3 The Government response
Commissioning
FRAGMENTATION
31. The Committee has consistently argued that multiple
services and budgets cannot be brought together if commissioning
is fragmented. Creating locally responsive hierarchies of care
can only be achieved if strong system leadership is embedded in
the local area. Management and commissioning go hand in hand and
must incorporate social care if an integrated response is to be
achieved. The complexity of commissioning is a fundamental weakness
in the system, and the lack of clarity around the purpose and
authority of the newly-established Urgent Care Boards (UCBs) risks
compounding the problem.
32. NHS England has said that UCBs will cover all
'communities' (not necessarily CCG areas) and will include "all
key stakeholders from health and social care as well as patient
representatives and the appropriate clinical expertise."[35]
The role that UCBs can play in implementing local improvements
to the emergency and urgent care system is discussed in more depth
later on this chapter.
33. Mike Farrar noted the complexity of commissioning
and said that:
I worry enormously that one of the things we
have structurally built into the new system is different budget
holders for different bits of the budget, social care, particularly
primary care, separate from hospital and community budgets, and
specialist services.[36]
34. The King's Fund echoed these concerns and said
that UCBs may be most useful in providing an additional layer
of management to the system. Outlining the commissioning system
the King's Fund's written evidence said:
There are now multiple commissioners of urgent
and emergency care: NHS England has responsibility for commissioning
primary care; clinical commissioning groups commission acute and
community services; and local authorities commission social care
and housing. Urgent care boards, now being established across
the country, may be a useful mechanism for developing system-wide
responses, although it will be important to be clear about their
role, leadership and accountability if they are not to become
just another component in a complex system. We remain concerned
that the fragmentation of commissioning and lack of strategic
responsibility will make system wide change more difficult to
implement.[37]
35. Anthony Marsh, Chief Executive of the West Midlands
Ambulance Service NHS Foundation Trust and Chair of the Association
of Ambulance Chief Executives, described the practical process
by which ambulance services are commissioned:
You have the core 999 emergency service being
commissioned in most parts by a consortium arrangement of clinical
commissioning groups across the geographical footprint of the
ambulance service, but then, more locally, through the urgent
care boards. In most places around the country, those arrangements
have existed to a lesser or greater extent—although they
may have been called something different—to pull together
some more local CCGs to ensure that the service is commissioned
locally for their people. In addition to that, sometimes further
local arrangements are put in place by clinical commissioning
groups for their local population.[38]
36. The successful provision of emergency and
urgent care is a matter of life and death and therefore clarity
in commissioning is vital. The Committee is concerned that the
lines of responsibility and accountability for funding and managing
services have been blurred. The Committee notes the concept of
UCBs putting local clinicians and commissioners together to make
practical changes and plan service improvement, but it is concerning
that new structures are required so soon after the establishment
of CCGs and Health and Wellbeing Boards. Health and Wellbeing
Boards have made an uncertain start but retain broad support and
they are structured to bring all parts of the system together.
The current problems should, theoretically, have provided them
with an opportunity to develop their functions, but they appear
to have been superseded by UCBs.
SIMPLIFYING COMMISSIONING
37. Dr Patrick Cadigan, Registrar of the Royal College
of Physicians, said in oral evidence that he hoped that CCGs would
be placed at the heart of UCBs because improvements to the system
were reliant on better commissioning. He told the Committee that:
It is very interesting, again, that those trusts
that have succeeded best in reducing hospital admissions have
been trusts with a single commissioner, so the development of
a relationship between a trust and a commissioner, which is capable
of constructing perhaps new ways of working financially.[39]
38. Dr Cadigan's argument ties in with the view of
Anthony Marsh, who told the Committee that in some commissioning
areas a single commissioner was taking responsibility for "out-of-hours
service, the 999 ambulance service and NHS 111."[40]
Mark Docherty, Chair of the National Ambulance Commissioners Group,
noted that within existing commissioning structures ambulance
services could be rewarded for "advising a patient over the
telephone and signposting them to the right service"[41]
so there was potential to operate a system which promotes a degree
of integration.
39. We recommend that CCGs and Health and Wellbeing
Boards explore the benefits of establishing single commissioning
teams for out of hours care, ambulance services, 999, and NHS
111. A single commissioner can lead across CCG boundaries in the
case of services which are most appropriately commissioned on
a regional or sub-regional basis. Fragmented commissioning and
provision results in a situation where patients are unaware of
many available services or are unsure of the most appropriate
service. The single commissioning teams for urgent care should
take responsibility for signposting patients to available services.
Solutions
40. The evidence taken by the Committee suggests
that the Government's proposals to address the failings in emergency
are twofold:
i. Alter local system management
ii. Restructure services
SYSTEM MANAGEMENT: URGENT CARE BOARDS
41. In May, NHS England published an improvement
programme for A&E departments in England to tackle the deterioration
in the number of providers meeting the 4 hour standard during
the first four months of 2013.
42. In order to facilitate local examination of the
systems which determine levels of attendance at A&E departments,
NHS England instructed its local area teams to convene Urgent
Care Boards (UCBs).
43. In March 2013 the King's Fund undertook a review
of Urgent and Emergency Care on behalf of NHS South of England.
The review said that:
some areas need to do more to provide clear strategic
oversight and drive to tackle the main challenges to emergency
care systems. Urgent Care Boards have been established in some
areas to provide oversight, evaluation, standardisation and communication
to all parts of the system, but Boards seem to be at different
stages of development and vary in effectiveness.[42]
44. They also added a note of caution regarding the
composition of the boards, warning that:
Boards appear to be a useful mechanism as long
as there is clarity of role, the right people sitting on them
(those able to deliver change directly and with a detailed knowledge
of the issues), top level sponsorship and methods to hold participants
to account. Without this, they have the potential to become somewhat
bureaucratic and lead to a proliferation of projects.[43]
45. We agree with the King's Fund on both points.
UCBs have the capacity, in principle, to contribute to improving
coordination of urgent care services, but we are concerned that
current plans suggest they are in danger of falling into precisely
the trap identified by the King's Fund.
46. Discussing the role of urgent care boards, Mike
Farrar, Chief Executive of the NHS Confederation, suggested that
they might be in a position to assume some functions that had
been lost within the commissioning environment as a result of
the implementation of the Health and Social Care Act 2012. He
said the creation of a UCB was:
a good move because, effectively, it is trying
to replicate someone. [...] If these things are multifactorial
and relate to all bits of the system, then a system management
approach, where you have somebody who can take that overview,
is really important. In the latest reform to the NHS, those kinds
of system management roles have been structurally removed so the
only way that you recreate them is by volition, where you create
something like a board where the parties can come together and
actually identify—and it will be different in different
parts of the country in different places—where the particular
investment or problem is.[44]
Sir David Nicholson, Chief Executive of NHS England,
accepted that UCBs were necessary to provide local oversight and
direction. He told the Committee that:
The way the system is constructed is that people
will come together in partnership to make it happen, and in lots
of parts of the country that is precisely what happens—but
not everywhere. It was important that it did happen everywhere,
and that was the way in which we thought about urgent care boards
to force that system management into the system, which, due to
lack of maturity or a whole set of other reasons, was perhaps
not quite operating in the way we had hoped.[45]
47. Explaining their purpose and function, Dame Barbara
Hakin, Chief Operating Officer and Deputy Chief Executive of NHS
England, told the Committee that, at a local level, it was the
responsibility of UCBs to drive performance in emergency care.
Dame Barbara said that:
one of the things the urgent care board should
do is to identify the use of the 70%.[46]
For that, we said that the chief executives of the local commissioners,
which is the CCG, the area team and all providers—the ambulance
trust, mental health trust and acute trust—should sign off
the use of that money. That is the minimum group of people who
would be there alongside the local authority, because we said
there had to be local authority input. Where it is appropriate
to have clinicians, they will have many clinicians on them, because
the idea of the board is to bring together local experts to determine
what they need to do.[47]
48. This statement, however, contrasts with Dame
Barbara's assertion that UCBs were not part of local governance
and management structure, would entail no significant cost to
the public purse and would not have staff employed to support
their activity.[48] Dame
Barbara told the Committee that UCBs would be looking:
at the day-to-day changes they need to make in
terms of patient management. How can they work better across primary
and social care, and so on? If in a meeting of the urgent care
board there is a decision that something major needs to happen,
that will have to go back through the formal channels of the CCGs.
(Clinical Commissioning Groups)[49]
49. It was unclear from the evidence presented by
the Minister and NHS England how these structures represent a
national response to the problems facing emergency care. The number
of UCBs remains unclear (with approximately 150 established in
England[50]), they have
no executive power but must develop local improvement plans and,
despite their responsibilities, no formal structures are in place
to ensure they are accountable. Exactly how improvement plans
can be implemented if UCBs, CCGs and Health and Wellbeing Boards
cannot agree on their content is by no means obvious. The principle
is understandable but the execution is unconvincing.
Funding
50. It is proposed that UCBs should take responsibility
for allocating the 70% of the excess care tariff not paid to acute
trusts by commissioners and returned to NHS England (the marginal
tariff). In oral evidence Earl Howe referred to this as "extra
money"[51] but clarified
the point acknowledging that this measure released existing money
into the system via a different mechanism and could not be regarded
as additional funding.[52]
The Secretary of State told us that UCBs had been given the "specific
task to make sure that that money is being used to reduce pressures
on A and Es."[53]
51. We are concerned about this approach on both
procedural and substantive grounds. Firstly, although UCBs are
supposed to mandate the use of the marginal tariff, they have
no statutory authority to do so and there are no accountability
or audit arrangements to track the impact of their decisions;
the effective deployment of this resource depends upon local commissioners
accepting the recommendations of their UCBs. The Committee regards
this as an inadequate basis on which to manage the service reconfiguration
which we believe is necessarily at the heart of a proper response
to service pressures in urgent care.
52. Secondly, it is unclear how the proposal to develop
UCBs relates to the parallel development of Health and Wellbeing
Boards. Any coherent plan to restructure the system to meet urgent
care needs will need to involve all participants in a Health and
Wellbeing Board; it is unclear to the Committee why a second coordinating
body needs to be created in parallel with Health and Wellbeing
Boards which are not yet four months old.
53. Thirdly, and most importantly, the Committee
is concerned about the implication that UCBs will be able to make
a difference by re-deploying the marginal tariff. These resources
are already being used. There may be better ways of using them,
but they do not represent "new money". All UCBs will
therefore be required to identify opportunities for "disinvestment"
if they are able to initiate any response to current service pressures.
54. The Committee was disappointed with the evidence
that was presented about the creation of UCBs. Ministers are relying
on UCBs to implement short-term practical changes to improve hospital
performance, but the composition, responsibilities and authority
of UCBs remain unclear. There is little evidence that any form
of national strategy exists beyond the creation of UCBs, and senior
figures in NHS England could not tell us precisely how many UCBs
have been established.[54]
55. The evidence presented to the Committee did
not persuade us that the structures existed to enable UCBs to
implement reforms or influence local commissioning arrangements.
The Committee believes that Ministers need to seek much greater
clarity from NHS England about its plans for UCBs and ensure that
they, or Health and Wellbeing Boards, are required to account
for an Urgent Care Plan for their area in the winter and spring
of 2013-14. The Committee recommends that NHS England should ensure
that these Urgent Care Plans are prepared and agreed before 30
September 2013.
56. It is concerning that UCBs appear to have
been created without any senior figure in NHS England being clear
whether they are intended to become permanent features in local
health systems. We agree with several witnesses that UCBs meet
an urgent need to introduce "system management into the system".[55]
If that is to be their role, we do not believe it should be regarded
as either voluntary or short-term.
35 Ibid, p 6-7 Back
36
Q 91 Back
37
ES 28, written evidence from the King's Fund, para 3 Back
38
Q 98 Back
39
Q 55 Back
40
Q 100 Back
41
Q 114 Back
42
Urgent and Emergency Care, A review for NHS South of England,
The King's Fund, March 2013, p 4 Back
43
Ibid, p 19 Back
44
Q 54 Back
45
HC 119-iii, Q 237 Back
46
Only 30% of the emergency care tariff is paid to providers for
activity over 2008-09 levels. The remaining 70% is retained by
the commissioner. Back
47
Q 236 Back
48
Q 239, Q 241, Q 246 Back
49
Q 248 Back
50
Q 234 Back
51
Q 225 Back
52
Q 227 Back
53
HC 119-iii, Q 235 Back
54
Q 231-234 Back
55
HC 119-iii, Q 237 Back
|
