Commissioning: further issues - Health Committee Contents

Written evidence from the Royal College of Surgeons of England (CFI 42)

1.  The Royal College of Surgeons is committed to enabling surgeons to achieve and maintain the highest standards of surgical practice and patient care.

2.  The College is pleased to provide written evidence to the Health Select Committee's follow-up inquiry into commissioning and would be willing to provide oral evidence if required.

3.  We have focused on those areas which are of most relevance to the College's role.


  • The College welcomes the essential focus on clinical involvement in commissioning; however, we have several unresolved concerns about the proposed arrangements for system reform.
  • We would like to see a formal requirement to involve specialists in commissioning decisions both locally and nationally.
  • Within specialities, many surgical services require commissioning and oversight on a regional or supra-regional basis and we remain unclear as to how this will be delivered.
  • There is a need for effective collaboration across primary and secondary care in order to improve services and we are concerned that the requirements of competition law may hinder this process.
  • We are concerned that patients do not have access to sufficient, high quality information to support treatment choices.
  • Patient choice, coupled with the policy of any willing provider and price competition will lead to unused capacity and waste in the NHS.
  • We have significant concerns about the future provision of training in an environment where any willing provider can deliver NHS funded care.
  • The potential for inconsistent application of national standards is concerning.
  • The College and surgical Specialty Associations are well placed to offer advice on national and local issues.


4.  The College welcomes the intention for greater clinical involvement in commissioning and we sincerely hope that the provisions made in the Health Bill will be sufficient to ensure this. We agree with the Committee that both national and local commissioning bodies will require specialist clinical input in order to achieve high quality, innovative and cost effective commissioning decisions.

5.  The College welcomes the provision for the Commissioning Board to obtain advice and professional expertise in discharging its functions. While we appreciate that not every specialty can be represented at board level, we would expect to see representation from major secondary care specialties so as to give a balanced and knowledgeable perspective on commissioning decisions. The College, with the support of the surgical Specialty Associations, hopes to have the opportunity to provide advice and support to the Commissioning Board on the standards to which surgical services should be commissioned.

6.  Similarly, we would expect a requirement for commissioning consortia to seek advice from specific secondary care groups within their governance arrangements, and also expect that they will consult relevant guidance from professional bodies on key aspects of their work.

7.  We welcome the development of a commissioning outcomes framework (to be led by the Commissioning Board) in order to hold commissioning consortia to account. Having a specification for secondary care clinical engagement within the framework would provide a key safeguard for the standards of patient care.


8.  It is vital that consideration of education and training needs runs alongside service commissioning decisions.

9.  The intention to open the provision of NHS-funded care to any willing provider raises concerns about the delivery of education and training. Even where contractual arrangements are in place, experience shows it is extremely unlikely that non-NHS providers will prioritise the training of the future generation of doctors and other healthcare professionals.


10.  It seems clear that a separation of provider and commissioner functions will remain. The College would like to see closer alignment and formal collaboration between providers and commissioners in order to bring about improvements to patient care.

11.  Current proposals suggest that the NHS Commissioning Board will purchase specialised services, which we assume to be those currently defined by the National Specialised Commissioning Group, and this we would agree with. It has been suggested that commissioning consortia might join together to commission those services which require regional oversight. We have significant concerns about this arrangement.

12.  In addition to services like trauma, general paediatric surgery and vascular services, there are a number of other services within specialties that require a broader geographical focus, which will require a critical mass of patients to enable effective delivery, both in terms of efficient use of resources and maintenance of clinical skills. Service networks will require professional support as they develop, and will require a continued coordinated approach across a number of consortia and providers as they come on stream. Our concern is that the competitive environment, particularly between foundation trusts, may create a problems leading to inefficiencies and possibly failure of the service.

13.  The creation of "PCT clusters" appears to be a pragmatic method of dealing with the transition. The commissioning support functions of PCT clusters could usefully have a continuing role for commissioning those services that require a broader regional perspective. The concept appears attractive in terms of maintaining the skills of high quality commissioners, reducing back office costs and enabling oversight/engagement with regulators and professional bodies on a manageable scale.

14.  The NHS Commissioning Board can intervene if a consortium does not (or cannot) carry out its statutory functions. We would question how disputes (either between providers and consortia or amongst consortia groups) in relation to clinical aspects of service commissioning/delivery will be resolved. There appears to be no mechanism (other than via local scrutiny committee, which we doubt would be competent or effective) to intervene. The College is in a position to provide advice and support to mitigate conflict at an early stage and would welcome interaction with the NHS Commissioning Board to discuss this area and develop a formal pathway.

15.  Currently, proposals in the Health Bill permit competition based on price. We consider this to be inappropriate as there is no evidence to suggest that competition on price in health services provides better quality. If anything, the opposite appears to be true. In a financially challenged NHS we would strongly urge against competition based merely on price, in order to avoid a "race to the bottom", where clinical quality is compromised and essential services become fragmented and unsustainable.

16.  The College remains concerned that the drive to localise the NHS may result in different interpretations of standards and that this could be to the detriment of patients.


17.  We would agree with the Committee that there is potential for conflict of interest where a commissioning consortium purchases services from general practice (particularly services which might be considered over and above the general range of services provided at primary care level). We have particular concern about the provision of surgical services at primary care level. While the College understands the need, in certain circumstances, to shift services from secondary to primary care where this might benefit the patient and be more cost efficient, we would wish to see adequate safeguards in place to ensure the requisite standards and outcome measures.

18.  We feel it is important for those practicing surgery to demonstrate that they meet the require competencies of the speciality, are up to date, participate in audit and practice in an appropriate clinical governance environment.


19.  We are concerned that the legislative requirements of a competitive environment may significantly hinder collaboration between clinical services. Provider units must be willing to allow their clinicians time to work with commissioners on designing care pathways. The balance between the requirements of competition law and the need to share expertise to bring about improvements in care requires clarification.

20.  The ability to deliver major service change may be hindered by the limited experience and parochial views of commissioning consortia. While the maintenance of local authority scrutiny arrangements is a welcome change to the government's original proposals, we remain concerned that the NHS will suffer from a lack of leadership and management with regard to major service change. We would like to see appropriate involvement of the professional bodies, the benefits of which are twofold - demonstrating impartiality and an adherence to standards, while providing professional leadership to doctors involved in service transformation. The College, working with the surgical Specialty Associations, is able to offer advice and support to commissioners and providers where major service reconfiguration is being considered.

21.  It will be important to ensure that commissioning decisions are transparent, take into consideration the long-term effects and avoid reactive steps to rectify short-term financial concerns. The recent media coverage on so-called "procedures of limited clinical value" is a case in point. Once again, the professional bodies are well placed to provide advice, on a national level to ensure consistency and an evidence-based approach.


22.  While we agree that patients must be involved in decisions about their care, we feel it is disingenuous to suggest that the choice agenda will be cost neutral.

23.  As patients are offered choices about their treatment, coupled with the policy of any willing provider and competition based on price, it is inevitable that there will be unused capacity within the NHS, leading to inefficiencies and waste. Evidence suggests that patients do not make choices based on best outcomes; often choices are made for more mundane reasons (eg car parking or next available appointment).

24.  There is good evidence to suggest that choice in healthcare benefits those who are sufficiently informed and socially mobile and may therefore disadvantage the poor, the elderly and less mobile members of society.

25.  The provision of high quality information is key to enabling choice. We have responded to the government's consultation on the "information revolution"[25] and welcome the principles enshrined within that document. A number of government agendas rely on high quality information in the NHS and it will be important for the government to capitalise on these to bring about economies of scale. Much work is required to ensure both commissioners and patients have access to information that is high quality, accessible and of sufficient depth to support true choice. The College is keen to work with government and with local providers and commissioners on this important topic.

26.   While we welcome Monitor's role in ensuring the provision of essential services (though the criteria for such services has yet to be defined), we would caution that extending patient choice threatens to undermine and destabilise those local services upon which some patients will rely.

27.  We are pleased at the government's intention to allow referral of patients to a named consultant-led team. We would also urge the government to reconsider its views on consultant-to-consultant referrals which, in the main, are made to ensure the most effective treatment pathway for patients.

28.  We would urge commissioners to engage local surgeons to ensure referral management arrangements are suitable, and also that decisions are audited to ensure effectiveness.

29.  As services are reconfigured and streamlined it is important that the risk of "postcode lottery" is guarded against.

30.  Safeguards are required to ensure that general practitioners continue to treat and refer patients based on their individual clinical need and accepted best practice.

31.  We welcome forthcoming guidance from the Commissioning Board on patient involvement in commissioning consortia decisions.

February 2011

25   The Royal College of Surgeons of England. Response to the Consultation "Liberating the NHS: An Information Revolution", January 2011 Back

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Prepared 5 April 2011