Written evidence from the Royal College
of Nursing (CFI 24)
1.0 INTRODUCTION
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.
2.0 EXECUTIVE
SUMMARY
- 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.
3.0 ASSURANCE
REGIME
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.
4.0 PROPOSED
ARRANGEMENTS FOR
LINES OF
ACCOUNTABILITY
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.
5.0 INTEGRATING
THE FULL
RANGE OF
CLINICAL EXPERTISE
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.
6.0 SEPARATION
OF THE
COMMISSIONER AND
PROVIDER FUNCTIONS
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.
7.0 ARRANGEMENTS
FOR THE
COMMISSIONING OF
PRIMARY CARE
SERVICES
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.
8.0 INTEGRATION
OF HEALTH
AND SOCIAL
CARE SERVICES
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.
9.0 ARRANGEMENTS
FOR RECONFIGURATIONS
OF 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.
10.0 ARRANGEMENTS
FOR COMMISSIONING
CONSORTIA TO
RECONCILE CONFLICTS
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.
11.0 ARRANGEMENTS
FOR PATIENT
AND PUBLIC
ENGAGEMENT
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.
12.0 ARRANGEMENTS
FOR DEBT
ERADICATION AND
TACKLING STRUCTURAL
DEFICITS
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
http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&PRid=756 Back
24
Nurse workforce planning in the UK, a report for the Royal College
of Nursing (2007) http://www.rcn.org.uk/__data/assets/pdf_file/0016/107260/003203.pdf
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