, may opt to have a GP near to their place of work, but may need care delivered nearer home. It is not clear how this will be joined up and could lead to fragmented services.


11.1  Are the arrangements for local accountability proposed in the Bill sufficient?

11.1.1  The RCN does not believe that the Bill delivers a consistent message around patient and public engagement. For example, there is no requirement for the NHS Commissioning Board, Commissioning Consortia or HealthWatch England to have a public representative on their boards.

11.1.2 The RCN believes that a further example of where the Bill does not go far enough is Clause 170, which instructs Local Authorities of their duty to provide a channel for patients and individuals to lodge a complaint about a healthcare service. However, it clearly states that it is up to Local Authorities to "make such arrangements as it considers appropriate". The RCN fears that this open ended clause will lead to an even further fragmented coverage of services, and in some areas will make it far more difficult for serious concerns to be aired. There should therefore be a degree of basic standardisation of the complaint procedure across Local Authorities to ensure that all patients have the same ability to lodge complaints.

11.1.3  A Local Authority's duty to host a Health Overview and Scrutiny Committee is amended by Clause 176, which shifts the scrutiny responsibility directly to the Local Authority. The Local Authority will have the option to form an Overview and Scrutiny Committee but will no longer be required to do so by law. The RCN has concerns that in the current climate, with extreme pressures being placed upon Local Authorities through budgetary cutbacks, the opportunity not to run a service will be seized upon due to financial necessity. This may have a disproportionate effect on those hard to reach patient groups, who are unlikely to speak out if it is proposed that their service may be decommissioned. The RCN believes that Health Overview and Scrutiny Committees carry out an important role at a local level, bringing to light areas of concern affecting local communities' healthcare services, and encouraging joined up working between health and social care services.

11.1.4  The RCN welcomes the intent by sections of the Bill such as Clause 19, subsection 13L, and Clause 21, subsection 14P, which state the need for the NHS Commissioning Board and Commissioning Consortia to ensure that service users are consulted on changes to the commissioning of services which affect them as well as in the planning of any commissioning arrangements. The RCN believes that it is important that this consultation and supplying of information is sufficiently robust to satisfy the needs of service users and provide the service which they require.

11.1.5 Under Clause 21, Subsection 14P, the NHS Commissioning Board "may" publish guidance for Commissioning Consortia on the discharge of their functions under public involvement and consultation. The Bill goes on to state that a Commissioning Consortia "must have regard" to any guidance published. However, the RCN believes that this is too weak and that there is no mandate for Commissioning Consortia to adhere to any guidance from the Board.

11.1.6  In addition, the RCN is concerned that there is no provision in the Bill for Commissioning Consortia to make public annual financial reports or to hold open board meetings. This raises concerns about transparency and accountability of these new bodies to their local populations.


12.1  What are the proposed arrangements for debt eradication and tackling structural deficits?

12.1.1  In December 2010, the NHS Operating Framework confirmed that Commissioning Consortia will not be responsible for resolving PCT legacy debt that arose prior to 2011-12, and this clarification is welcome. However despite these assurances the RCN remains concerned whether PCTs and SHAs will be able to eliminate their structural deficits over the next two years.

12.1.2   The Government needs to acknowledge that they must support Commissioning Consortia and existing commissioning organisations to form transparent and realistic plans for debt eradication and for tackling structural deficits within their local health economy. The target of 4% efficiency gains for four years running is unprecedented and the RCN's Frontline First campaign has identified that many PCTs are already struggling to maintain financial balance, and resorting to short term cuts to jobs and services.

12.1.3  Overall the proposed arrangements for debt eradication and tackling structural deficits are not sufficient. It appears that an adequate risk management regime has not been thought through, which could result in serious consequences for patient services and healthcare staff.

February 2011

23   Nuffield Trust report GP commissioning: insights from medical groups in the United States Back

24   Nurse workforce planning in the UK, a report for the Royal College of Nursing (2007)  Back

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Prepared 5 April 2011