Urgent and emergency services - Health Committee Contents


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


 
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© Parliamentary copyright 2013
Prepared 24 July 2013