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.
KEY POINTS
- 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.
CLINICAL ENGAGEMENT
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.
EDUCATION AND
TRAINING
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.
SEPARATION OF
COMMISSIONER AND
PROVIDER FUNCTIONS
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.
COMMISSIONING OF
PRIMARY CARE
SERVICES
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.
CO -OPERATIVE
ARRANGEMENTS
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.
PATIENT CHOICE
AND COMMISSIONING
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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