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House of Commons Health Committee Commissioning Third Report of Session 2010–11 Volume III Additional written evidence Ordered by The House of Commons to be published 13 January 2011 Published on 21 January 2011 by authority of the House of Commons London: The Stationery Office Limited The Health Committee The Health Committee is appointed by the House of Commons to examine the expenditure, administration, and policy of the Department of Health and its associated bodies. Membership Rt Hon Stephen Dorrell MP (Conservative, Charnwood) (Chair)1 Rosie Cooper MP (Labour, West Lancashire) Nadine Dorries MP (Conservative, Mid Bedfordshire) Yvonne Fovargue MP (Labour, Makerfield) Andrew George MP (Liberal Democrat, St Ives) Grahame M. Morris MP (Labour, Easington) Mr Virendra Sharma MP (Labour, Ealing Southall) Chris Skidmore MP (Conservative, Kingswood) David Tredinnick MP (Conservative, Bosworth) Valerie Vaz MP (Labour, Walsall South) Dr Sarah Wollaston MP (Conservative, Totnes) The following was a member of the Committee during this inquiry: Fiona Mactaggart MP (Labour, Slough) Powers The Committee is one of the departmental select committees, the powers of which are set out in House of Commons Standing Orders, principally in SO No 152. These are available on the Internet via www.parliament.uk. Publications The Reports and evidence of the Committee are published by The Stationery Office by Order of the House. All publications of the Committee (including press notices) are on the Internet at www.parliament.uk/healthcom. The Reports of the Committee, the formal minutes relating to that report, oral evidence taken and some or all written evidence are available in printed volume(s). Additional written evidence may be published on the internet only. Committee staff The staff of the Committee are David Lloyd (Clerk), Sara Howe (Second Clerk), David Turner (Committee Specialist), Steve Clarke (Committee Specialist), Frances Allingham (Senior Committee Assistant), and Ronnie Jefferson (Committee Assistant). Contacts All correspondence should be addressed to the Clerk of the Health Committee, House of Commons, 7 Millbank, London SW1P 3JA. The telephone number for general enquiries is 020 7219 5466. The Committee’s email address is [email protected]. 1 Mr Stephen Dorrell was elected as the Chair of the Committee on 9 June 2010, in accordance with Standing Order No. 122B (see House of Commons Votes and Proceedings, 10 June 2010). List of additional written evidence (published in Volume III on the Committee’s website www.parliament.uk/healthcom) 1 The Royal College of Radiologists Ev w1 2 Cystic Fibrosis Trust Ev w2 3 Sustrans Ev w4 4 Mary E Hoult Ev w7 5 National Kidney Federation Ev w8 6 Specialised Healthcare Alliance Ev w10 7 Mr Gerald Rigler Ev w12 8 Royal College of Paediatrics and Child Health Ev w14 9 Family Planning Association Ev w15 10 Mencap Ev w17 11 Londonwide LMCs Ev w19 12 City of London LINk Ev w20 13 Independent Mental Health Services Alliance Ev w21 14 Help the Hospices Ev w23 15 Partnerships in Care Ev w27 16 Oxfordshire County Council Ev w28 17 National Centre for Young People with Epilepsy Ev w32 18 The Company Chemists’ Association Ltd and the Association of Ev w36 Independent Multiple Pharmacies Ltd 19 RNIB Ev w39 20 UK Commissioning Public Health Network Ev w41 21 Central London Healthcare CIC Ev w43 22 Society of Chiropodists and Podiatrists Ev w45 23 Benenden Healthcare Society Ev w47 24 Association of Directors of Adult Social Services Ev w50 25 2020 Public Services Trust Information and Technology Group Ev w54 26 Audit Commission Ev w58 27 National Children’s Bureau Ev w65 28 Dr Corinne Camilleri-Ferrante Ev w71 29 Terence Lewis, Lewis Governance Ev w72 30 The Kidney Alliance Ev w75 31 Shire Pharmaceuticals Ltd Ev w79 32 Better Value Healthcare Ev w82 33 Allied Health Professions Federation Ev w83 34 Independent Midwives UK Ev w86 35 National Osteoporosis Society Ev w89 36 The Chartered Society of Physiotherapy Ev w93 37 Muscular Dystrophy Campaign Ev w97 38 Weight Watchers UK Ev w100 39 London Specialised Commissioning Group Ev w104 40 Royal College of Psychiatrists Ev w108 41 Baxter Healthcare Ltd Ev w112 42 Royal College of Midwives Ev w113 43 Ultrasis UK Ltd Ev w116 44 Haringey Better Local Healthcare Campaign Ev w119 45 The Pharmaceutical Services Negotiating Committee Ev w121 46 Genzyme Therapeutics Ltd Ev w124 47 Dr Jonathan Howell Ev w125 48 British Pregnancy Advisory Service Ev w129 49 LighterLife Ev w131 50 National Association for Voluntary and Community Action Ev w135 51 County Councils Network Ev w139 52 Genetic Alliance UK Ev w141 53 Cambridge Weight Plan Ev w143 54 Mr David Allen Ev w147 55 Paediatric Continence Forum Ev w149 56 National Specialised Commissioning Group and NHS Specialised Ev w151 Services Team 57 Assura Medical Limited Ev w155 58 National Infertility Awareness Campaign Ev w157 59 Actelion Pharmaceuticals Ltd Ev w159 60 Parkinson’s UK Ev w161 61 Joint Epilepsy Council Ev w163 62 National Housing Federation Ev w167 63 South East Coast Specialised Commissioning Group Ev w172 64 Brook Ev w175 65 British Dental Association Ev w177 66 Rare Disease UK Ev w181 67 British Heart Foundation Ev w183 68 The LIFT Council Ev w187 69 Samaritans Ev w189 70 Tunstall Healthcare Ltd Ev w192 71 Action Duchenne Ev w194 72 Health Foundation Ev w197 73 British Association for Adoption and Fostering Ev w201 74 Turning Point Ev w206 75 British In Vitro Diagnostics Association Ev w213 76 National Spinal Cord Injury Strategy Board Ev w214 77 Optical Confederation Ev w220 78 Lundbeck Limited Ev w222 79 Association of the British Pharmaceutical Industry Ev w226 80 Intellect Ev w231 81 St Mungo’s Ev w233 82 Changing Faces Ev w236 83 Royal College of Physicians Ev w239 84 North West Specialised Commissioning Group Ev w242 85 Dr Daphne Austin Ev w245 86 The Hepatitis C Trust Ev w247 87 Abbott UK Ev w249 88 Bliss Ev w253 89 Cancer Research UK Ev w254 90 Urology Trade Association Ev w257 91 Keep Our NHS Public Ev w260 92 The Mental Health Foundation Ev w263 93 Dr Giri Rajaratnam Ev w268 94 Breakthrough Breast Cancer Ev w270 95 The Princess Royal Trust for Carers and Crossroads Care Ev w271 96 Sands Ev w274 97 National Family Intervention Strategy Board Ev w277 98 Managers in Partnership Ev w280 99 Royal College of Nursing Ev w283 100 Homeless Link Ev w289 101 Carers UK Ev w293 102 Experts in Severe and Complex Obesity Ev w296 103 UnitedHealth UK Ev w300 104 Aetna UK, Humana Europe, Tribal Group and UnitedHealth UK Ev w304 105 Atrial Fibrillation Association Ev w305 106 Macmillan Cancer Support Ev w307 107 Arrhythmia Alliance Ev w311 108 British Association for Sexual Health and HIV Ev w313 109 PNH Alliance Ev w316 110 Astellas Pharma Ltd Ev w317 111 Terrence Higgins Trust Ev w318 112 Neurological Commissioning Support Ev w321 113 Professor Alan Maynard Ev w326 114 Air Products Healthcare Ev w330 115 Motor Neurone Disease Association Ev w332 116 Manchester Joint Health Unit Ev w337 117 Health Care Professionals Commissioning Network Ev w344 118 Dr Stan Darling Ev w345 119 Centre for Public Scrutiny and NHS Alliance Ev w346 120 Health Experiences Research Group Ev w351 121 Centre for Public Policy and Health, Durham University Ev w354 122 Royal College of Midwives further evidence Ev w359 Health Committee: Evidence Ev w1 Written evidence Written evidence from the Royal College of Radiologists (COM 02) 1. The Royal College of Radiologists (RCR) has approximately 8,300 members and Fellows worldwide representing the disciplines of clinical oncology and clinical radiology. All members and Fellows of the College are registered medical or dental practitioners. The role of the College is to advance the science and practice of clinical oncology and clinical radiology through a range of activities, including setting and maintaining the standards for entry to, and practise in, the specialties of clinical radiology and clinical oncology, and arrangements for continuing professional development (CPD) in both specialties. 2. This response outlines the impact and implications within clinical oncology and clinical radiology of the effect of current commissioning policies and the proposals for commissioning outlined in the Government’s White Paper: Equity and Excellence: Liberating the NHS.1 Clinical Engagement in Commissioning 3. Commissioning should encourage and promote innovation and deliver the services patients need locally. However, many Primary Care Trusts (PCTs) have been ignoring and discouraging innovation and failing to recognise the infrastructure that underpins commissioned services. An example might be the commissioning of dialysis services which, though now being delivered locally, has failed to recognise the vital role that diagnostic and interventional radiology plays in this service. Radiological innovations underpin dialysis services yet receive little or no funding for doing so. This has resulted in failed fistulae, long waiting lists and femoral and other lines being left for too long in patients, which has contributed to infection rates. Oncology services, such as radiotherapy, are often ignored by commissioners since referral to these services are from secondary care and not primary care. 4. If commissioning is to be truly effective, there will need to be a much better understanding of the services being commissioned and what they entail. 5. At the present time commissioners of health care have little accurate information on which to base decisions about the commissioning of specialist services. It will be vital for new commissioning arrangements to recognise the need for consultation and information from professional bodies like The Royal College of Radiologists and its representatives. 6. The new commissioning arrangements must also not ignore the delivery, funding and good health of academic university based medicine. This is what underpins the NHS as a whole and the development of faster less invasive diagnosis and safer treatments for patients. The potential financial gains that academic medicine contributes must not be forgotten by commissioning arrangements that might concentrate too much on the cost effectiveness aspects of the QIPP (Quality, Innovation, Productivity and Prevention) agenda. Specialist Services Radiotherapy 7. The Government’s White Paper2 proposes that resources should be shifted to geographically based GP consortia who will be responsible for commissioning and budgetary controls over services, including cancer services. The RCR considers that local commissioning will be entirely inappropriate for specialised services such as radiotherapy. 8. The failures in implementing the National Radiotherapy Advisory Group recommendations3 in the Cancer Reform Strategy, and the variable commissioning of specialist radiotherapy techniques such as IMRT (Intensity Modulated Radiotherapy), new capacity and machine replacement, are drivers that all radiotherapy should be regarded as specialist commissioning. Many specialised services are already currently commissioned at a level higher than PCT but even now poor specialist knowledge and a lack of a national perspective have held back developments e.g Stereotactic Brain Radiotherapy. The proposed Proton Beam service would be nationally commissioned and would need to be integrated with many conventional radiotherapy services. This will drive a greater degree of specialisation and centralised services in paediatric, sarcoma and CNS (central nervous system) radiotherapy. Central commissioning would facilitate opportunities for greater efficiency and flexible use of capacity within networks. It would potentially allow greater purchasing power for lower cost capital equipment purchasing and replacement as has happened in the past. Therefore, in order to have equitable access to the appropriate range of radiotherapy services and technology across England with appropriate commissioning expertise, it would be logical for the commissioning function to rest centrally. 1 2 3 Department of Health. Equity and Excellence: Liberating the NHS. DH, 2010. Ibid. Radiotherapy: developing a world class service for England. Report to Ministers from National Radiotherapy Advisory Group. DH, February 2007. Ev w2 Health Committee: Evidence Chemotherapy 9. For chemotherapy—although procurement of individual treatments should be at the local level, the strategic planning of chemotherapy services should rest at cancer network level. Interventional Radiology 10. Many of the low volume yet vital Interventional Radiology (IR) services cannot be delivered in every hospital Trust. If they are to be available 24/7, commissioners will need to recognise that networked IR systems will have to be commissioned. September 2010 Written evidence from the Cystic Fibrosis Trust (COM 03) — This is a representation from the Cystic Fibrosis Trust, which is one of the specialist conditions for which there is a National Definition Set (Number 10). — The Cystic Fibrosis Trust (CF Trust) has been actively involved in trying to improve the arrangements for commissioning Cystic Fibrosis (CF) services for many years. After a great deal of frustration, the CF Trust was very pleased when the Carter Report was accepted by Lord Warner and was implemented. For the first time there were clear plans in place to commission CF, which is one of 34 specialist conditions, in a cohesive and constructive way. — Whilst matters have undoubtedly improved as a result of the Carter Report, the Cystic Fibrosis Trust has been disappointed in two respects. First, it has been patchy in terms of geographical area as to which commissioners have actively engaged with the CF service and which have not, and secondly, in that many recommendations within the Carter Report adopted by Lord Warner have not as yet been implemented. Of particular importance is the delay in designating appropriate specialist CF centres and clinics to offer CF care. — The CF Trust has worked systematically to put the tools in place to deliver excellent CF care. These include appropriate and agreed national standards of care, as embodied in the CF Trust’s consensus document Standards of Care—Standards for the Clinical Care of Children and Adults with Cystic Fibrosis in the UK 2001, the National Definition Set Number 10 (third edition), and the paper produced at the request of the specialist commissioners e Care, Network Care, Shared Careo at the request of the specialist commissioners the Trust has developed a clinical care pathway, which will be launched and available both to clinicians and those affected by CF later this summer. — The other initiatives in which the CF Trust has been heavily involved are firstly a programme of peer reviews, whereby a vast majority of specialist CF centres and a large proportion of specialist CF clinics have been thoroughly reviewed by an expert peer review panel and their findings have been made available to the commissioners as well as to the Chief Executives of the hospitals hosting the services in question. Secondly, the CF Trust has for some years had a national clinical database and is working with the Department of Health to use this database to allocate the funding for CF care via an annual banded tariff. The work to agree this tariff has been ongoing for the best part of two years. In conjunction with the Department of Health the CF Trust has obtained detailed data for an annual package of care for around 2,000 CF patients in England. The CF Trust is currently addressing a number of outstanding issues, including how high cost drugs should be incorporated in the tariff, especially nebulised drugs which currently may be prescribed by the GP rather than by the hospital, the costs of shared care arrangements for children with CF and the additional costs for particular categories of patients, such as those in their first year of diagnosis that require a great deal of support, those with atypical mycobacterium infection, women with CF who become pregnant, and patients who are post transplant and who continue to seek their care with their local CF centre rather than their transplant centre. Patients in the latter category tend to include those whose transplant has not been particularly successful and those that live at a distance from the transplant centre. — With these tools, the CF Trust would hope to be able to address many of the questions in the consultation document and would see CF as an example as to how commissioning of the highest standard can be achieved for a complex life-threatening disease. To comment on the particular themes identified in the invitation to submit written evidence, the Cystic Fibrosis Trust would make the following observations on those which are relevant to CF. 1. Clinical Engagement in Commissioning The CF Trust has worked closely with commissioners throughout England where they have been responsive and willing to be involved. The CF Trust has had particularly fruitful relationships with the commissioners in the North West, the South East, the West Midlands and South Central. The commissioners from these areas have attended peer reviews and have responded to peer review reports when they have received them. They have discussed with the CF Trust the need for additional specialist CF centres in their Health Committee: Evidence Ev w3 area, and they have also considered how they might designate CF centres, possibly using the CF Trust peer review programme as a base. As the peer review panels comprise four clinicians (two consultants from other parts of the country to the centre being peer reviewed, and two other multidisciplinary team members, including nurses, physiotherapists and dietitians), a strong relationship between clinicians and commissioners has already been forged. The Standards of Care consensus document and the clinical care pathway address issues of clinical practice in some details, and these have been encompassed within the National Definition Set. In terms of GPs, CF care is a tertiary referral service, and although there has been a role for GPs to date, specifically in terms of prescribing some of the everyday drugs involved in CF care, as well as some of the higher cost nebulised drugs, and in offering support at the palliative care stage where appropriate, most CF care comes from the specialist CF tertiary referral centre. The CF Trust would very much welcome a scheme whereby all drugs were controlled by the centre, in the sense that they would be resourced to fund them and they would be able to prescribe appropriate drugs. However, it is important that a convenient method be devised of delivering these drugs to patients, either in their own home or to allow them to collect them from a pharmacy close to their own home. CF patients rely on a very heavy burden of daily medication to ensure the best quality and length of life, and as they often live quite a way from the specialist CF centre, it is unreasonable to ask them to attend the centre every few days or every week or so for prescriptions. 2. How Open will the System be to New Entrants? Most hospitals offering CF care have been doing so for many years, and most are appropriate to be offering such care. However there are some hospitals offering CF care with an under resourced and a poorly educated team, and this should be addressed via designation. In terms of new entrants offering care, there is a clear opportunity within CF for this to happen in the near future, as it is recognised that there is an urgent need for a number of new adult centres, as the number of adults with CF is increasing significantly year by year. There has already been an attempt to move forward in this respect in the North West, where invitations to develop a new adult centre were invited, and three hospitals currently not recognised as specialist CF centres put themselves forward for consideration. After a thorough review of their applications, it was hoped that a decision would be made and the location for a new centre would be agreed. Unfortunately, it appears that this has not happened and this initiative is now on the back burner. However, as long as it is clear that any provider is wishing to offer the highest quality of service and is not simply wishing to offer CF care because it thinks it will be lucrative and the job can done “on a shoe string”, the CF Trust would welcome new entrants. 3. Accountability for Commissioning Decisions The CF Trust always involves patients or the parents of children in its peer reviews and on all its committees. It also employs seven Expert Patient Advisers, who all have CF, and whose job is to ensure that they and their fellow patients’ voices are heard in whatever decision making processes are in hand. The CF Trust recognises the importance of patient choice and the appropriate funding following the patient to the service of their choice as long as it is a designated one. In terms of the NHS Commissioning Board, the CF Trust is pleased to learn that specialist conditions will be commissioned directly by the national Board rather than by GP fund holders, which gives a great deal of reassurance about equity and quality of care. However, the CF Trust is keen to know how the strategic planning arrangements will be developed. 4. How will the New Arrangements Strengthen Commissioners against Provider Interests? As commissioners will control the budget, they will be in a position to withhold funding from providers who are not offering an appropriate level of care or who are not using their budget in a proper manner. Vulnerable patients, such as those with CF, will be protected by the various measures already outlined to establish their level of care. Most importantly, outcomes via Port CF, the national clinical database for those with CF, will give a clear indication as to where care is of a high standard and where it is not. 5. How will the Proposed System Facilitate Service Reconfiguration? This is an area which the CF Trust finds unclear in the proposed new arrangements. As already identified, it is important that services continue to be developed to meet changing circumstances, such as the increasing number of adults with CF. Attempts to develop new specialist adult centres have been made, but have not been achieved successfully to date. Whether the national NHS Commissioning Board will take on this responsibility or whether there will still be specialist commissioners who have responsibility for their own area is not clear. The CF Trust is firstly of the opinion that whoever has the responsibility must have the authority and the money to make it happen, otherwise it will be another level of bureaucracy attracting heavy salaries but with little to show for it. Ev w4 Health Committee: Evidence 6. Resource Allocation In terms of resource for CF care, the work in which the CF Trust has been involved with the Department of Health to establish an annual banded tariff for the care of those with CF should provide an answer for appropriate allocation of resource. Depending on the severity of their condition, and the amount of care required to keep well, a tariff for a year’s worth of care for each patient will be agreed. This will follow the patient to the centre of their choice, as long as it is a recognised designated specialist CF centre. This would negate the need for tiers of committees to try and decide on what the appropriate funding should be. Each patient would then know that the resource needed to provide appropriate care for them had been made available to their hospital. They would have the power of moving to another designated centre if they felt their service was inadequately resourced. They would also have access to all of the consensus documents and the clinical care pathway, which has been developed at the suggestion of the specialist commissioners to ensure patients are getting the necessary care to ensure the longest and the best quality of life. 7. Specialist Services On the specific question of specialist services, the CF Trust is very pleased that specialist services will become the responsibility of the national NHS Commissioning Board. The CF Trust would be pleased to learn whether it is intended that the national NHS Commissioning Board will hold the funding for the care of all those with CF and will distribute it as has been agreed to date with the Department of Health according to the national clinical database run by the CF Trust and approved by the Department of Health, to the hospitals providing care for patients whose data is captured on this clinical registry, which it is estimated will be over 95% by the time the new arrangements come into play. For the first time, the appropriate costing of a CF service has been addressed in considerable detail, and although there are a number of outstanding areas of work to be completed over the next few months, it is expected that a robust funding agreement which will form the basis of excellent CF care throughout England will be available from April 2011. To conclude, the CF Trust welcomes the new arrangements but recognises that more detailed work needs to be done to ensure these laudable aims are met. It must be ensured that the appropriate tariff is in place, that it gets to the appropriate provider, and that they in turn ensure it gets to the frontline of the service in question and is not held back for other purposes or to meet hospital deficits. It is also important that robust arrangements are in place to ensure the necessary strategic planning of the service for future developments. August 2010 Written evidence from Sustrans (COM 04) Summary — Sustrans specialises in environmental and behaviour change programmes promoting active travel—walking and cycling—and our submission is focused on commissioning in this field; — walking and cycling are now fully recognised as components of any healthy lifestyle strategy; — we work with the Department of Health and others on policy and evidence, and with the NHS, public health bodies and local authorities on delivery: some of our local projects are currently commissioned by PCTs; — we are concerned about, and already beginning to see, discontinuities in health promotion programmes caused by the upheaval of transition in public health commissioning; — we are critical of the “Let’s Get Moving” guidance on physical activity promotion, which ignored evidence provided on successful walking and cycling interventions and cited unproven examples; — Sustrans sees real potential for improvement in public health commissioning and delivery in our field arising from the transfer of public health functions into local authorities; — important gains could arise from the development of inter-disciplinary partnerships within local authorities, with public health, planning, regeneration and transport (and possibly other departments) sharing objectives and strategies; — in particular, we would like to see a training and management regime around local authority public health commissioning, to ensure that public health revenue investment is matched by capital funds from transport, regeneration etc; — we regard as crucially important the integrated application of environmental intervention (such as city-wide traffic speed reduction or pedestrian improvements) with behaviour change focused public health approaches: local authority public health commissioning will facilitate this; and — we draw the Committee’s attention to the fact that much NICE public health guidance is targeted on local authorities: we hope the new system will ensure its implementation. Health Committee: Evidence Ev w5 1. Sustrans Background 1.1 Sustrans is the UK’s leading sustainable transport charity. We deliver national programmes of practical intervention which promote regular walking and cycling and the use of public transport. These programmes raise physical activity levels and improve public health, reduce climate change emissions, improve road safety and enhance wider quality of life. 1.2 Our comments are therefore restricted to the commissioning of public health and health promotion work, in the field of physical activity or active living. 1.3 The significance of active travel—walking and cycling for daily travel purposes—is clearly evidenced in the mainstream of public health policy and evidence review. We base our strategies and project design particularly on “At Least Five a Week”,4 the “Foresight Tackling Obesities”5 report, guidance from the National Institute for Health and Clinical Excellence (NICE) such as “Physical activity and the environment”6 and “Prevention of cardiovascular disease”7 and our own, published, evidence review.8 1.4 Work that we have done for the Department for Transport (DfT) on the English Sustainable Travel Demonstration Towns programme quantified a large potential for change from sedentary to active ways of travelling. In the three demonstration towns (Darlington, Peterborough and Worcester) almost 50% of local car trips could have been made by at least one other, more active and sustainable, mode of transport: in many cases, the only obstacle to such a change was lack of information.9 1.5 Sustrans’ programmes have a significant impact on public health:10 — the National Cycle Network carried 407 million walking and cycling trips in 2009, with over two thirds of users reporting increased activity levels thanks to their local routes; — our Bike It programme doubled regular cycling to school, and has now worked with over 400,000 children; — TravelSmart has worked with over 250,000 households, providing travel information and support and consistently achieving shifts of between 10% and 15% of car trips to walking, cycling and public transport; and — we lead the Travel Actively consortium—all of the national walking and cycling groups jointly delivering 50 projects across England, with a target to get 1.8 million people more active through walking and cycling. 1.6 A number of Sustrans’ local projects are delivered in partnership with National Health Service (NHS) bodies, particularly Primary Care Trusts (PCTs), commissioned as part of the PCT public health function; uncertainty and disruption during the transition of public health functions from the NHS to local authorities and the Public Health Service will put many of these proven, effective local projects at risk. 1.7 We also contribute to the development of policy (for example, working with the Department of Health (DH) on two of its Coalition for Better Health leadership groups), guidance (eg work on NICE guidance development groups) and capacity (founder member and board of the Physical Activity Alliance; co-founder of the Take action on active travel alliance). In this we collaborate with most of the national public health organisations, including the Association of Directors of Public Health, British Heart Foundation, Faculty of Public Health, National Heart Forum, Royal Society for Public Health, UK Public Health Association and many others. 2. New Approaches to Commissioning Health Promotion 2.1 Sustrans has studied the “Equity and excellence: Liberating the NHS” white paper and taken soundings from our professional public health partners. We consider that the planned reorganisation of public health has the potential to improve the planning and delivery of health promotion in its widest sense, disease prevention and general public wellbeing. However, we also see real risks. 2.2 We are particularly concerned that the process of transition should not create funding discontinuities for proven local projects. 2.3 Local projects of community engagement to promote healthy living, such as Bike It (see 1.5 above) are effective over a period of engagement: they take time to become established and win the trust of the people at need, and so they cannot be turned on and off. If funding is withdrawn even for a short time, the project ends and the community relationships are lost: a restart will then require reconstruction of the project from the ground up. 4 5 6 7 8 9 10 Department of Health, 2004 At least five a week. Evidence on the impact of physical activity and its relationship to health. A Report from the Chief Medical Officer. Government Office for Science, 2007 Foresight Tackling Obesities: Future Choices project report. National Institute for Health and Clinical Excellence, 2008 Promoting and creating built or natural environments that encourage and support physical activity. National Institute for Health and Clinical Excellence, 2010 Prevention of cardiovascular disease. Sustrans Active Travel information sheets at http://www.sustrans.org.uk/what-we-do/active-travel/active-travel-publications Sustrans, 2005 Travel Behaviour Research Baseline Survey 2004: Sustainable Travel Demonstration Towns. Sustrans, 2010 (currently in print) Sustrans monitoring report 2009. Ev w6 Health Committee: Evidence 2.4 In our opinion, existing commissioning systems and structures within today’s NHS are (understandably) focused on the commissioning of traditional healthcare services—medical, surgical and so on, and so are not the best for commissioning health promotion or disease prevention services. It will be important that the new public health systems and structures are designed specifically for purpose. 2.5 We have concerns about the DH guidance on physical activity commissioning “Let’s Get Moving”. Sustrans has over time provided detailed information to the Department about the measured impacts of proven walking and cycling programmes, such as those mentioned at 1.5 above. We were disappointed to see that “Let’s Get Moving” referenced instead two unproven interventions in this field, neither of which could bring evidence of impact. 2.6 We feel it is of great importance that future official commissioning guidance should be firmly based in evidence of effectiveness, and that only proven interventions should be cited as good practice by the DH. 3. Public Health Commissioning Integrated within Local Authorities 3.1 We note potential benefits from the incorporation of public health into local authorities. The local authority culture seems less evidence based than is the norm in health, which may explain why transport funds have historically often been invested into local road expansion projects whose benefit to cost ratio forecasts do not meet DfT ‘good value’ standards. We hope that public health professionals may bring more evidence-based commissioning practice into the local authorities. 3.2 We would like to stress the importance of environmental interventions, making the environment more supportive of healthy lifestyle choices, to support the social marketing and behavioural interventions delivered by public health professionals. In the case of physical activity, it is clear that walking and cycling for daily trips represent an accessible and practical way for many inactive people to increase their physical activity levels. The form of the built environment is an important factor in determining their ability to choose walking or cycling when considering the choices available for any particular trip.11 3.3 The move of public health commissioning into local authorities offers an opportunity for improved practice, with cross-disciplinary partnerships between health promotion specialists and those in transport, planning and regeneration. This would facilitate the integrated application of environmental change (such as city-wide traffic speed reduction or pedestrian improvements) and behaviour change approaches. 3.4 Local authority departments investing capital in the built environment, such as through the Local Transport Plan funding allocation, could share objectives and investment planning priorities with the public health team investing revenue funds into the commissioning of local behaviour change interventions. 3.5 In our view, this opportunity is of central importance. The scoping and establishment of local public health commissioning systems, and their support from the new Public Health Service, should explicitly direct public health professionals to collaborate with their transport and planning and regeneration peers within the local authority, to establish joint “healthy living” objectives and to create investment plans which integrate the revenue and the capital investment, so that “soft” behavioural and “hard” environmental measures jointly promote healthy living. 3.6 We therefore also consider that the Department for Communities and Local Government (CLG) and DfT should be asked to issue guidance through their own systems, encouraging the transport and planning and regeneration teams actively to seek partnership and shared delivery with public health. 3.7 We do not wish to speculate on the performance management regimes which may be established for public health in the forthcoming White Paper, but we hope that local Directors of Public Health (DsPH) and their local authorities will be assessed on the extent to which the DPH is able to influence local development and transport plans and strategies. 3.8 We draw the Committee’s attention to the fact that much NICE public health guidance is targeted on local authorities. For example, the “Physical activity and the environment” guidance is overwhelming addressed to planners, transport strategists, developers etc. We hope the new system will ensure the implementation of this body of guidance, by establishing the type of regime suggested above. 3.9 We are also interested in the eventual division of health promotion commissioning responsibility between local authority Directors of Public Health and GP consortia. GPs may well wish to commission “exercise on prescription” type interventions, and this would not be illogical. However, it is likely that the GP consortia will have commissioning expertise in traditional healthcare services but less so in healthy lifestyle interventions. If GP consortia are likely to commission services of this kind, they should be well trained in public health evidence, NICE public health guidance, and the practicalities of this type of programme. August 2010 11 National Institute for Health and Clinical Excellence, 2008 Promoting and creating built or natural environments that encourage and support physical activity. Health Committee: Evidence Ev w7 Written evidence from Mary E Hoult (COM 05) I am submitting this from a patient/carer perspective and welcome this new commissioning enquiry. I do not belong to any organisation involved in the delivery of health care. I have done so in the past and still show a keen interest in health policy. I have been a regular attender at many local health economy board meetings. I feel that this experience has given me the ability to make some relevant observations and to ask some pertinent questions. Taken from your list of where you want the main focus of enquiry to be, re commissioning, I aim to address these themes: — clinical engagement in commissioning; — accountability for commissioning decisions; — integration of health and social care; and — resource allocation. Overarching all of these themes is, I believe the patient’s voice. Governments pay lip service to this initiative, but true patient involvement remains light years away. Vulnerable groups, such as the ones discussed in my submission below often find it even harder to have a voice. The NHS must be the best example of how not to listen to its customers, users, clients or whatever is today’s preferred collective noun. I have many concerns over the future of health care delivery. Most of these concerns are as a result of how it has been delivered historically here in Leeds. I am in broad agreement that good commissioning is the key to good health care, both from the patient and state perspective. The trick will be to ensure confidence in the commissioning ability of whatever structure is in place. To illustrate my concerns I have chosen to concentrate on eye care in its various forms. Age related health problems such as cataracts and macular degeneration are just two examples. How can we bring alive the NHS Constitution for blind and partially sighted patients? We are an aging population and this is a growth area that we all might have to use sometime during our lifetime. It is therefore essential that there is transparency in the Commissioning process and that relevant information is available to those that need it, when they need it. World Class commissioning has now been scrapped. It was complicated by Practice Based commissioning. It’s like being on a merry go round for patients. I know it is still early days but it is very unclear who will commission services for this group of patients. Will it be the NHS Board local authority/GP consortia? Are these patients being left behind in the rush to introduce savings? Significant gaps in the provision of eye care services have been identified in our deprived area. The last eye care strategy published, appeared to quote figures that had already been exceeded, giving the impression services were being reduced. Yet we are told the NHS budget is ring fenced. East Leeds faces major challenges in terms of addressing the historic balance between community and hospital services. During 2009–10 our Strategic Health Authority received £1.9 million innovation funds in support of Health Ambitions and QUIPP. 254 applications were received and 15 successful. I have chosen two that relate to this group of patients as examples. 1. Bradford and Airedale established a pilot service in the community for newly diagnosed people with visual impairment, counselling these patients and accessing the infrastructures that currently exist within the community to make the transition to living with a visual impairment. 2. RNIB was also successful and is developing integrated eye care pathways for people with learning difficulties called Bridge to Vision. This bridges the gap between Health & Social Care. These are first good steps for a very small outlay but are they enough to protect/ support these vulnerable patients who may continue to need both secondary and community/social care? Previously social workers were allocated to this group to provide advice and support and worked under an accountability protocol. Rapid access to low vision aids & support is a huge concern as is the lack of rehabilitation officers. Access is another area that presents difficulties. The Choose & Book system is a good example. Providers have to make slot availability in advance(slot plotting). Prior to C&B hospitals were able to react to demand by flexing their capacity in response to that demand to ensure fair play. Now it’s down to individual commissioners and robust contract management which has resulted in large follow up backlogs especially for ophthalmology outpatients. Has the detailed understanding of the needs of this group of patients, to avoid unwarranted variations in practice and outcomes, been addressed? Leeds City Council have recently been quoted as saying that “we only issue the documents, it is not our job to provide large print, videos or Braille”. And this to produce tender documents for services for blind/partially sighted users. The consortia for my area of East Leeds was established in 2007 and is led by the Ex Chief Executive of the previously disbanded Leeds West PCT. They were responsible for the redesign of hospital services. He was also seconded as Chief Executive for the Lift Co until 2006. So is very experienced in the local health Ev w8 Health Committee: Evidence community. How has this consortia faired during the last three years? How will they fair if the support of the local Leeds PCT is withdrawn? Following their progress to date might just answer some of the questions the enquiry board want answers for. To conclude, there has been so much change since 2006. We’ve seen four Chief Executives at a Strategic Health Authority level and at least three at PCT level with a lot of interplay between. It is very hard to tell just who has been in control and patients are confused. IT informatics systems are poor so it is hoped the infrastructure is there to support further change. Were the health inequalities targets met for ophthalmology patients for 2010? I hope this new enquiry will go some way to answer at least some of these questions. August 2010 Written evidence from the National Kidney Federation (COM 06) 1. The National Kidney Federation UK Charity (No1106735) is a Federation of 70 Kidney Patient Association representing the interests of all renal patients across the UK. The NKF has been associated with the specialised services commissioning of renal services since Regional Specialised Services Commissioning Groups were first setup in 1999. In that time we have represented our patient’s interests as members of the regional/local commissioning groups and renal services strategy groups (later renal networks) throughout the country. We welcome the opportunity to contribute to a consultation on a subject that can have such a direct affect on long term condition patients and particularly the opportunity to highlight the exceptional effect changes such as those proposed can have on renal patient services provision. 2. The Carter review recognised that Primary Care Trusts (PCTs) were not collaborating effectively in the specialised services area to the potential detriment of people in need of specialised care. Despite some progress since the Carter reports with 10 SCGs now in existence and a revision of the National Definition Set. The extent of genuine, clinically aware collaborative commissioning in specialised services still varies widely nationally and, in many parts of the country is very limited. 3. Although we can only comment on specialised services and in particular renal services, we would agree with many of your comments in the Health Select Committee report published on 30th March 2010, reviewing the progress of commissioning in the NHS. We particularly share the concerns regarding the problems PCT’s have in commissioning Specialised Services. There is still a desperate need for continuity and stability in both the structure and staffing if Specialised Services Commissioning is to deliver the high quality cost effective services renal patients need. 4. One comment in your report that clearly illustrates the reality of the problems that renal services and other specialised services are facing is: “Worryingly the evidence which we received indicates that many PCTs are still disengaged from specialised commissioning. Furthermore, there is a danger that the low priority many PCTs give to it will mean that funding for specialised commissioning will be disproportionately cut in the coming period of financial restraint”. With the transfer from PCT to GP consortium commissioning this position will not improve and could worsen. Localism is an important principle but it has its limitations. Local people need specialised services but they cannot be effectively funded and provided at a local level. The appropriate commissioning tier should receive its funds direct and be held to account for their use. 5. In spite of the problems, a key factor in gaining the renal services improvements we have achieved to date was the forming of renal networks throughout the country. They are made up of all stakeholders including Patients, Clinicians, PCT representatives, specialised services commissioners etc. In general terms they develop the forward strategy, identify health needs, demand models, projections, budgets and delivery plans in close cooperation with regional specialised services commissioners. 6. We welcome the establishment of an independent dedicated NHS Commissioning Board and note that the Board will be given responsibility for national and regional specialised services, as defined by the Specialised Services National Definitions Set (third edition 2009). We also note however that the Liberating the NHS document clearly states that renal dialysis will be commissioned by the Board at the appropriate level? Our general comments are given later in this document but we must first address this point and state in the strongest terms possible, the need for the whole of renal services as defined in Specialised Renal Services (adult)—Definition No 11 to remain in specialised services and be commissioned by the Board as a specialised service on a regional basis. Health Committee: Evidence Ev w9 7. In answer to the question raise in the Liberating the NHS document: Are there any services currently commissioned as regional specialised services that could potentially be commissioned in the future by GP consortia? On behalf of our renal patient members we can only repeat the answer we gave in 2008 when asked a similar question by the National Specialised Services Commissioning Group, National Definition Set review. 8. The National Kidney Federation could not support any proposal to remove any part of renal services from its specialised status as it would have a significant detrimental affect on the quality and standards of the treatment patients would receive and quickly return renal services to the “dark ages” with the postcode lotteries that existed at that time. The NKF statement and submission to the National Specialised Services Commissioning Group received quote (NSSCG) “overwhelming support from all sectors of the renal community”. There are many reasons why renal services should remain in specialised services: 9. Patient numbers are small and spread across the country (Circa 14,400 HD patients unit based and 4,265 PD home based). Many of the specialist renal units look after small numbers of patient (40 to 150). At the same time however the costs involved in delivering renal replacement therapy are high. 10. Very few PCTs even with the recent reduction in number would have renal patients within there compass of care. Of those that do the renal patient numbers are small and have very low visibility in general PCT considerations. Although the inclusion of early detection of Chronic Kidney Disease in the QOF has raised GP awareness of kidney disease in the scheme of things only a small number of GPs will ever see or have experience of renal patients. 11. When patients reach Established Renal Failure (their kidneys fail) they will need dialysis. Without this treatment or a transplant they will die. A patient’s dialysis treatment unlike other disease areas requires four to six hour sessions three days every week perhaps for the lifetime of the patient. Treatment capacities requirements are therefore treble that of a normal treatment. Even with renal dialysis units operating three shifts six days a week most units are now at capacity. 12. Renal services should not be split into specialised and non specialised services. There is a need to work closely with the General Nephrology Services as patients in their lifetime will change modality during their treatment, they may have a transplant (sometimes more than one) returning to dialysis each time a transplant fails. The planning for such movement is enhanced by ensuring that all components of the service for renal patients is planned and resourced on a regional basis. 13. Patients often have more than one co-morbidity, diabetes and coronary heart problems being the most common. Treatment of renal failure requires a multi discipline team of many specialised consultants and nurses supported by specialist laboratory and research facilities. The skills required to provide these services efficiently and cost effectively therefore need to be centralised in specialised renal units. In the past individual PCT’s could not cover these requirements effectively. 14. Specialised care for people with Acute Kidney Injury in renal high dependency beds also requires centralisation to achieve the optimum outcomes for such critically ill patients. We feel that it would be unwise to separate out the specialised commissioning arrangements for ESRF, Acute Renal Services, General Nephrology and Transplantation due to the extensive overlap in relation to the resources used to provide these services. 15. In the past PCT’s have had problems understanding the “open ended” long term nature of renal treatment. It does not comply with the norm of detect—diagnose—treat—cure and discharge. The patients are few and the costs high both in terms of treatment and facilities cost. 16. With the transfer from PCT to GP consortium commissioning the PCTs will focus on supporting the establishment of GP consortia. The danger then is that their already inadequate commitment to specialised commissioning will wane with potentially damaging results for patients during the change over period. 17. Another factor to consider is the agreed implementation of the Payment by Results (PBR) national tariff in renal dialysis—non mandatory in 2011 but mandatory in 2012. This is the first critical step in the introduction of PBR in renal dialysis services. Early work is also underway on transplantation costing. 18. Due to the wide ranging costings that have existed nationally in dialysis this will be a difficult and critical changeover period for renal funding and commissioners. Combined with the changes in commissioning arrangements and the present NHS financial situation it is absolutely essential this PBR implementation is closely monitored and reviewed. Failure to do so could have serious funding consequences. 19. The Renal community has worked hard to provide a truly patient centred service that ensures the delivery of high-quality, clinically appropriate forms of treatment designed around individual needs and preferences’ of the patient. We have come a long way within the present specialised services arrangements but we still have a great deal more left to achieve. Decisions on the future of this service have a critical affect on the lives of the vulnerable patients concerned and we feel strongly that their needs should continue to be provided within specialised services. Ev w10 Health Committee: Evidence 20. The existing definition set Specialised Renal Services (adult)—Definition No 11 includes a by no means complete listing of some outstanding renal issues (home dialysis, end of life care etc). We would be happy to expand on this detail if required. August 2010 Written evidence from the Specialised Healthcare Alliance (COM 07) 1. The Specialised Healthcare Alliance (SHCA) is a coalition of 54 patient organisations supported by eight corporate members, which campaigns on behalf of people with rare and complex medical conditions for whom key services cannot be sensibly planned, procured and delivered at a local level. It is chaired by Baroness Pitkeathley. 2. The Alliance submitted written and oral evidence to the Health Select Committee’s inquiry into commissioning before the General Election in May 2010. Our written evidence included a brief history of developments in specialised commissioning leading up to and following the Carter Report of 2006. This submission concentrates on the continuing weaknesses we identified and whether the coalition government’s White Paper addresses them effectively in the context of some of the questions posed by the new Committee. Executive Summary 3. The White Paper holds out the prospect of addressing the major weaknesses in regional specialised commissioning identified in the Health Select Committee’s last report. Crucial detail, however, remains to be elaborated. 4. The scope of the NHS Commissioning Board’s remit for specialised services needs to be clearly defined. In the Alliance’s view, the only credible basis for doing so is the current edition of the Specialised Services National Definitions Set. This should be in its entirety, though subject to regular revision. 5. Similarly, the Board’s regional structure needs to be clarified and sufficiently extensive to sustain effective engagement with the NHS at local level, eg to ensure that referrals management is consistent with more timely diagnosis of rare and complex conditions. The Alliance recommends a minimum of eight offices. This would also make it easier to retain the best of the important expertise in the current Specialised Commissioning Groups (SCGs). 6. Urgent priority should be attached to costing patient pathways covered by the National Definitions Set to inform the budget required by the Board for specialised commissioning purposes from April 2012. A buffer fund may be required to accommodate likely inaccuracies in the sums retained by the Board or devolved to GP commissioning consortia, especially in the first years of the new arrangements. 7. In the meantime, PCTs are likely to become increasingly distracted by the move towards GP commissioning consortia. The NHS Commissioning Board should therefore assume early oversight of specialised services from April 2011, initially working through the existing SCGs. 8. The accountability of the Board for commissioning specialised services needs to be clearly defined with recourse for individuals and groups who feel they have been poorly served. These patients must also be enabled to play a role in the new Healthwatch arrangements. Current Position 9. Historically, specialised commissioning has often been overlooked in the initial development of policy despite accounting for an estimated 10% of NHS expenditure, affecting large numbers of highly vulnerable people. The attention given to it by the Health Select Committee and in the White Paper is therefore most welcome. 10. Our previous evidence expressed concern about stalled progress in implementing the fundamentally sound Carter reforms of specialised commissioning, stemming from the reluctance of Primary Care Trusts to pool sovereignty and resources. We suggested that this reluctance might grow as PCTs sought to protect local services in the downturn, to the detriment of clinically and cost effective specialised care. We also highlighted that as a pooled responsibility between PCTs, specialised commissioning sat in a limbo, where it was not properly regulated or performance managed. 11. In order to address these weaknesses, we suggested that regional Specialised Commissioning Groups should be re-located within SHAs and funded directly. We also proposed that nationally commissioned services should no longer be funded by top-slicing PCTs but directly, with performance management conducted by the DH. These suggestions found support from the previous Health Select Committee, while observing that there was some risk that they could lead to a lack of coordination and disruption in services more locally. 12. In its response to the last report on commissioning, the coalition government broadly accepted the deficiencies in current arrangements, pointing out that under the White Paper, all national and regional specialised services encompassed by the National Definitions Set would be the responsibility of the NHS Commissioning Board. The response expressed the view that this should “ensure that patients with rare Health Committee: Evidence Ev w11 conditions can be sure of high-quality and cost effective treatment and are treated equitably with people who have more common conditions. It will also help ensure more effective implementation of Sir David Carter’s 2007 (sic) review.” 13. At the national level, important changes have been introduced since the General Election, with a single Advisory Group on National Specialised Services providing advice to the Secretary of State on which services, products and technologies—usually for patient populations below 500—should be commissioned nationally. This advice will be developed on the basis of an ethical decision-making framework which, in the Alliance’s view, could act as the starting point for a more consistent, value-based approach to funding decisions in the wider NHS. 14. At the regional level, the current PCT-based arrangements remain in place with a significant risk of deterioration during the transition to the structures outlined in the White Paper. The White Paper and Specialised Services 15. The Specialised Healthcare Alliance agrees with the government that the White Paper’s proposal to place specialised commissioning with the NHS Commissioning Board has the potential to address the shortcomings identified in the Health Select Committee’s last report. Much important detail, however, remains to be agreed. In particular, early clarification is required in the following areas: (a) The number of regional offices and their role will be important in maintaining effective links between the NHS Commissioning Board and the wider NHS, especially if GP commissioning consortia are local in character. From a specialised commissioning perspective, we would see it as desirable to have no fewer than eight regional offices to reflect patient flows and the character and culture of different health economies. These offices should facilitate liaison to ensure the engagement and input of GP consortia and effective provision of those primary and community care services best commissioned at local level for people with specialised conditions; (b) While it makes sense for the NHS Commissioning Board to assume responsibility for assessing commissioning from the CQC where GP consortia are concerned, a third party needs to assess the Board’s performance for those services which it commissions. The DH would seem best suited to fulfil this role or, alternatively, it could remain with the CQC for those services commissioned by the Board; (c) As PCTs focus on supporting the establishment of GP consortia, the danger is that their already inadequate commitment to specialised commissioning will wane with potentially damaging results for patients. We would therefore advocate an early transfer of oversight to the NHS Commissioning Board, initially working through the existing regional Specialised Commissioning Groups and their constituent PCTs; (d) During this period a high priority should also be attached to costing the services covered by the National Definitions Set to enable accurate budgets to be set in 2012–13. The survey conducted by the SHCA in late 2009 for the Committee’s last inquiry found that the extent to which SCGs were commissioning the National Definitions Set was highly variable and in no case complete. The SCGs’ current levels of expenditure do not therefore represent the aggregate funds the NHS Commissioning Board will require for specialised commissioning purposes. These points are relevant to several of the key issues raised by the Committee. Others are covered below. Clinical Engagement in Commissioning 16. Clinical engagement in specialised commissioning is generally above average, with clinicians often appreciating the greater degree of knowledge which specialised commissioners possess. This situation should be strengthened as a result of the White Paper with the NHS Commissioning Board also being well placed to address unwarranted variations in clinical practice, providing scope for innovation is not squeezed out in the process. 17. The greater problem arguably arises in relation to GPs and referral. Late diagnosis is a major problem with rare conditions and has important ramifications for clinical outcomes. In a recent study, the King’s Fund observed that GP commissioners are likely to turn to referral management when they take responsibility for the bulk of the NHS commissioning budget. It will be important for the NHS Commissioning Board to ensure that referral management adopts an even-handed approach between over-, under- and mis-directed referral to protect and promote the interests of people needing speedy specialist assessment and care. 18. More generally, a range of approaches will be required to ensure the engagement of GPs and their consortia with specialised commissioning. In addition to the role of the regional offices in facilitating liaison (see above), consideration should be given to an extended range of clinical networks in key therapeutic areas, which might also engage local authorities where public health is a major upstream influence on downstream levels of disease. It is important to ensure that those with rare and complex conditions can access generalist services at the local level which meet their needs. Ev w12 Health Committee: Evidence How Open will the System be to New Entrants? 19. The White Paper gives Monitor the role of promoting competition and guarding against purchasers acting anti-competitively. A key tenet of the Carter Report on specialised commissioning is that specialised commissioners should be able to designate providers of specific specialised services using a robust, transparent process. 20. The Alliance supports the Carter Report’s view that designation of specialised providers helps to secure an appropriate concentration of clinical expertise and activity to safeguard patient access to highquality, cost-effective services located to maximise geographical convenience. It is important that Monitor’s terms of reference recognise the need for some curtailment of free competition in this area. Accountability for Commissioning Decisions 21. The proposed remit of HealthWatch is couched in almost entirely local terms. Specialist providers will usually be delivering services to patients from outside the local area and sometimes right across the country. It is important that HealthWatch makes provision to capture the views of such users to help inform specialised commissioning as well. HealthWatch England may be the most appropriate vehicle for doing so. 22. As touched on previously, the Specialised Healthcare Alliance also has concerns about the accountability of the NHS Commissioning Board for its commissioning performance (who will guard the guardians?). This needs to be to the Department and, through the Secretary of State, to Parliament. How will the New Arrangements Strengthen Commissioners against Provider Interests? 23. The establishment of a dedicated NHS Commissioning Board should itself help to re-balance the relationship between purchasing and provision, which is vital to the delivery of high-quality care and best value. This needs to include the status of commissioning, which has long trailed that of hospital management. The proposals for specialised commissioning, which concentrate resource and expertise through the Board, should be especially effective in delivering these results. 24. Similarly, the new arrangements should improve the position of people with rare and complex conditions who have historically been vulnerable to locally led commissioning. A heavy responsibility will however reside with the NHS Commissioning Board to protect the interests of everyone covered by the National Definitions Set and some form of recourse will be necessary for those who may be let down. How will the System Facilitate Service Reconfiguration? 25. Specialised services by definition cater for larger populations crossing local and regional boundaries, sometimes up to national level. The configuration of services is important in ensuring sufficient patient volumes to support clinical standards and safety on the one hand, while offering the best possible access on the other. 26. Current overview and scrutiny arrangements mean that proposals to re-configure national services need to be referred to local committees right across England, generating considerable cost and delay. The Alliance sees merit in the NHS Commissioning Board being able to consult on such proposals with the Secretary of State acting as final arbiter. October 2010 Written evidence from Mr G M Rigler (COM 08) Retired surveyor and project manager—currently an elected governor to an acute hospital NHS foundation trust—acting in a personal capacity, having obtained a “governor perspective on trust performance” in accordance with relevant statutory duties as defined by “Monitor”. A. Executive Summary 1. It is agreed that the commissioning processes within the NHS are inadequate. 2. The proposals being considered are unnecessarily draconian and involve too many avoidable risks. 3. Relevant evidence is not available and is needed to make sound decisions affecting the public health of the nation. B. Information 1. I am an active governor to a foundation hospital trust that consistently receives awards for the services it provides with staff numbers (when considered in whole time equivalents) that are not wildly different from other similar hospitals but the trust has moved from a substantial financial surplus to a substantial financial deficit within a year. 2. The financial situation (at “1” above) is considered to arise largely from the inadequacies of the “commissioning” processes involved. Health Committee: Evidence Ev w13 3. The inadequacies (of “2” above) appear to be already recognized by your committee but, for clarity in this memorandum, are considered to include too many people involved in negotiations, complicated systems and formulae, a need for relatively small provider trusts to take “insurance risks” for treating accidents in exceptionally bad weather and political interventions which adversely affect evolving attitudes and understandings of the many people involved. 4. The above inadequacies are not manageable at the moment since there is no practical means whereby the negotiating parties can seek sensible redress for past errors and/or misunderstandings : a factor that is exacerbated not only by the absence of any “governors” within the commissioning bodies who could provide the communication but also by the absence of any readily available audit reports upon the commissioning processes concerned. To this day, apart from the evidence I have received from the trust directorate (which may be considered biased, in their own cause) I am not absolutely sure that the trust negotiating team has ever gained the best possible deal for the benefit of the local population that I have been elected to represent. 5. The proposed changes do not appear to resolve the above difficulties and there is no evidence available to me to suggest otherwise. 6. The medical doctors that I know confirm my opinion that they already have a time consuming job and that the suggested move to require their active involvement in commissioning processes could easily affect their “gate keeping” duties in an adverse manner within our health care system—worsening the “GP lottery” that does affect access to specialist clinicians. 7. It is understood that affordable improvements to the general health of our nation is required and the evidence for success in the matter is derived from a working understanding of appropriate elements of certain statistics which become extremely esoteric and require a particularly expert understanding that is not readily available to the nation at large. It is not known whether the evidence exists to assure anyone that such skills can be multiplied to suit the requirements implied by the proposed changes to commissioning. In view of “6” above, it is not likely that general practitioners can (or should) be diverted into the detailed understandings of Public Health Statistics and associated methodologies. 8. The concentration upon the proposed enhanced role of the general practitioner diverts one from considering the need for specialist clinicians to contribute to the strategies for seeking improvements in public health. It is trusted that some means can be found to ensure that such a pool of invaluable advice and aspiration is harnessed into (certainly not excluded from) the commissioning processes. 9. There is no evidence available to me that the proposed revisions to commissioning processes represent good value-for-money at a time of financial stringency and at a time when public health is being stressed to the point of creating additional illnesses. 10. There is no evidence available to me that yet another change to the NHS (ie the commissioning restructuring) has been sensibly designed for implementation—rather the reverse, since redundancy expenditure (which could otherwise be avoided) is understood to be involved in the proposed re-structuring of the inadequate commissioning processes that do need to be improved without demoralizing existing statistically competent people and without disruption to the provider processes : processes which can ill afford diversion of resources from clinical services into the revised conduct and administration of fragmented negotiations with a plethora of inexpert (novice ?) commissioning bodies. 11. At a time of financial stringency, it is not considered acceptable that other public services (particularly the armed forces) should become aware that Parliament has allowed further changes to the health services that are not evidence based, risk poor value-for-money, risk the demoralisation of scarce people and appear to confuse “change” with the need for managing “desirable progress”. 12. There appears to be no evidence that the progress (at ‘11’ above) cannot be achieved by evolution in a reasonable time. C. Recommendations 1. Parliament should accept the need to follow the general medical practice of seeking to make decisions (about treatments) upon the basis of relevant evidence. 2. Relevant evidence should be sought (and publicised) about the various issues mentioned in Section B of this memorandum and tested for soundness before any proposals for changes to the NHS Constitution (ie “treatments”) are approved by Parliament for implementation to secure better public health for the nation. October 2010 Ev w14 Health Committee: Evidence Written evidence from the Royal College of Paediatrics and Child Health (COM 09) 1. The RCPCH welcomes the opportunity to respond to the Health Select Committee Commissioning Inquiry. As a professional body seeking to ensure the best outcomes for children, we want to highlight the particular implications for children and young people of commissioning, as the healthcare needs of children are different from the adult population. We have responded directly to the Department of Health consultation on their commissioning proposals, and our response has informed our submission to this inquiry. 2. We welcome the recognition that commissioning in the past has not always achieved the outcomes we would expect of a well developed health system and therefore support the need for reform. Furthermore we support the increased focus on clinician-led commissioning and the emphasis on shared decision-making across health professions. However we have concerns that the proposed arrangements of a National Commissioning Board and GP consortia will not ensure the development of integrated services that meet the needs of children and young people. 3. Given that less than a third of all GPs have had any specific paediatric experience during their professional training we have concerns that consortia will lack the necessary clinical skills to best commission services for children and young people. 4. High quality commissioning will require access to timely and relevant information to inform decisionmaking, however there is a considerable gap between what is available now and is needed. Given the problems with the National Programme for IT, there is considerable concern with regard to how the relevant information will be made available. 5. GP Consortia will have the freedom to decide which aspects of commissioning activity they undertake—it is not clear what happens to those services that they chose not to commission. What happens if commissioned funding and tariff are insufficient for provision of a quality service? There is a risk of a vicious spiral where inadequate funding reduces quality so a licence is revoked; who is then responsible for meeting the needs of the local population? 6. Further clarity is required on the future commissioning structure. Some services will require a more strategic view than can be offered by a GP consortia yet are not a specialised national service that might be overseen by the Commissioning Board. We would support the development of sub-national commissioning arrangements that enable either subgroups of the National Commissioning Board or clusters of GP consortia to collectively consider commissioning requirements. Clearly appropriate input from relevant specialists or services would be required depending on the service being commissioned. We could envisage services such as safeguarding, which require close working with local authorities to be commissioned by consortia clusters, whereas a subgroup of the National Commissioning Board would be well placed to consider commissioning of General Paediatric Surgery. 7. The idea of sub-national commissioning is pertinent for any service area that is best delivered through networks. For many aspects of children’s health services (such as neonatal services, general surgery), a network approach is seen as the most appropriate way in which to deliver a high quality and equitable service. There is almost no reference to of the role of networks or pathways of care. Furthermore there is no recognition of the significant potential benefits of integrated commissioning (between health and other sectors) when developing joined-up services that meet the needs of patients whose requirements extend beyond NHS services. This is particularly important for children and young people with long-term conditions whereby integrated care between health, social services and education is pivotal. 8. We perceive the role of the proposed Health and Wellbeing Boards to be crucial in terms of ensuring appropriate local engagement, scrutiny and governance of consortia. The NHS Commissioning Board is too far removed from service delivery to account for quality, and the future role of Care Quality Commission (CQC) is unclear in terms of whether they will only regulate for minimum standards. Therefore Health and Wellbeing Boards need to have an explicitly stated and statutory role in terms of holding consortia to account. We would also recommend that, in order to prevent increased fragmentation of care, that it be mandated that all children’s services should be jointly commissioned by the Health and Wellbeing Board and the GP Consortia. For this to work in practice, there should be an alignment of incentives across children’s education, social care and health services, perhaps via the use of a composite measure of child wellbeing. This proposal echoes those made in the recent Kennedy review, though we are not arguing for a single integrated provider. Rather, we are proposing mandated integrated commissioning. 9. The membership of NHS Commissioning Board is unclear, we would strongly recommend that there by appropriate representation for children and young people’s services. We hope you find this submission useful and we would be very happy to discuss any of these in further detail, if required. October 2010 Health Committee: Evidence Ev w15 Written evidence from the Family Planning Association (COM 10) 1. Executive Summary 1.1 FPA is one of the UK’s leading sexual health charities, with an 80 year history of providing the UK public with accurate sexual health information, advice and support services. 1.2 FPA represents a national voice on sexual health, working with and advocating for the public and professionals to ensure that high quality information and services are available for all who need them. 1.3 This submission is closely based on the response FPA submitted to the consultation on the Department of Health’s White Paper, Equity and Excellence: Liberating the NHS. 1.4 FPA is concerned that devolving commissioning of sexual health services to GP-led commissioning consortia may have adverse consequences for people’s sexual health and wellbeing. 1.5 We welcome the Government’s plans to publish a White Paper on Public Health in due course and we strongly recommend that sexual health services are an integral part of that White Paper. However, in the absence of the Public Health White Paper there remains a great deal of uncertainty around the provision of sexual health services in the current proposals for the reform of commissioning. 1.6 FPA is concerned GP-led commissioning consortia may not have the capacity or expertise to assess local sexual health needs accurately. In addition, people’s concerns about their confidentiality may deter them from approaching a sexual health service if they think their GP will be informed. 1.7 FPA is concerned that some GPs’ conscientious objections to some health services could have an impact on GP-led commissioning. 1.8 It is vital that holding commissioning consortia accountable for their stewardship of NHS resources does not lead to short-term decision-making which restricts services on the basis of cost but is ultimately more costly in the longer-term. 1.9 Local authorities’ involvement in public health services must be sufficiently resourced and must not lead to a separation between public health services and the NHS. 1.10 FPA anticipates that sexual health services will be commissioned through the Public Health Service, but if this is not the case they should be commissioned nationally to overcome the stigma and embarrassment that they still attract. 2. Clinical Engagement in Commissioning 2.1 FPA is concerned that devolving commissioning of sexual health services to GP-led commissioning consortia may have adverse consequences for people’s sexual health and wellbeing. 2.2 Sexual health is not something many people are willing to talk openly about, even if they have accessed sexual health services. Consequently it can be difficult to assess accurately the need for sexual health services in a local area, compared to the apparent demand for services. 2.3 FPA is concerned that GP-led commissioning consortia may not have the expertise or capacity to undertake the in-depth needs assessments required to commission appropriate sexual health services. 2.4 FPA is also concerned that the creation of GP-led commissioning may lead to confusion about GPs’ involvement in sexual health services and therefore deter people seeking the advice and help they need. FPA understands that not all GPs will be personally involved in the commissioning process. However, many people may believe that GP-led commissioning means their own GP will individually commission services on their behalf. If they do not want their GP to know about them accessing sexual health services this could deter them from coming forward. 2.5 FPA is concerned that some GPs have a conscientious objection to some sexual health services and this may affect commissioning decisions, resulting in people in a particular area being unable to access services. A survey conducted by Marie Stopes International in 2007 found that 20% of GPs described themselves as anti-abortion12 and some of these doctors exercise a conscientious objection and refuse to refer women for abortion services. If GPs were to exercise their conscientious objection by refusing to commission abortion services, women would be denied access to a service they need to maintain their health and wellbeing. 3. Accountability for Commissioning Decisions 3.1 FPA welcomes the proposals in Equity and Excellence: Liberating the NHS, that GP-led commissioning consortia will be held to account for their stewardship of NHS resources. As investment in contraception is cost-saving we would anticipate that this would lead to an improvement in the provision of contraception services. However, it is vital that this accountability does not deter long-term decision making or lead to services being restricted inappropriately. 12 Marie Stopes International, General practitioners: attitudes to abortion, 2007 (London: MSI, 2007). Ev w16 Health Committee: Evidence 3.2 Previous experience has shown that commissioners can be concerned about the upfront costs of treatment without considering the longer-term cost-effectiveness of them. For example, in the past, services have avoided providing long-acting reversible methods of contraception (LARC) because they were more expensive initially without recognising that LARC methods have been shown to be more cost effective than other methods of contraception even after one year of use. 3.3 Similarly, there is a risk that commissioning consortia could seek to restrict access to procedures such as abortion on the basis of cost which would inappropriately deny women access to services they need. It will be vital under the new arrangements to ensure that services are commissioned to meet identified local need and that services are commissioned cost-effectively rather than access simply being restricted or denied. 3.4 FPA has welcomed the proposals in Equity and Excellence: Liberating the NHS to publish assessments of commissioners’ performance so that they can be held to account for their use of public money. However, we are concerned that this may not be meaningful for many people. It is unclear as yet how the information will be published to enable people to make accurate comparisons and judgements about the value for money achieved, rather than simply which commissioner appears to have spent the most or the least. 4. What will be the Role of Local Authorities in Public Health and Commissioning Decisions? 4.1 FPA welcomes the proposals to create a national Public Health Service and the Government’s commitment to provide ring-fenced local public health budgets. FPA strongly recommends that all sexual health services are included in the Public Health Service because of both the financial benefits that can accrue from investment in sexual health services and the social benefits. 4.2 In addition, FPA welcomes the role of local authorities in the proposed Public Health Service. Many factors can affect people’s health and wellbeing not simply access to health services. Rates of teenage pregnancies are strongly associated with rates of deprivation but are also affected by educational attainment, good quality sex and relationships education and access to sexual health services. We believe local authorities should be well placed to provide leadership and co-ordination on all of these elements. 4.3 However, it will be important that there are sufficient resources for local authorities to invest in services and to develop the necessary expertise to assess local needs accurately. Public health can be complex precisely because so many factors can play a role; this requires a sophisticated response which it is not clear local authorities are currently in a position to deliver for sexual health. 4.4 There is a risk that the devolution of powers over public health to local authorities could lead to a separation between public health and delivering health services to people who are ill. Health services play a significant role in both primary and secondary prevention and it is therefore vital that they continue to be involved in public health. FPA would be keen to see the responsibilities of both the GP-led commissioning consortia and local authorities include specific reference to public health and prevention to provide greater clarity. 5. Specialist Services 5.1 There are some elements of sexual health service provision, for example public information and prevention work, which will benefit from economies of scale and where national commissioning would be of significant benefit. 5.2 For example, FPA currently provides the sexual health direct service on behalf of the Department of Health. This includes the provision of expert information services including: a telephone helpline; a web enquiry service; a sexual health clinic finder search facility; a library service for professionals; and a comprehensive specialist website as well as the development and review of over 30 different booklets on all aspects of sexual health which are disseminated to every general practice and sexual health clinic in England and which are considered to be the gold standard in sexual health information. 5.3 It would not be possible for GP-led commissioning consortia to develop and deliver these services individually to the same standard or as cost-effectively given the levels of quality assurance and consumer testing that is required. 5.4 Similarly, some elements of sexual health services are only required for a relatively small number of people and consequently would also benefit from a national approach to commissioning. For example, very few abortions take place at later gestations and the GP-led commissioning consortia are therefore unlikely to have significant experience of commissioning them. However, for women who need these services, swift access is paramount and clear pathways have to be in place to ensure that this is the case. Health Committee: Evidence Ev w17 5.5 FPA anticipates that all sexual and reproductive health and HIV services, including the provision of information, will be commissioned through the proposed Public Health Service. However, if this is not the case, we would like to see these services commissioned nationally because the stigma that continues to surround sexual health services risks deterring people from being open about the services they need and consequently there is a danger that services will not be commissioned and people’s sexual health and wellbeing will be adversely affected. October 2010 Written evidence from Mencap (COM 11) About the Organisation Mencap is the voice of learning disability. Everything we do is about valuing and supporting people with a learning disability, and their families and carers. We work with people with a learning disability across England, Northern Ireland and Wales. All our services support people to live life as they choose. Our work includes: — providing high-quality, flexible services in things like housing, employment, education and personal support that allow people to live as independently as possible in a place they choose; — providing advice through our help-line and website; and — campaigning for the changes that people with a learning disability want. We work with people with a learning disability of all ages. All our services are tailored to the individual so we can provide support throughout their life, ranging from support for a child at each stage of their as they grow up, through adulthood and into old age. Thank you for the chance to input to your inquiry. In the NHS White Paper two key themes stand out as directly relevant to ensuring the lives of people with a learning disability are equally valued—reducing avoidable, premature death and tackling persistent health inequalities. Despite valiant efforts by some individual healthcare professionals (and good progress by the Department of Health) serious health inequalities still remain for the 1.5 million people with a learning disability in the UK. The true impact of health inequalities is best characterised by the fact that, over the past three years (since 2007) over 70 families have contacted Mencap following the avoidable deaths of valued and loved relatives with a learning disability while in NHS care. Mencap is continuing to support a number of families through both the NHS complaints process and the courts, through our Death by Indifference campaign. We are also pushing for nationwide recognition by healthcare professionals of the need to make reasonable adjustments when delivering healthcare. Commissioning is crucial if the ambitions set out in the NHS White Paper are to be realised. Key Points 1. Looking back at the history of the provision of healthcare for people with a learning disability, Mencap agrees with the Select Committee’s findings that PCTs have not always worked well. 2. People with a learning disability still experience worse healthcare and get worse outcomes than the general population. People with a learning disability are at disproportionate risk of premature death, epilepsy and mental health problems. 3. Raising our Sights,13 a recent report (commissioned by the Department of Health) showed that for patients with the most complex needs joined up planning is essential if people are to live longer and healthier lives. This joined up planning needs to span both health and social care. 4. Raising our Sights made 33 individual recommendations but as yet this report has received no official response from the Department of Health; Mencap looks forward to hearing how the Department plans to implement these recommendations and Mencap would welcome any help the Committee could give in achieving a response from the Department to Raising our Sights. 5. As outlined in the NHS white paper, Mencap is pleased to see the government’s commitment to the pilot of personal budgets. Mencap believes that personal budgets lead to greater choice and control for people with a learning disability with the most complex needs (and their families) and would like to see these rolled out across the country. In times of constrained finances, unfortunately personal budgets may be seen to be an easy target for cost cutting by local authorities and ultimately by GP consortia—Mencap believes this must be vigorously resisted or the lives of some of the most profoundly ill people in the country will be put at risk. 13 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH 114346 Ev w18 Health Committee: Evidence 6. Given the changes planned to commissioning, Mencap believes that there is a real risk of fragmentation and the possibility of a triple discrimination. A triple discrimination could occur if GPs fail to make reasonable adjustments in their work (recent Mencap polling showed that GPs did not feel they had enough training to reasonably adjust their services for patients with a learning disability).14 This could then be compounded as patients with a learning disability go into hospital—where there lives have often not been properly valued. If commissioning is then done by consortia of GP, without the right training, people with a learning disability may not be fully considered when designing services. 7. Mencap believes that GP Commissioners and the NHS Commissioning Board need to be given explicit guidance from the outset as to the importance, in all clinical specialties, of making reasonable adjustments to include people with a learning disability. 8. Reasonable adjustments have a clear basis in law (Disability Discrimination Act, Equality Act and are implicitly backed up by the Human Rights Act). 9. Making reasonable adjustments makes good clinical sense for healthcare professionals, particularly given the increasing tendency towards payment by results, which should incentivise professionals to deliver the right healthcare first time. 10. Mencap believes that within the proposed changes to NHS, a key reasonable adjustment should be continuation of the Annual Health Check. The Annual Health Check is offered to people with a learning disability known to services and is a sort of health MOT. The Annual Health Check is offered by some GPs (after training by people with a learning disability). The Annual Health Check is currently funded under a DES (Direct Enhanced Scheme) payment—due to end in 2011. 11. Evidence from Australia has shown that, the use of a health check with people with a learning disability led to a 6.6-fold increase in detection of vision impairment,15 inter alia. The use of annual health checks has also been reported to deliver positive gains in health outcomes over a 12-month period.16 While in England17 41% of those eligible had a health check –this has meant that nearly 6/10 people are not getting a service that could be extremely helpful in realising the preventative health agenda. 12. Mencap would like to see the annual health check continue ideally as a universal provision as part of the renegotiated standard GP contract. Mencap would value any input the Select Committee could give in questioning those involved in Commissioning Services as to how they plan to continue to tackle health inequalities for people with a learning disability, through primary and secondary care—including the continuation of the annual health check. Case Study on Annual Health Checks Dr Muna Al-Hashimi, Practice Manager to Dr Haider, St John’s Therapy Centre “Our Practice started doing annual health checks for people with a learning disability in September 2009. As a practice we code all patients who have moderate to severe LD on a register, liaising closely with relevant agencies such as Social Services, Educational Support Services and Secondary Care. We ensure that annual Health Checks are offered to all patients with severe to moderate LD who are aged 18 or over. These checks include: — Physical examination. — Reviewing the behaviour and mental health of the individual. — Identifying any health promotion issues. — Chronic disease review. — Epilepsy review if applicable. — Specific Syndrome Check. — Medication review. — Review Patient Health Care Plan. — With patient consent, we aim to involve a patient’s carers and support workers”. 13. Mencap understand that one of the key roles of the Secretary of State, as outlined in the NHS White Paper, will be defining the overall Quality Outcomes Framework. Mencap welcome the framework and believe that it will be key to mainstreaming improvements in healthcare for all patients (including those with a learning disability). 14 15 16 17 http://www.mencap.org.uk/news.asp?id%14983&pageno%2&year%&menuId%90 http://ije.oxfordjournals.org/cgi/content/full/36/1/139 Cooper S A, Morrison J, Melville C, Finlayson J, Allan A, et al (2006) Improving the health of people with intellectual disability : outcome of the health screening programme after one year. Journal of Intellectual Disability Research 50, p 667–77. http://www.improvinghealthandlives.org.uk/numbers/checks/ Health Committee: Evidence Ev w19 14. If the government is to truly realise true choice for all patients (including those with a learning disability) Mencap believes that all NHS datasets (and outcome data) must have, as an urgent priority an LD marker attached. This would allow commissioners to see, eg, the number of patients with a learning disability dying from different causes, year on year 15. The outcomes framework should also be seen in the context of the existing Public Health Observatory and Confidential Inquiry into the deaths of people with a learning disability, recently awarded by the DH, following competitive tenders. The Inquiry and Observatory work in tandem to review the reason for deaths and also to understand how amenable to public health interventions these deaths could be. Mencap campaigned hard for the establishment of both and want to see these continued beyond the 1yr break clause—coming in 2011. October 2010 Written evidence from Londonwide LMCs (COM 12) 1. Introduction Londonwide LMCs is the umbrella body for statutory Local Medical Committees (LMCs) across the capital, representing 6,500 GPs, 3,000 practice nurses and over 1,300 practices across 26 (of the current 31) PCT boundaries. The remaining five PCT areas are served by LMCs outside Londonwide LMCs jurisdiction but who often work in collaboration with ourselves. 2. Summary and Main Points 2.1 Londonwide LMCs is supportive of a new approach to commissioning if it improves services for patients/carers; empowers GPs and practice staff to deliver sustainable services based on local population needs; and is properly resourced, managed and implemented to achieve the aspirations set out in the White Paper. 2.2 To date, where practice based commissioning has worked due to strong local GP leadership, constituent practices have responded energetically and enthusiastically. 2.3 Between 80%–90% of patient interaction with the NHS occurs at primary care level (GP practices and community services). 2.4 London’s unique population profile requires further attention on a number of points: 2.4.1 The 1991 census population figures are inaccurate as many people ordinarily resident in London did not register. 2.4.2 London has a very high population turnover—for many inner city practices the turnover rate is 30%. This creates significant difficulties in stabilising patients with long-term conditions. 2.4.3 A very high proportion of London’s patients are new/first arrivals in the UK. Many of these do not know how to access NHS services appropriately. Many are from countries with less welldeveloped healthcare systems, particularly in terms of screening and the systematic management of long-term conditions. As a result, there is often a much heavier workload as conditions are either diagnosed or adequately managed for the first time. It is also worth noting London receives 1million daily visitors, some of whom will be accessing primary and/ or secondary care services. Plus, the high number of economic migrants who initially arrive in London, access the capital’s health services, and then move on to other parts of the UK. 2.4.4 London has a very high proportion of patients who do not speak English as a first language. This has consequences—in terms of the direct provision of care by GPs and in terms of the patient’s ability to self-care—as patients may not access all the self-care resources available for which speaking/reading English is a prerequisite. 2.4.5 London has a very high BME population and many suffer ill-health. 2.4.6 London has an unknown but very large population of undocumented migrants—it is local GPs and hospital A&E departments providing care to this hidden and hard-to-identify sector of the population. 2.4.7 London’s significant health inequalities, as documented by Lord Darzi’s example of one year life expectancy lost for every tube stop as one moves eastward on the Jubilee Line. 2.5 Commissioning budgets and resources will need to be properly constructed to allow local commissioning plans to succeed and address impacts around: the ageing population/increases in chronic long term conditions; high deprivation levels (London has 11 of the 70 areas in England that are in the most deprived areas); plus the broad range of socio-economic factors around health, housing, unemployment, transport etc—all of which need to be looked at in conjunction with any health service planning. Ev w20 Health Committee: Evidence 2.6 For commissioning to truly work, any consortia must not be saddled with historical PCT debt. General practice and all those involved in wishing to make commissioning work, must not be made into scapegoats for the failings of previous administrations. 2.7 The inadequate premises and infrastructure gaps across the capital will require serious investment if the White Paper’s aspirations around commissioning locally integrated health and social care services are to be met with more care shifted out of hospital settings into community ones. 2.8 London has a high number of teaching and specialist hospitals. Whilst they bring huge reputational benefits to the city, they are costly—how will these and locally based community services be funded during these difficult economic times? 2.9 Possible predatory activity by—some Foundation Trust hospitals—could their size/influence seriously damage the effectiveness of local health and social care commissioning? 2.10 The politics need to be taken out of local health and social care commissioning decisions—clinical decisions need to be based and funded on clinical need. 3. Conclusion General practice is the gateway for primary care and historically has been forced to operate in a highly bureaucratic manner. The bureaucracy of multiple layers of decision making (31 PCTs across the capital) has reduced the effectiveness and efficiency of healthcare decision making and funding in the patient’s interest. The true cost of providing healthcare for London’s diverse population based on accurate population figures requires serious consideration and action. Each of the issues identified in this paper must be addressed for the sake of patients, carers and the thousands of hardworking and committed NHS staff across the capital if the new era of commissioning is going to succeed. October 2010 Written evidence from City of London LINk (COM 13) Summary — The City of London LINk opposes the abolition of Primary Care Trusts, on the grounds of: loss of expertise; costs of restructuring in a time of financial restraint; need to maintain existing local knowledge in commissioning services; threat to opportunities for individual service-user representation. — Reforms will lead to the break-up of the NHS and privatisation of services, undermining the aim of putting the patient first. — Measures intended to strengthen scrutiny will lead to conflicts of interest; compromised relationships and weaker scrutiny functions. — The City of London LINk questions the democratic mandate for pushing through reforms and the limited nature of consultation. — Capacity and capability issues exist around new responsibilities for Local Authorities, Health Watch and GP Consortia. Clinical Engagement in Commissioning 1. With overwhelming reforms proposed, concerns exist that GPs are not currently in a position to take over an extensive new remit. The expertise and knowledge built up by Primary Care Trusts risk being lost. 2. The size of GP groupings threatens the ability to commission services according to local needs and cultures. It will be vital to protect the concerns of smaller areas, such as the City of London, against the needs of larger neighbouring populations. The influence of local GPs, service-user representatives and Local Authority officers will be greatly reduced. 3. The proposals will lead to the break-up and privatisation of the health service. Private companies have a legal duty to shareholders, over the needs of patients. There are also many examples of private companies failing, for example, the recent collapse of Camidoc’s Out-of-Hours Service in Central/North London. 4. Duty of Care to patients could be compromised by financial concerns as GPs take responsibility for commissioning budgets. Accountability for Commissioning Decisions 5. With the closure of Primary Care Trusts, opportunities for patient involvement will be greatly reduced. If local Health Watch remains the only channel for service-user involvement, it will fall to elected representatives to provide community feedback, removing the voice of individuals and unelected special interest groups, such as Forensic Mental Health groups. The influence of existing patient groups and networks will be challenged. Health Committee: Evidence Ev w21 6. Measures need to be put in place to protect the GP-patient relationship if service-users involved with Health Watch are to scrutinise commissioning GPs. 7. It is unclear how local Health Watch will support additional functions, such as providing an advocacy service. With these services commissioned by the Local Authority, Health Watch will not be seen as an independent voice for service-users. There will also be a conflict of interest with Health Watch’s role in monitoring and scrutinising the Local Authority. 8. The proposals rely heavily on the willingness of volunteers to undertake Health Watch roles, with high levels of responsibility and heavy meeting attendance commitments. Concerns exist that resources will not be put in place to support volunteer involvement and that levels of interest/uptake may not be adequate. 9. The merging of Health and Wellbeing Boards and Scrutiny Committees will create a conflict of interests, where responsibility is held for both the commissioning and scrutiny of services. It will be vital that service-users and local Health Watch are represented on boards. 10. To avoid further conflicts of interest, Health Watch England would be better placed to monitor local Health Watch, rather than the commissioning Local Authority. Attention needs to be given to scrutiny arrangements for Health Watch England. 11. Health Watch will require greater powers to provide effective monitoring and scrutiny. 12. Access to information required for effective monitoring will be restricted as trusts move towards Foundation status and services are privatised. Integration of Health and Social Care 13. The ability of Local Authorities to undertake Public Health commissioning should be investigated, particularly where prior experience may not exist in smaller authorities, such as the City of London. The combining of roles could lead to the loss of expertise. 14. The new remit for GPs will weaken commissioners against provider interests. Transitional Arrangements 15. There is grave concern over continuity of work as LINk contracts come to an end in March 2011. It is vital that local developments and knowledge are protected in the interim period before Health Watch is established in 2012. 16. The continual transformation of service-user involvement channels, from Community Health Councils, Patient and Public Involvement forums, LINks and the proposed Health Watch, does not allow time for programmes to become well established and risks generating “involvement fatigue” amongst the target audience. Resource Allocation 17. As budgets are pooled over large areas, there is a potential for the needs of smaller populations, such as the City of London, to be overlooked. Economies of scale will dictate services are located in more densely populated areas. 18. A holistic approach to resource allocation is required in specific areas such as the City of London, which hosts a small residential population and vast numbers of commuters, all potential users of services, with differing needs. 19. A transparent system for back-charging between areas is required if commuters are to be allowed to access GP and other services in the City of London. October 2010 Written evidence from the Independent Mental Health Services Alliance (COM 14) About IMHSA The Independent Mental Health Services Alliance (IMHSA) is a group of nine leading independent providers of mental health services, including Ansel Group, Care UK, Castlebeck, Craegmoor, Cygnet, Partnerships in Care, Pastoral Care, St Andrew’s Healthcare and The Retreat at York. Collectively, we run more than 500 settings across the country delivering a wide range of high-quality services to adults with mental health problems. Our aim is to improve outcomes for people with mental health needs. We plan to meet this aim by constructively informing central and local government policy that relates to our work, through positive dialogue with policymakers. We also work collectively as a sector in understanding developments in government policy and in discovering how our services might adapt to meet the requirements of policy changes. Ev w22 Health Committee: Evidence Summary of Response — There should be a coalition between commissioners, providers and users with a focus on collaborative commissioning shared outcomes and key performance indicators. — Commissioners should expect and encourage variation of practice within a clear framework. — The NHS Commissioning Board must include some people without long careers in the NHS and the system should permit new entrants provided they meet agreed criteria such as an accreditation system. — A specialised commissioning negotiating board should be created. This will lead to national (service specific) standards for all. – GP practices should be coterminous with local authorities. This will prevent people falling through the gaps in services. — Support and facilitate a pathway approach to commissioning to ensure co-ordination and cost efficiency. Responses to Questions Clinical Engagement in Commissioning Q1. How will commissioners access the information and clinical expertise required to make high quality decisions about the shape of clinical services? 1.1 There should be a coalition between commissioners, providers and users with a focus on collaborative commissioning shared outcomes and key performance indicators. There should be national standards and an accreditation system for specialist services, ideally that are service specific. 1.2 The Board should include a broad range of expertise. This should involve independent providers, user groups, representative organisations, the voluntary sector and the NHS. There should be clear definitions of quality with a focus on user experience. Q2. How will commissioners address issues of clinical practice variation? 2.1 Commissioners should expect and encourage variation of practice within a clear framework, otherwise this will stifle innovation and research. There should be national care standards which feed in to a managed care system. Best practice should be shared and people should have the required resources to challenge commissioning decisions without fear. Regular decision reports should be published. Q3. How will GPs engage with their colleagues within a consortium and how will consortia engage with the wider clinical community 3.1 Local arrangements will vary however there will be a need for GPs to evidence inclusion of a wide range of stakeholders within a defined health economy. Decisions should be made transparently and open to all and founded on objective assessment of need, choice and competency. 3.2 Patients or their representatives should be fully involved in decisions involving their care and understand the reasoning behind the decisions. All information should be accessible and easy to understand. Q4. How open will the system be to new entrants? 4.1 The NHS Commissioning Board must include some people without long careers in the NHS and the system should permit new entrants provided they meet agreed criteria—accreditation process. Q5. Will care providers be free to offer new solutions which offer higher clinical quality, better patient experience or better value? 5.1 Yes. However, innovation must be balanced against stability. Quality, not just cost should be closely monitored. There needs to be a commonsense approach to new services that are based on what users want and need. Q6. Will commissioners be free to access new commissioning expertise? 6.1 Yes as long as organisations that provide support and expertise are forced to demonstrate cost savings and competence and are not allowed simply to supply expensive consultants. Q9. How will patients make their voice heard or their choice effective? 9.1 User groups should be involved in a way that goes beyond tokenism. Constant, publicly available user-generated feedback should be openly considered in decision making. Health Committee: Evidence Ev w23 9.2 Clinical outcomes should be published online. A full list of measures and their importance to commissioning decisions should be available. Reports should be accessible and jargon-free where necessary a glossary of terms should be made available. 9.3 The Board should take account of user feedback and work with service providers to develop quality improvement plans based on that feedback. Q18. What will be the role of local authorities in public health and commissioning decisions? 18.1 GP practices should be coterminous with local authorities. This will prevent people falling through the gaps in services. There should also be a duty on consortia to ensure that any gaps in services that develop are quickly addressed. 18.2 The care pathway should also be co-commissioned in a way that involves both health and local authority services. This would need to be individually case managed to ensure a coordinated approach. Q29. What arrangements are proposed for commissioning of specialist services? 29.1 There should be a clear focus on the care pathway with a single contract, a single set of standards and a single CQUIN. This should create a consistent approach supported by national negotiations. 29.2 A specialised commissioning negotiating board should be created. This will lead to national (service specific) standards for all. There should also be agreed common outcome measures, including some reported by patients. Q30. How will these arrangements interface with the rest of the system? 18.1 Consortia should have representation in specialised commissioning decisions. They should understand the interlinked nature of services and support a pathway approach to commissioning. Recommendations 1. There should be a coalition between commissioners, providers and users with a focus on collaborative commissioning shared outcomes and key performance indicators. There should be national standards for specialist services, ideally that are service specific. 2. There should be national care standards which feed in to a managed care system. Best practice should be shared and people should have the required resources to challenge commissioning decisions. Regular decision reports should be published. 3. Patients or their representatives should be fully involved in decisions involving their care and understand the reasoning behind the decisions. All information should be accessible and easy to understand. 4. There needs to be a commonsense approach to new services that are based on what users want. 5. Clinical outcomes should be published online. A full list of measures and their importance to commissioning decisions should be available. Reports should be accessible and jargon-free where necessary a glossary of terms should be made available. 6. A specialised commissioning negotiating board should be created. 7. There should be a clear focus on the care pathway with a single contract, a single set of standards and a single CQUIN. 8. Consortia should have representation in specialised commissioning decisions. They should understand the interlinked nature of services and support a pathway approach to commissioning. October 2010 Written evidence from Help the Hospices (COM 15) 1. About Help the Hospices 1.1 Help the Hospices is the leading charity supporting hospice care throughout the UK. We want the very best care for everyone facing the end of life. 1.2 The majority of hospice care in the UK is provided by our member hospices. Care is given free of charge to the patient and their friends and family. It can be at home, in the hospice and in the community and can be for days, months or years. We are here to represent and support our members. We work with our members and other organisations as they strive to grow and improve hospice and palliative care throughout the UK and across the world. 1.3 Our services are here to support hospice people and champion the voice of hospice care. They include a wide range of training and education programmes, informative and practical resources for hospice staff, work to influence government policy and support for quality care and good practice. Ev w24 Health Committee: Evidence 2. About this Memorandum 2.1 This memorandum is based upon information provided by independent charitable hospices around England, and draws on their experience of commissioning at a local level. It also contains key points included in our response to the Government’s consultation on Liberating the NHS: Commissioning for patients. It is supplemented by reference to research conducted by Help the Hospices and others. 2.2 We have limited our comments to the key questions posed by the Committee where we feel we have a contribution to make. 2.3 Help the Hospices recognises the need to make efficiencies in care services, and supports the overall objectives of the Coalition Government’s plans for commissioning reform. However, we are keen to ensure that the implementation of that reform is informed by the experiences of local charitable hospices that have a long history of working in partnership with the NHS. 3. Summary of Key Points — The NHS funds, on average, 34% of the costs of the care provided by local charitable hospices, although there is wide variation in the level of funding that hospices receive (4.4). — Many of the commissioning agreements that the NHS has with local charitable hospices are for shorter periods than the recommended three years (4.5). — In the current system, the NHS has already frozen funding for local charitable hospices in 2010–11 (4.6). — Hospices are the local experts in the care and support of people affected by terminal illness (5.1). — Inadequate commissioning and funding relationships inhibit the ability of local hospices to develop innovative services (5.3). — Devolving commissioning to GP consortia runs the risk of increasing the administrative costs for providers such as local charitable hospices (6.2). — There are creative approaches to joint commissioning beginning to emerge in the relationships between NHS commissioners and some local hospices (6.3). — The White Paper sets out the Coalition Government’s vision for the NHS, but it has been published in the absence of an equivalent vision for social care (8.2). In addition, there is a risk that social care budgets could come under considerable pressure in the coming months (8.3). — There is a risk that commissioning decisions for 2011–12 could be adversely affected by the pace of the implementation schedule (9.2). — Commissioning of hospice and palliative care should be done at an appropriate level, with GP consortia expected to collaborate (11.2). 4. The Commissioning of Hospice Care 4.1 Hospice care grew from the concern and commitment of organisations and individuals outside of the NHS who believed there was a gap in provision that needed to be filled. It is perhaps unique among health care services for being predominantly provided outside of the NHS. 4.2 The independent charitable hospice sector provides over two thirds of the specialist inpatient palliative care in the UK.18 The vast majority of hospice care is, however, provided in the community, most commonly in people’s own homes. In the last five years, there has been a 58% increase in the services provided by local charitable hospices to people in their own homes.19 4.3 Expenditure by independent charitable hospices in the UK was £686.9 million in 2009 (a rise of 20% since 2007). 4.4 For every £1 that the state invests in local charitable hospices, those hospices deliver £3 worth of care.20 However, there is wide variation in the level of government funding that hospices receive. In 2009, five hospices received no government funding at all. 4.5 In recent years, although there has been some progress towards commissioning relationships with local charitable hospices that are compliant with the principles of the Compact with the Third Sector, the fact remains that many local hospices still do not have three year agreements with NHS commissioners, relying instead on year-on-year negotiations that are, by their very nature, subject to budgetary pressures within the NHS.21 4.6 A survey of member hospices undertaken by Help the Hospices in March 201022 found that 64% of primary care trusts had frozen NHS funding for hospices in 2010–11. A further 6% of primary care trusts had actually cut the amount of NHS funding for hospice care in 2010–11 by between 1.7 and 10%. Only 21% of primary care trusts had increased the funding to local hospices in the current financial year. 18 19 20 21 22 Hospice Information, Hospice and Palliative Care Directory, 2009. Unpublished analysis of the Minimum Data Set for palliative care, Help the Hospices, 2009. Help the Hospices (2010) Hospice Accounts. National Audit Office (2008) End of Life Care. Unpublished survey undertaken by Help the Hospices, March 2010. Health Committee: Evidence Ev w25 4.7 With the increasing pressure on public spending in the coming years, we are concerned that the level of NHS funding to support hospice care will continue to be eroded in future years, despite the Coalition Government’s commitment to protect NHS spending on frontline services. 5. Clinical Engagement in Commissioning 5.1 Hospices are local experts in the care of people affected by terminal illness, providing a holistic, person-centred approach to the needs of patients, their families and carers. The type of care that is provided within the voluntary sector is often the type of care which people most value.23 5.2 Hospices play an important role in supporting service improvements across the health and social care system. They play a key role in providing education and training to the wider health and social care workforce, and in developing creative partnerships with other providers, such as care homes and hospitals. Help the Hospices believes that the commissioning of professional education within the health and social care system should feature more prominently within the Coalition Government’s plans. 5.3 One of the strengths of the hospice movement as a collection of voluntary sector organisations is its ability to innovate with greater ease than the NHS. When ideas emerge, the relative flexibility of hospice budgets, (they may be able to call on reserves or access one off grants for new work) the commitment of staff and volunteers, and their place within local communities often means that they are able to create and deliver innovate services which could not emerge as easily within the NHS. Such flexibility though can be significantly compromised when income streams are uncertain. Innovation is likely to occur more often where stable funding can be found outside of government sources. Where this is not possible, innovation can be compromised as a result of the unwillingness of commissioners to assure funding for the recommended three year period. However, the hospice movement has always seen its role as being one of innovation to meet the gaps in need that exist within their communities. 5.4 There are, however, examples of creative partnerships between hospices and commissioners, as described below. In particular, the emergence of formal joint commissioning agreements between local hospices and the NHS goes a long way to recognising not only that hospices hold a great deal of expertise in the care of people affected by terminal illness, but also that in many instances, local hospices are the majority funders of palliative care services locally. Help the Hospices believes that this approach is one that should be replicated in other areas. 5.5 The risk with the proposals contained within the White Paper is that such partnerships will inadvertently be disincentivised as a more competitive market emerges within health care provision. This, in our view, would not serve the interests of patients and their families as it will reduce efficiency and increase administrative costs for voluntary sector providers such as local hospices. 6. How Open will the System be to New Entrants? 6.1 Historically, the NHS has not commissioned care provided by local charitable hospices on anything near a “full cost” basis. On average, the NHS contributes 34% of the costs of care provided by local hospices,24 although there is widespread variation in the level of funding that local hospices receive. 6.2 We are concerned about the transactional costs that will be incurred by local hospices under the new commissioning arrangements. In the current system, it is not unusual for local hospices to have commissioning relationships with more than one Primary Care Trust. This is particularly the case for children’s hospices, whose catchment areas are much larger than adult services. There is, in our view, a real danger that the devolution of commissioning responsibilities to GP consortia could significantly increase the administration costs for local hospices in negotiating commissioning arrangements. A solution would be for the Department of Health to ensure that consortia work collaboratively in commissioning palliative and end of life care. 6.3 In recent months, we have seen some innovative approaches to local commissioning of hospice and palliative care beginning to emerge. In particular, some hospices in the West Midlands have worked with their local Primary Care Trusts to agree joint commissioning agreements. These agreements recognise that in many cases it is the local hospice that is the majority funder (and commissioner) of hospice care within a community. These joint commissioning agreements have been agreed as an alternative to the NHS Community Contract, which is often an inappropriate tool for commissioners to use in commissioning hospice care. 6.4 This kind of innovative commissioning is a good example of the kind of “collaborative behaviour” that the Coalition Government has indicated that it wishes to promote, and we are keen to ensure that such an approach can be adopted in other commissioning relationships between the NHS and local hospices. 23 24 Aspinal, F, Hughes, R, Dunckley, M and Addington-Hall, J (2006) What is important to measure in the last months and weeks of life?: A modified nominal group study. International Journal of Nursing Studies, 43, (4), 393–403. Help the Hospices (2010) Hospice Accounts. Ev w26 Health Committee: Evidence 7. Accountability for Commissioning Decisions 7.1 Help the Hospices shares the aspiration to give patients and service users more choice and control over their care. 7.2 The lines of accountability set out within the White Paper are very unclear. The nature of the relationship between individual GP consortia and the NHS Commissioning Board is particularly opaque. 7.3 The White Paper explains that the NHS Commissioning Board will utilise a suite of quality standards developed by NICE to guide the decision making of GP consortia. However, those quality standards will be aspirational in nature, rather than absolute, providing individual patients with little clarity on the service that they can expect to receive in their locality. In our view, it is essential that patients and service users have a clear consistent understanding of the quality of care that they can expect to receive, in order to then be able to hold local commissioners to account. 8. Integration of Health and Social Care 8.1 Historically, hospices have had their primary commissioning relationships with the NHS, rather than local authorities. This is despite the fact that much of what constitutes hospice care would “fit” within a social care definition. For example, some models of hospice day care, home care, bereavement counselling and carer support. 8.2 While the White Paper sets out a reform agenda for the NHS, it has been presented in the absence of clarity about how the Coalition Government intends to reform social care. Indeed, the Commission on Social Care is not expected to report until summer 2011. 8.3 We are also concerned that although NHS spending has been protected from public spending cuts, there is no such guarantee for local authority funded social care services, which seem likely to come under considerable pressure as local councils seek to make savings, and threatening the opportunities for integrated approaches to meeting care needs. 8.4 Local hospices also play a key public health role in raising awareness of death and dying, and helping people with life-limiting conditions live well until they die. We are concerned that the Coalition Government’s plans for public health reform have not been clearly defined within the White Paper, as an essential element of the integration of care services. 8.5 The White Paper also describes a new NHS Outcomes Framework. In our view, it is essential that there are shared outcomes for health and social care services. This is particularly important for people affected by terminal illness, whose needs will span a full spectrum from highly technical health care to social, psychological and emotional needs. 8.6 There is evidence that the quality of care provided by specialist palliative care providers produces better outcomes than provision within generalist services.25 As the majority of specialist care is provided by voluntary hospices, the new focus on outcomes should be developed in partnership with local hospices and their representatives. 9. Transitional Arrangements 9.1 The White Paper sets out a timetable that suggests that GP consortia would be established in shadow form during 2010–11, and would slowly take on increasing responsibilities currently held by Primary Care Trusts. 9.2 Help the Hospices is concerned that this could lead to a confusing fragmentation of commissioning decisions for 2011–12. Different GP consortia will be at different stages in their development, resulting in a situation where our member hospices who work with more than one Primary Care Trust in the current system could find themselves working with multiple commissioners within multiple systems. This, in our view, presents a real risk that innovation in the commissioning of hospice care, such as that described earlier in this paper, could be stifled. We are not confident that learning from Primary Care Trusts would be so readily and rapidly transferred to the new consortia. 9.3 Research conducted by the Commission for the Compact highlighted the critical importance of personal relationships in the commissioning of hospice care, and the wide variation in the approaches taken by commissioners.26 While we support the view that commissioning by Primary Care Trusts was anything but perfect, we remain concerned about the destabilising effect of further reform on the relationships between commissioners and local charitable hospices. We are not opposed to the reforms that the Coalition Government is proposing, but believe that further consideration needs to be given to how to sustain and safeguard existing good relationships during the transitional period. 25 26 J Hearn, I J Higginson, Do specialist palliative care teams improve outcomes for cancer patients? A systematic literature review, Palliative Medicine, 1998. Commission for the Compact and Help the Hospices (2008) Positive Engagement, Future Practice: Learning for End of Life Care. Health Committee: Evidence Ev w27 9.4 There is a further complication for hospice and palliative care providers such as local charitable hospices. The Coalition Government has initiated a Review of Palliative Care Funding that is due to report in summer 2011. While we welcome the review, there is a risk that decisions on the transitional arrangements for the new commissioning system will be taken before a decision is made on how hospice and palliative care should be funded (and therefore commissioned) in the future. 10. Resource Allocation 10.1 As described above, Help the Hospices is concerned about the possible fragmentation of commissioning in hospice and palliative care. In particular, given the uncertainty about the size of GP consortia, and the extent to which they will be required to collaborate on commissioning decisions, we are concerned that the proposals run the risk of adding further complexity to decision making. The White Paper describes the take up of existing Health Act flexibilities as having been disappointing, but says surprisingly little about the nature of collaboration that the Coalition Government hopes will be evident in the new system. 10.2 Our concerns about fragmented decision making also apply to the allocation of resources. It is unclear, for example, how consortia resources will be calculated and distributed. In the present system, many hospices provide services on behalf of two or more Primary Care Trusts (this is particularly true for children’s hospices). If the resources currently provided by the NHS to hospices are devolved to consortia, this will increase the complexity of the relationships that local hospices will have with their commissioners, increasing the administrative costs and reducing the efficiency by increasing the number of commissioning relationships that an individual hospice will need to negotiate. This is why we believe that commissioners should be required to collaborate at a higher level in the commissioning of hospice and palliative care services. 11. Specialist Services 11.1 The Coalition Government has talked about the importance of GP consortia working collaboratively to commission services where that is the most expedient approach to securing appropriate services for patients. The White Paper, however, talks in very black and white terms about the division between responsibilities at national level through the NHS Commissioning Board and at local level through GP consortia. 11.2 Help the Hospices believes that there is currently inadequate information on how specialist or lower volume services might be commissioned. As mentioned previously, in the current system, local hospices frequently have commissioning relationships with more than one Primary Care Trust, particularly for hospices serving children and young people. We are concerned that the White Paper fails to recognise the nature of commissioning hospice and palliative care. While we are not arguing that commissioning of hospice and palliative care should be a responsibility reserved by the NHS Commissioning Board, we do however believe that the Coalition Government needs to be more explicit about the nature and level of collaboration between GP consortia that they expect, particularly in the absence of any clarity about the size and number of consortia that the Coalition Government intends to establish. October 2010 Written evidence from Partnerships in Care (COM 16) 1. PiC is the largest independent sector provider of psychiatric beds in the United Kingdom with more than 1,200 beds in 23 hospitals, all purchased by the NHS. That purchasing, usually through the offices of Specialist Commissioning Groups or occasionally PCTs. 2. PiC welcomes the innovations in the Health White Paper and particularly the changes in commissioning arrangements that the liberation of the NHS will bring about. However, it is imperative that the changes in the way that the NHS operate and care is delivered, truly reflect the needs of the patients and are not mere rhetoric. 3. Currently, commissioning in specialist mental healthcare is based primarily on process rather than quality and does not reflect individual patient need. NHS commissioners continue to favour NHS providers rather than accept a wider market for healthcare that has, in truth, existed for some years. 4. On occasions, NHS patients are removed by commissioners from high quality independent sector beds and placed in more expensive NHS services on the basis of negotiated block contracts. Such arrangements do not reflect a true market for healthcare. 5. PiC would urge the Select Committee to consider the following points when coming to their decisions and recommendations: (a) The Any Willing Provider model of commissioning reinvented yet again in the Health White Paper must be allowed to be a principle driver for quality and outcomes. The AWP model must include on the same basis all providers, be they independent or NHS. Ev w28 Health Committee: Evidence (b) Service costs must be whole and not hide pension, training and capital costs. All commissioning must be on the basis of an equitable “level playing field”. (c) Consideration should be given to the appetite of GP consortia to commission services with less tangible outcomes such as low secure and step down psychiatry. Consideration should be given to the use of third party specialist commissioners for in-patient psychiatry or, alternatively, such commissioning remains with the NHS Commissioning Board. (d) Consideration should be given to allowing the new commissioning arrangements to commission the whole patient care pathway at a fixed rate. Current changes of commissioning along the pathway are clumsy and significantly disadvantage the patient. (e) The new commissioning arrangements must not be allowed to favour the NHS above other providers. If block contracts are to be let, they should be released to all willing providers. (f) In secure mental healthcare, cognizance must be paid by commissioners to a vibrant and effective independent sector that already provides 40% of all secure beds. The engagements of the independent sector in strategic planning is essential if limited resources are to be used effectively. (g) Regionalised outposts of the NHS Commissioning Board must principally represent the centre and not be allowed to set local contracts with local tariffs and quality standards. The new commissioning landscape gives the opportunity for efficiency and consistency in outcome measures across the whole of the United Kingdom. (h) It should no longer be assumed that for specialist services local is necessarily best. The needs of the individual patients must be considered and commissioning decisions based primarily on outcomes and quality. There is a real risk that with as many as 500 GP consortia, the opportunities for developing national centres of excellence will be lost. (i) We believe that the “choice agenda” can be applied to secure psychiatry offering services to detain patients. PiC will be happy to engage in detailed discussions with your Committee on regards to choice. (j) There is a body of research that suggests that in forensic psychiatry, hospitalisation significantly reduces long term risks and reoffending. PiC would welcome the opportunity to enter the debate that might lead to commissioning for outcomes that include reduced offending as well as health gain. October 2010 Written evidence from Oxfordshire County Council (COM 17) Summary This submission on behalf of Oxfordshire County Council concentrates on the issues of accountability, integration of services across health and social care, the effectiveness of commissioning, and the role of local authorities and public health. Discussion of these issues is prefaced by some more general consideration on commissioning in the NHS, which conclude: — The NHS lacks a coherent approach to commissioning. — World Class Commissioning did not get down to changing and developing the practical approaches necessary for sound commissioning practices. — The centralised approach to the management of the NHS and establishing its priorities has undermined the development of effective commissioning. — Commissioning in the NHS has failed to achieve a significant shift in the use of resources from acute hospital services to community services and prevention. Our other conclusions are given below. Accountability — Accountability will be a major issue. GP Consortia should be accountable to the NHS Commissioning Board for their commissioning arrangements and to the local Health and Well Being Boards for the decisions that they reach. — The Health Overview Scrutiny Committees should remain to ensure that there is effective scrutiny of the Health and Well Being Board and the decision making of GP Consortia. — The involvement of HealthWatch on Health and Well Being Boards will enhance the role of patients and service users in setting standards for service delivery and holding GP Consortia to account. Health Committee: Evidence Ev w29 Integration of health and social care — Partnership and joint working arrangements should be the expectation for appropriate services, supported by a statutory requirement for them to be considered. — Joint or lead arrangements for commissioning are as important as pooled or shared budgets for the successful integrated and joint working. — The arrangements for integration and joint working should be reviewed to see where arrangements could be made simpler, but, at the same time, guidance on the significance, development and maintenance of effective joint working arrangements should be prepared. The effectiveness of commissioning — GPs working as commissioners should lead to better clinical engagement with service providers, which will improve the effectiveness of commissioning. — Arrangements should be made to ensure that the skills and experience in commissioning in local authorities can be used to take forward joint working, increase efficiency in commissioning across health and social care, and improve the skill level in commissioning NHS services. Public health and the role of local authorities — The transfer of public health responsibilities to local authorities reinforces and strengthens the role that they already have in meeting public health objectives. — When taken together the new arrangements for public health and the responsibility that local authorities will have for taking forward partnership working with the NHS will significantly strengthen strategic planning and the capacity in commissioning services across health and social care. Introduction This submission on behalf of Oxfordshire County Council concentrates on the issues of accountability, integration of services across health and social care, the role of local authorities, public health and service reconfiguration. These issues are considered after discussion on some general considerations. General Considerations There is a long history of joint and partnership working between the County Council and the NHS, with four significant pooled budget arrangements, two lead commissioning arrangements and one integrated service. The pooled budget that we have with NHS Oxfordshire for services for older people is one of the largest arrangements in England. We have extensive joint working arrangements and experience of working with commissioning across the NHS. In our experience the conclusions of the previous review ring very true. The successive reorganisations in the NHS threw into clear relief the lack of a sound understanding of the principles underpinning commissioning, and of the various elements that comprise a comprehensive approach. We find the skill levels in commissioning in the NHS to be very variable, and overall there is a serious confusion between commissioning, procurement and contracting. We take commissioning to be a process that analyses needs and priorities, establishes plans to deal with gaps the basis of evidence and within resources, establishes how services are to be delivered and then monitors and reviews the delivery and the outcomes of the service investments. This is entirely consistent with the definition given in “Liberating the NHS: Commissioning for Patients (p2, paragraph 1.7)”. On this basis, we suggest that NHS commissioning does not consistently apply the available evidence on needs and establishing priorities, particularly with regard to the longer term benefits to be gained from a shift of resources from services provided in acute hospital services to services provided in community settings. There is little evidence that NHS commissioning has been able achieve such a shift of resources. Many of the NHS commissioners are technically adroit in the complex mechanisms of NHS pricing and tariffs, but their achievement has been to move money around an acute hospital trust; they have not been able to reshape NHS services in a significant way. The dominance of central decision making in the NHS has undermined local decision making and the development and role of commissioning. It would appear that on occasion NHS Trusts and NHS Foundation Trusts have used their historical and organisational weight to influence and over ride decisions that they may not like made locally by commissioners. There have been a number of initiatives to improve the level and impact of commissioning in the NHS. The World Class Commissioning programme was a significant attempt to improve commissioning in the NHS and increase its effectiveness and impact. It had a vision and an understanding of the importance of commissioning but operated more as a model for organisational development. It did not equip PCTs and their staff with a better understanding of the principles of commissioning, or with practical skills and tools. Ev w30 Health Committee: Evidence “Equity and Excellence: Liberating the NHS” contains a number of proposals that can improve the practice and performance of commissioning across the NHS, primarily through opportunities for integrated working, but it does appear to assume that commissioning in the NHS is working at a reasonable level of competence. We would not agree that this is the case. The conclusions to be drawn from this are: — The conclusions of the earlier inquiry are well founded and still apply. — The NHS lacks a coherent approach to commissioning. — World Class Commissioning did not get down to changing and developing the practical approaches necessary for sound commissioning practices. — The centralised approach to the management of the NHS and establishing its priorities has undermined the development of effective commissioning. — Commissioning in the NHS has failed to achieve a significant shift in the use of resources from acute hospital services to community services and prevention. — The NHS White Paper does give the opportunity to improve commissioning in the NHS. Accountability for Commissioning Decisions The proposed NHS Commissioning Board will have a very significant role in ensuring that there is proper accountability for the commissioning decisions that GP Consortia will be making. It will also have a significant role in the direct commissioning of a broad range of services as well as setting the framework within which GP Consortia will commission services. It will have a major challenge in supporting the transition to a new and complex set of arrangements. It must resist the temptation to manage centrally all aspects of commissioning and it must allow for the development of local arrangements, local decision making and local priorities. It should prepare and support the use of the practical frameworks for commissioning. The establishing of Health and Well Being Boards, which we believe must be on a statutory basis for them to be effective, have the potential to make a major contribution to the governance and accountability arrangements for commissioning. The role of these boards should be broad in scope and strategic in focus. The proposed HealthWatch arrangements will give a better basis for involving patients and service in the development of strategy and monitoring against outcomes. Patient involvement can make a major contribution to establishing quality standards that will reflect public perceptions and expectations. The inclusion of HealthWatch on the Health and Well Being Boards will enhance the impact of the patients’ and service users’ voice in holding services to account for commissioning decisions that they make. Accountability for the GP Consortia is a major issue which, if unclear, will undermine confidence in their role and how they understand and reflect local priorities. We suggest that: — GP Consortia should be accountable to the NHS Commissioning Board for their commissioning arrangements and to the local Health and Well Being Boards for the decisions that they reach. — The Health Overview Scrutiny Committees should remain to ensure that there is effective scrutiny of the Health and Well Being Board and the decision making of GP Consortia. — The involvement of HealthWatch on Health and Well Being Boards will enhance the role of patients and service users in setting standards for service delivery and holding GP Consortia to account. We do not agree with the proposal for Health Overview Scrutiny Committee functions to be vested in the Health and Well Being Board, because this board will be part of the arrangements for determining the objectives and how they are being met. Independent Health Overview Scrutiny Committees should be retained. Independent scrutiny will reinforce the accountability that GP Consortia should have to the public through their elected representatives. In summary: — Accountability will be a major issue. GP Consortia should be accountable to the NHS Commissioning Board for their commissioning arrangements and to the local Health and Well Being Boards for the decisions that they reach. — The Health Overview Scrutiny Committees should remain to ensure that there is effective scrutiny of the Health and Well Being Board. — The involvement of HealthWatch on Health and Well Being Boards will enhance the role of patients and service users in setting standards for service delivery and holding GP Consortia to account. Health Committee: Evidence Ev w31 Integration of Health and Social Care We think that partnership working should be the expectation and a requirement, supported by statute, for appropriate services. The Health and Well Being Boards will have the responsibility to promote and support partnership working in the commissioning and delivery of services. The commissioning framework for GP Consortia should provide guidance on partnership working, and the NHS Commissioning Board should work with local authorities, the Association of Directors of Adult Social Services and the Association of Directors of Children’s Services in drawing the guidance on joint and integrated working to GP Consortia, and on the development of commissioning in the NHS. Giving GPs significant responsibilities for commissioning NHS services should help them to understand the cost benefits from working with social care in a consistent and integrated way. This perspective is not as clear to many GPs at present because they do not have a need to be aware of the efficiencies that can be gained from closer partnership or integrated working. A shift in approach and assumptions may be required and the new arrangements should give some incentive and drive for this to happen. Sharing or pooling budgets across health and social care is a very important component in partnership work and service integration but it is not the whole story. There should be an equal understand of the importance of having commissioning and service planning arrangements that are also joint, and the use of lead or joint commissioning arrangements are as important as pooled budgets. Not having sound commissioning strategies, developed, agreed and implemented jointly will significantly undermine the impact that pooled budgets are able to have on service delivery and efficiency because there would be no overarching purpose to hold arrangements together. This is particularly true at times of financial stringency. The powers and opportunities for joint working contained in the NHS Act 2006 should be reviewed to see what improvements or additions could be made. The use of these arrangements nationally is relatively low. It would be useful to see what other arrangements authorities may have used. However, there may also be questions about the assumptions and attitudes that people may have to the powers, which in fact are simply a reflection of the fact partnership working is sometimes hard work and requires effort and commitment from everyone involved for the full benefits to be gained. An analogy would be the workman blaming his tools. In summary: — Partnership and joint working arrangements should be the expectation for appropriate services, supported by a statutory requirement for them to be considered. — Joint or lead arrangements for commissioning are as important as pooled or shared budgets for the successful integrated and joint working. — The arrangements for integration and joint working should be reviewed to see where arrangements could be made simpler, but, at the same time, guidance on the significance, development and maintenance of effective joint working arrangements should be prepared. The Effectiveness of Commissioning and the Role of Providers There may be an assumption that these interests are often in opposition. Both commissioners and providing are concerned with outcomes for patients and their families and the wider community. The conflicting interests come primarily over costs, activity, and performance levels. We suggest that the clinical expertise of GPs, their awareness of local needs and priorities and their skill in generating data and using evidence will provide powerful levers to commissioning and engagement across the NHS on how to best meet the required outcomes. GPs, working as commissioners, should be able to harness their clinical skills to the commissioning role and have a more effective clinical and commissioning engagement with NHS Trusts, Foundation Trusts and other providers. But GP Consortia must be properly supported in this. It is not sufficient to assume that a shift of the people currently involved in NHS commissioning into a new set of arrangements will improve the ability of commissioners to challenge and engage with the providers. As we have said already, there is little evidence that the current arrangements have been able to achieve any significant shifts of activity and resources from the acute sector into community services. GP Consortia should use the expertise in commissioning, procurement and contracting that there is in local authorities, particularly in social care, and use the experience that local authorities have of dealing with large private and independent sector enterprises at a local level for the provision of services. In summary: — GPs working as commissioners should lead to NHS Commissioning having better clinical engagement with commissioning decisions and improve the effectiveness of commissioning to drive service changes. — Arrangements should be made to ensure that the skills and experience in commissioning in local authorities can be used to take forward joint working, increase efficiency in commissioning across health and social care, and improve the skill level in commissioning NHS services. Ev w32 Health Committee: Evidence Public Health and the Role of Local Authorities There is already a close relationship between local authorities and public health, and the proposed arrangements reflect the reality of how health inequalities are tackled and health gains are achieved. The transfer of responsibilities for health improvement to local authorities is welcomed and it will be strengthened by the accountability of the Directors of Public Health to the local authority, alongside their accountability to the National Public Health Service. The JSNA should be the driving force for strategic change through the systematic evaluation of needs and evidence of what works. The linking of public health and local authorities should mean that JSNAs can reflect the evidential rigour of public health and the benefits of well founded qualitative data that local government has strengths in generating. Local authorities will be able have an integrated approach to the use of their skills and experience in commissioning to drive forward health improvements and deal with health inequalities. The NHS White Paper puts these transfers of responsibility from PCTs to local authorities in the context of local authorities’ responsibility to promote and take forward partnership and integrated working. This is appropriate. It gives a sound basis for a proper understanding to be gained at a local level of the relationships between the health of the individual with the health of the community, and of the importance of community services in reducing the demands for and costs of acute services. This understanding can then be acted on locally through commissioning decisions. However, this will not happen automatically. It will require continued attention and effort. It is essential that local authorities get the authority and the resources to match these important responsibilities. In summary: — The transfer of public health responsibilities to local authorities reinforces and strengthens the role that they already have in meeting public health objectives. — When taken together the new arrangements for public health and the responsibility that local authorities will have for taking forward partnership working with the NHS will significantly strengthen strategic planning and the capacity in commissioning services across health and social care. October 2010 Written evidence from the National Centre for Young People with Epilepsy (COM 18) Executive Summary (a) Children with epilepsy deserve better lives. They have to cope with unnecessary seizures, have a poorer quality of life than children with other long term conditions, and face an unacceptable risk of death. Misdiagnosis is a significant issuei—up to 40% of children may be taking anti-epileptic drugs without need. Three-quarters of children who could have their epilepsy cured do not have access to the surgery which would change their lives. (b) Current practice in the commissioning of paediatric epilepsy services is varied. There are very few, if any, examples of childhood epilepsy services being re-designed or actively planned using the World Class Commissioning approach. The result is a continuation of the traditional hospital clinic model of service provision. (c) The evidence from a recent survey shows that little note is taken of either the NICE Clinical Guideline covering childhood epilepsy or the supporting guidance on commissioning. The National Centre for Young People with Epilepsy (NCYPE) believes that adherence to this guidance could dramatically improve services and outcomes for this group of patients, for example through a well designed and communicated care pathway or the provision of paediatric epilepsy specialist nurses. (d) The NCYPE believes that failure to adequately commission services for children with epilepsy not only results in significantly worse outcomes, but wastes money and leads to very large lifetime costs to the NHS and across the public sector. (e) Through its Champions for Childhood Epilepsy Campaign the NCYPE seeks to work collaboratively with service providers to improve health and education services for young people with epilepsy. The campaign has made considerable and effective progress in education. It has however proved difficult to engage in a practical pilot project with any health body. (f) Having met with a large number of primary care trust (PCT) and strategic health authority (SHA) commissioners there is clear agreement that existing services fall short and that the Campaign’s objectives and plans are reasonable. A solid body of research supports this view. Engagement with the NCYPE’s Champions Campaign would help to move services closer to compliance with NICE guidance in an affordable and effective way—yet to date no NHS body has committed to this collaborative working. Health Committee: Evidence Ev w33 (g) Any changes to the NHS, and to health commissioning in particular, must deliver improved childhood epilepsy health services. Indeed, outcomes for children and young people with epilepsy might provide an excellent indicator as to whether the reforms are working. 1. Introduction 1.1 Epilepsy is the most common serious neurological condition in childhood. With a prevalence of around 1:240 epilepsy amongst the under-18s, it is as common as insulin dependent diabetes. There are approximately 60,000 children and young people with epilepsy in the UK. 1.2 Epilepsy is a complex condition more commonly described as “the epilepsies” by medical professionals. With over 40 different categorisations of the disease, symptoms can vary enormously both in presentation and in severity. The primary clinical objective in the treatment of epilepsy is the reduction or elimination of seizures. 1.3 There is no single diagnostic “test”—diagnosis is based on a series of tests, observations and clinical judgements. Well-established NICE clinical guidance states that diagnosis and continuing treatment should not be managed in general practice or by general paediatricians. Instead, it should be the responsibility of paediatricians with expertise and training in the epilepsies. Misdiagnosis rates are as high as 40%, resulting in some children taking powerful anti-epileptic drugs unnecessarily and others not receiving the medication they need to control their seizures. Inappropriate clinical management is likely to result in poor seizure control, increase the risk of Sudden Unexplained Death from Epilepsy (SUDEP), and impact significantly on general health, wellbeing and quality of life. 1.4 Research has indicated that over half of the deaths of children and young people are possibly or potentially avoidableii—that amounts to almost one unnecessary death each week. The Government response to a recent Parliamentary Question indicated that the death rate for epilepsy across the whole UK population was 40% higher than the median rate for a comparable set of European countriesiii. 1.5 An average primary care trust has around 320 cases of childhood epilepsy; on average there are five children with epilepsy in every secondary school and one with epilepsy in every primary school. 2. Current provision 2.1 The NCYPE can find little fault in the general concept of World Class Commissioning, or in government policies and strategies such as the National Service Framework for Long Term Conditions. Although there are areas where the NICE Clinical Guidelineiv might be improved, it provides a very good statement of the services which should be in place for children and young people with epilepsy. However, when it comes to childhood epilepsy health services, there is little evidence of active commissioning where services are re-designed to meet needs and deliver better outcomes. 2.2 Epilepsy services for children and young people can be characterised as traditional hospital-based clinics led by paediatricians. These services will often fall short of the recommendations in NICE Clinical Guideline 20 in that: — The clinicians are often not paediatricians with expertise and training in the epilepsies. — Well designed care pathways, including referral opportunities to tertiary centres, may not exist. — There is limited understanding of when surgery might provide a complete cure. — There are few acute or community based paediatric epilepsy specialist nurses. 2.3 The Epilepsy Action survey of services in England, “Time for Change”v, provides clear evidence of the “patchy at best” services for children and young people with epilepsy. Only 18% of primary care trusts were able to estimate the number of the children and young people with epilepsy in their area. There were very few paediatric epilepsy specialist nurses, and limited transition planning from childhood to adult health services. Waiting times for initial appointments and diagnostic tests were either not measured or often exceeded the NICE clinical guidance targets. 2.4 Epilepsy surgery (the only curative treatment) is conducted on around 100 children annually in the UK yet research demonstrates that there are around 400 suitable cases each year.vi Each year, another three hundred children miss out on potentially life changing surgery. 2.5 In its 2007 report “Wasted Money, Wasted Lives”, the All-Party Parliamentary Group for Epilepsy recommended a review of the implementation of NICE guidelines—there is little evidence of compliance. They further recommended that all those who could benefit from surgery should have access to it as the cost savings of a lifetime of medical support are far greater than the cost of the surgery. The “Epilepsy12” initiative is auditing the provision of services but will not complete its work for another two years. 3. Commissioning Health Services for Children and Young People with Epilepsy 3.1 Poor outcomes for children with epilepsy demand a different approach in the future to the design and delivery of their health services. However, there are concerns that the move towards commissioning by GP consortia will do little to deliver services which are in line with the NICE Clinical Guideline (or, in the future, a NICE Quality Standard): Ev w34 Health Committee: Evidence — Childhood epilepsy services are unlikely to be a priority for GP consortia during the transition to new commissioning arrangements, or in the period after new commissioning arrangements are implemented. — Many children with epilepsy will never see their GP in relation to their epilepsy as GPs play a limited role in the diagnosis, treatment or review of children with epilepsy. GPs cannot therefore bring significant clinical experience to bear in a GP consortia commissioning role. — Children with epilepsy cannot afford the risk of a “postcode lottery” of locally designed and developed services. 3.2 Some childhood epilepsy services are currently commissioned regionally as they fall within the specialised services national definition set (SSNDS 23). These include epilepsy surgery and paediatric neurology services. NICE Clinical Guideline 20 recommends that all children suspected to have epilepsy should be seen by a specialist for diagnosis, with a specialist defined as a paediatrician with expertise and training in the epilepsies—there is evidence that this is not happening at present. It also recommends that referral to an expert takes place in a wide variety of situations, including where seizures are not controlled— probably less than a half of children have their seizures controlled. 3.3 There are two options that warrant further consideration: — The NHS Commissioning Board should increase the scope of the childhood epilepsy services covered by SSNDS, so that these services are commissioned on a regional basis using the NICE Clinical Guideline or a NICE Quality Standard. — The NHS Commissioning Board should host a clinical commissioning network covering childhood epilepsy services, to pool expertise in the commissioning of these services. 3.4 The specialist services which should to be commissioned regionally or through a network include: — Diagnosis by a paediatrician with expertise and training in the epilepsies. — Diagnostic tests such video telemetry. — Multi-disciplinary assessment. — Referral to a tertiary centre for review of all children whose seizures are not controlled and/or if there is diagnostic uncertainty or treatment failurevii. 3.5 Other services, such as the provision of epilepsy specialist nurse services, must be more commonly available than they are currently and might well best be included in the list of specialized services to avoid a “postcode lottery”. 3.6 It is important to remember that although these specialized services are likely to be based in less than 50 hospitals across England, they might well be delivered through clinics at local hospitals; or, in the case of specialist nurses, through locally organized services. 3.7 The government’s NHS White Paper proposes that, to improve outcomes, Quality Standards to be developed by NICE, will inform the commissioning of all NHS care and payment systems and that inspection will be against essential quality standards. One hundred and fifty of these Quality Standards are to be developed by 2015. It is vital that an urgent priority is given to a Quality Standard covering paediatric epilepsy services, to set very clear expectations for commissioners and clinicians. 3.8 Finally, there is an economic case to made, in addition to the clinical and quality of life cases, for better childhood epilepsy services. It is time to end the perverse incentive of paying providers when children are admitted to hospital, but starving the funding for services such as expert diagnosis and community specialist epilepsy nurses. At its simplest, better diagnosis and treatment will reduce hospital admissions. More generally, if their epilepsy is diagnosed accurately and early, and an effective treatment regime put in place (including referral for surgery where appropriate), then the education and work outcomes will be significantly improved—with whole life savings in direct medical and non-medical costs. 4. The NCYPE’s Champions for Childhood Epilepsy Campaign 4.1 The NCYPE’s Champions for Childhood Epilepsy Campaign is pressing policymakers, health trusts, local authorities and schools to provide improved services and support for the 60,000 young people with epilepsy across the UK. We are asking everyone from teachers to paediatricians and NHS commissioners to “go the extra mile”. Healthcare professionals can go the extra M.I.L.E. for young people with epilepsy by: M Measuring I Including and informing children, parents or carers — Commissioners must know the number of young people with epilepsy in their area — Commissioners must know what level of resources they have in place — Commissioners must know how long young people with epilepsy are waiting for initial appointments, diagnosis, treatment and tertiary assessment — Commissioners must know what young people with epilepsy and their parents think about services Health Committee: Evidence Ev w35 — Children, young people and their parents/carers need easy access to high quality information and advice material about epilepsy L Looking after the “whole” child — Children and young people with epilepsy and their parents/ carers must have easy access to high quality multi-disciplinary services such as speech and language therapy and psychology E Ensuring services meet national recommended guidelines — Commissioners must adopt an easy to use, efficient process for referring children and young people to specialist epilepsy services — Commissioners must have one or more care pathways that ensure all young people with epilepsy are seen by paediatricians with training and expertise in the epilepsies — All children and young people with epilepsy must be offered a care plan, and there should be a high adoption rate — All children and young people with epilepsy must have their case reviewed annually by a health professional with training and expertise in the epilepsies 4.2 The NCYPE’s experience is that NHS staff—clinicians and commissioners—accept that childhood epilepsy services need to be improved. However, to date, no primary care trust has agreed to work with the NCYPE to explore how local services might be improved using some or all of the actions listed above. 5. Recommendations 5.1 The NCYPE recommends the following actions to improve NHS commissioning of childhood epilepsy services: (a) That an urgent priority be given to the development of a NICE Quality Standard for childhood epilepsy health services. (b) That the implications of the White Paper for commissioning childhood epilepsy services be carefully considered, with a view to the NHS Commissioning Board holding responsibility for all childhood epilepsy health service commissioning rather than delegating it to GP consortia. (c) That the NHS Quality Innovation, Productivity and Prevention (QIPP) programme be used to learn the lessons from the “Epilepsy12” audit to explore the barriers to commissioning excellent paediatric epilepsy services and how those barriers might be overcome. (d) That continuing measurement of clinical outcomes, such as the number of seizures over the previous 12 months, be introduced for children and young people with epilepsy. (e) Despite cost and resource pressures, and perhaps because of those pressures, NHS bodies should link with the NCYPE’s Champions for Childhood Epilepsy Campaign to explore how to improve health services. Notes i Up to 40% of children referred to a tertiary clinic did not have epilepsy when assessed: “The misdiagnosis of epilepsy in children admitted to a tertiary epilepsy centre with paroxysmal events”; Uldall P, Alving J, Hansen L K, Kibaek M, Buchholt J; 2006; Archives of disease in childhood 2006;91(3):219–21. ii “The National Sentinel Clinical Audit of Epilepsy Related deaths : epilepsy death in the shadows”; May 2002: Jane Hanna et al; published by Epilepsy Bereaved and The Stationary Office. iii “World Health Organization age-standardised death rates for epilepsy indicate that the United Kingdom has 1.5 deaths per 100,000 population, compared with the median rate of a comparable set of European countries (the EU-15) of 1.07 deaths per 100,000. All international comparisons should be interpreted with caution, due to differences in registration systems and coding conventions”, response to PQ 12538, September 2010. iv NICE CG20, “The epilepsies—The diagnosis and management of the epilepsies in adults and children in primary and secondary care”. v “Epilepsy vi in England, Time for Change”, Epilepsy Action, January 2009. Professor Helen Cross, Prince of Wales’s Chair of Childhood Epilepsy. Ev w36 Health Committee: Evidence vii “In children, the diagnosis and management of epilepsy within the first few years of life may be extremely challenging. For this reason, children with suspected epilepsy should be referred to tertiary services early, because of the profound developmental, behavioural and psychological effects that may be associated with continuing seizures … Behavioural or developmental regression or inability to identify the epilepsy syndrome in an individual should result in immediate referral to tertiary services”. (NICE Clinical Guideline, CG20). Written evidence from the Company Chemists’ Association Ltd and the Association of Independent Multiple Pharmacies Ltd (COM 19) 1. Introduction 1.1 The CCA & AIMp Ltd, as the trade association forum for large and medium sized businesses engaged in community pharmacy, welcomes the opportunity to respond to this consultation. The CCA and AIMp Ltd represents Alliance Boots, The Co-operative Pharmacy, Lloydspharmacy, Rowlands Pharmacy, ASDA, Morrisons, Sainsburys, Superdrug ,Tesco and over 30 independent multiple chains of pharmacies. Our member companies own over 7,000 pharmacies and employ over 10,000 pharmacists in the United Kingdom and dispense approximately 70% of all NHS prescriptions annually. 1.2 CCA and AIMp welcome the Committee’s inquiry into how it can contribute to the debate about the implementation of the policies for commissioning outlined in the Government’s White Paper Equity and Excellence: Liberating the NHS. The findings and conclusions of the Committee will assist the new government, Department of Health, the NHS Commissioning Board, other Government departments, Local Authorities, Health and Wellbeing Boards and GP Consortia to resolve the issues which have undermined the effectiveness of commissioning in the NHS. 1.3 CCA and AIMp believe that the effective commissioning of community pharmacy can improve the experience of service users, reduce health inequalities by making it easier for people to access services and is a cost-effective use of NHS resources. We would like to provide evidence in support of this for the Committee’s attention. 2. Clinical engagement in commissioning: access the information and clinical expertise, reduce clinical practice variation and engage with the wider clinical community 2.1 Community pharmacy has a vital role in delivering high quality, accessible services to patients for the vast majority of the population and to do that community pharmacy must be represented at national, regional and local levels of commissioning organisations and clinical leaders’ networks. 2.2 Commissioning community pharmacy to ensure patients use their medicines safely, reduce drug wastage, maximise productivity of appropriate prescribing and help patients get the best use of their medicines is one of the solutions. The potential opportunity is highlighted below: — Around 12% of total NHS expenditure is on drugs—£11 billion for 2007–08—and there is evidence of significant failings in the way that medicines are used, such as misprescribing, overprescribing and poor patient compliance (National Patient Safety Agency (NPSA) 2010; General Medical Council (GMC) 2009; NPSA 2008; Medical Defence Union (MDU) 2009). Medicines may also cause harm—for example, through adverse drug reactions leading to hospitalisation and premature death (Pirmohamed et al 2004; Patel et al 2007). According to the Patient Safety Observatory of the National Patient Safety Agency (2009), preventable harm from medicines may be costing £750 million a year. Also, the NAO estimates that the NHS could save more than £200 million a year by GPs prescribing generic drugs (NAO 2009a). — Pharmacists are real experts in medicines and can help patients use them more effectively and for what they were intended. Between 4% and 5% of hospital admissions are due to medicines-related problems which are preventable (NICE, National Costing Statement: Medicines Adherence, 2009). Between 11% and 30% of these admissions result from patients not using their medicines as recommended by the prescriber (NICE, National Costing Statement: Medicines Adherence, 2009). Avoiding such hospital admissions can save significant amounts of money as well as improving patient care. — Between one third and a half of all medicines prescribed for long term conditions are thought not to be taken as recommended in the CBI report “Doing more with less: A credible strategy for restoring the public finances”. Medicines supplied on prescription costs the NHS billions. If as many as 50% of patients don’t take their medicines as recommended, it is clear how much money is wasted (NICE, 2009, National Costing Statement: Medicines Adherence). There is an evidence base which shows that a wide range of patients have problems when they start a medicine that is new to them (Barber et al, 2004, Qual Saf Health Care), that short patient centred telephone advice services can reduce non-adherence and the number of problems patients have with the medicines (Clifford et al, 2006, Pharmacy World & Science) cost-effectively (Elliott et al, 2008, ibid). Prevention of this type of ineffective use of NHS funds can be facilitated through community pharmacy. Health Committee: Evidence Ev w37 — Treating minor ailments in a community pharmacy setting rather than in general practice can save money and allow the GP to concentrate on more serious conditions. The average GP surgery consultation lasts 11.7 minutes and costs £32. The same 11.7 minute consultation in pharmacy would cost £18 and deliver an equally, or even more effective outcome (Bow Group, September 2010, Delivering Enhanced Pharmacy Services in a Modern NHS). — Stop Smoking Services within a community pharmacy setting helped 62,000 people to successfully quit 2009–10 compared to 55,000 in 2000–09, resulting in an increase of 15% (Statistics on NHS Stop Smoking Services: England, April 2009–March 2010, NHS Information Centre). 2.3 Community pharmacy must be a full member of clinical networks because of the significant contribution we could make. The importance of clinical networks were highlighted in the King’s Fund report “Improving NHS Productivity” July 2010 “Clinical microsystems are important because they are the point at which patients experience care, because it is within these microsystems that decisions are taken on the use of resources. These decisions account for the bulk of spending of NHS resources”. 2.4 A system needs to be in place that will link the strategies of Commissioning, Clinical Networks and Quality, Innovation, Productivity and Prevention (QIPP) together in order to deliver quality outcomes that benefit patients, through greater efficiency and best value for money. 2.5 Leadership and innovation are required to make the system work effectively. CCA and AIMp call upon the government and the Department of Health to facilitate the inclusion of community pharmacy at national, regional and local levels. 3. How open will the system be to new entrants? 3.1 Community pharmacy as a sector is a vibrant and well-established competitive market, where market entry has been managed. The customer is at the centre of our activities and success depends on customer choice, service and loyalty. 3.2 From advice on giving up smoking, to medicines for babies whilst teething, the general public has come to trust their community pharmacist for many of their healthcare needs. An estimated 1.6 million people choose to visit a pharmacy each day, of which 1.2 million do so for health-related reasons. (Department of Health—Improving quality in primary care, 2009). The public have many options of how, where and when they want pharmacy services. This is not the case for accessing general medical services. Community pharmacy understands customer service and patients’ needs. The trust and loyalty of our customers enables community pharmacy to deliver an expanding variety of services. 3.3 The proposed role of Monitor as the new powerful economic regulator will have a significant impact on the market in which competition law will apply. There are potential conflicts of interests of price, quality, integration of services and failing organisations. Transparency is required to ensure a level playing field is created for all providers, both public and private. 4. Will care providers be free to offer new solutions which offer higher clinical quality, better patient experience or better value? 4.1 One of the roles of Monitor is to set a maximum price for services leaving providers to compete. It is important that Monitor has access to the best information available since providers investing in higher clinical quality services and better patient experience may otherwise cost more than the maximum price set, which could act as a disincentive to commissioning by GP consortia. 4.2 CCA and AIMp believe that community pharmacy should be consulted when setting tariffs, as we consider this sector a potentially major provider. The tariffs set must not disadvantage one provider compared to another and must allow fair and equitable competition, even for what are currently considered non-NHS providers. The tariffs must be inclusive and be fully justifiable and transparent. 5. Will commissioners be free to access new commissioning expertise? 5.1 There are many competencies required to be an effective commissioner. The challenge is identifying capabilities and capacity that are in the service currently and accessing the commissioning expertise that is in the private sector. Investing in commissioning expertise will have significant management costs and recruiting these resources will be difficult because of financial constraints. CCA and AIMp will seek discussions with the NHS Commissioning Board, Monitor, GP Consortia and Health and Wellbeing boards so that we can share community pharmacy’s expertise in understanding customers, because engaging public and patients will be essential. 6. Accountability for commissioning decisions 6.1 What will be the role of the NHS Commissioning Board? — Establishing the system of GP consortia with the power to assign individual practices to local GP consortiums. — Allocating resources to GP consortia based on need. Ev w38 Health Committee: Evidence — Attaining the national outcomes goals outlined in a new NHS Outcomes Framework. — Commissioning GP, dentistry, community pharmacy and primary ophthalmic services. 6.2 The Department of Health launched Primary Care and Community Services: Improving pharmaceutical service in April 2009, as a further resource to improve commissioners’ ability in commissioning high class pharmaceutical services. This guidance explains how commissioning is distinctive in pharmaceutical services, and outlines the levers and tools available to make change in these services happen. Important inclusions in the guidance are mapping the base line of the services which currently exist in each PCT and developing a clear vision for pharmaceutical service provision. 6.3 The CCA and AIMp urge the NHS Commissioning Board and the new Health and Wellbeing Boards in Local Authorities to incorporate this guidance in their new organisations. 6.4 It is encouraging that the guidance states that PCTs must ensure that there is appropriate pharmacist input at Board level whenever decisions about commissioning pharmaceutical services are taken and that PCTs should have a named Board member with responsibility for pharmaceutical services and to support strong and effective leadership for pharmacy. The CCA and AIMp will urge the NHS Commissioning Board to carry this forward to ensure pharmacy is represented at senior level within national, regional and local commissioning organisations. 6.5 The CCA and AIMp support the “Any Willing Provider” (AWP) model for delivering care and we will seek to demonstrate to commissioning organisations the vital contribution pharmacists can make to the care of patients and the public. 6.6 We would like to see information about how GP Consortia and Health and Wellbeing boards are commissioning community pharmacy in an annual assurance process. 7. How will commissioning interface with the Public Health Service and the role of local authorities in public health and commissioning decisions? 7.1 Local authorities will take responsibility for improving the health of the population and will jointly appoint Directors of Public Health who will be given control over ring-fenced public health budgets in their local area. 7.2 Health and Wellbeing boards will be created within local government to help coordinate commissioning of NHS services, social services and health improvement. 7.3 A system needs to be in place to ensure effective commissioning of the whole population. This will require clinical leaders and commissioners working together in a joined-up approach. 7.4 CCA and AIMp call for commissioners to ensure that community pharmacists are involved through the Pharmaceutical Needs Assessment (PNAs) process, and that the clinical services within the PNA are incorporated into Joint Strategic Needs Assessments which are the responsibility of the Directors of Public Health. This will allow community pharmacy to be included in integrated care pathways. 7.5 The current Government should build on the previous Government’s White Paper, Pharmacy in England, published on 3 April 2008 to “build on pharmacy’s strengths”, ensuring that community pharmacies “are commissioned based on the range and quality of the services they deliver”. 7.6 Many of the outcome measures of effective commissioning, particularly in the “staying healthy” and “long term conditions” categories, could be supported by the effective commissioning of pharmacy and would require partnership working by Health and Wellbeing Boards and GP Consortia. 7.7 Pharmacy’s future contribution to medicines management, patient care, delivering real and measurable outcomes and its ability to meaningfully contribute to future integrated care agendas remains wholly contingent upon the introduction of a national set of agreed standards and interfaces for IT and data management. The national definition of these is urgently required as this will support the transparent delivery of outcomes by all healthcare providers. 7.8 CCA and AIMp welcome the support from the CBI in their report Best of Health, Improving Lives through Smarter Care, which stated “Community pharmacy is highly accessible for patients of the NHS and those seeking to maintain good health. As well as being trusted by many patients, retail pharmacies make an obvious venue for delivery of NHS primary care services. The informality and accessibility of pharmacy encourages patients to feel comfortable to raising difficult or embarrassing problems that they may not want to see the GP about, such as sexual health advice. It also means that when patients present themselves with one problem, other aspects of their health can be assessed and responded to.” Recommendations — Commissioning of community pharmacy must be something which the NHS Commissioning Board, GP Consortia and Health and Wellbeing boards are measured on. Community pharmacy is an important component of primary care and must not be ignored simply because it is a contracted service rather than a direct part of the NHS family. — Every commissioning organisation and clinical network at national, regional and local level should have an identified Board member with direct responsibility for pharmacy services. Health Committee: Evidence Ev w39 — Commissioners should commission more services from community pharmacy because they are cost effective, are the subject of a developing body of evidence, and community pharmacy is a good way to engage the public and patients. — The introduction of a national set of agreed standards and interfaces for IT and data management. The national definition of these is urgently required as this will support the transparent delivery of outcomes by all healthcare providers October 2010 Written evidence from Royal National Institute of Blind People (RNIB) (COM 20) Summary Key points: — 85% of sight loss is avoidable, yet people continue to lose their sight unnecessarily, resulting in costs to the nation of £4.3 billion due to lower employment, informal care costs and the cost of devices and modifications. — More, not less needs to be spent on eye health promotion, detection and access to treatment. Eye clinics are struggling to meet the growing demand for treatment due to the licensing of new treatment and the ageing of the population. Commissioners should not be allowed to cut corners but must provide licensed and NICE approved treatments to all patients. — Patients whose sight cannot be saved rarely experience a smooth journey from health to social care. In some areas they benefit from Eye Clinic Liaison Officers that signpost them to available support services. These are often co-funded by Social Service departments. Cuts to Social care funding risk jeopardising this essential resource to support independent living. — Social services often underestimate the support needs of blind and partially sighted people. As a result blind and partially sighted people are often excluded from personal budgets and receive little or now support. Further cuts to social care funding is likely to exacerbate this situation leaving blind and partially sighted ever more isolated and unable to lead fulfilling lives in their communities. — This lack of support is likely to result in health services bearing the costs of providing treatment for depression, falls and health problems experienced by carers. RNIB Submission 1. As the largest organisation of blind and partially sighted people in the UK, RNIB is pleased to have the opportunity to respond to this consultation. 2. As a campaigning organisation of blind and partially sighted people and leading organisation in the UK Vision Strategy we fight for the prevention of avoidable sight loss as well as the rights of people with sight loss in each of the UK’s countries. 3. In our submission we will focus on the impact of cuts to Local Authority funding and the need to find up to £20 billion savings in the NHS on the services provided to people with sight-threatening eye disease and those who are blind or partially sighted. Current Challenges in the Area of Eye Care Services and the Impact of Funding Cuts 4. According to NHS Choices 85% of all sight loss is avoidable.27 This is to some extent a reflection of the development of new, effective treatments for the main cause of blindness and partial sight in the UK— wet age-related macular degeneration. Eye clinics across have struggled to meet the challenge of increasing treatment capacity in line with growing demand. Despite ongoing efforts to streamline services and patient pathways we are aware of considerable problems around the provision of treatment for glaucoma, access to wet AMD treatment and diabetic eye disease and, most recently, anecdotal evidence of the imposition of tougher criteria for cataract surgery. In addition, many patients are denied treatment for conditions, such as central retinal vein occlusion, which are not yet subject to NICE guidance or where no licensed treatment is available. 5. People are losing their sight unnecessarily and the costs to the nation are massive; in 2008 the indirect costs of sight loss in the UK (including lower employment, informal care costs and the cost of devices and modifications) were estimated to have amounted to £4.3 billion.28 27 28 Available at: http://www.nhs.uk/conditions/visual-impairment/pages/introduction.aspx Access Economics (2009): Future Sight Loss UK (1): the economic impact of blindness and partial sight in the UK population. Available at: www.rnib.org.uk Ev w40 Health Committee: Evidence 6. The challenges facing eye health care providers at present are likely to increase further due to higher demand as a result from the imminent licensing of new treatments for other conditions with previously limited or no treatment options (diabetic macular oedema, central retinal vein occlusion). The risk is that commissioners will cut corners to reduce treatment costs by opting for cheaper unlicensed treatment alternatives. We are aware of at least two Primary Care Trusts who have pursued this avenue in relation to the treatment of wet age-related macular degeneration. RNIB continues to challenge their approach, expressing particular concern about patient information leaflets that provide biased and incomplete information about the unlicensed treatment alternative. The pressure to cut costs is clearly undermining the mandatory nature of NICE technology guidance and the effectiveness of the current regulatory system that has been developed in the interest of patient safety. 6. Stakeholders in eye health (including pharmaceutical companies, the Royal College of Ophthalmologists and patient organisations) are working on a set of recommendations to disseminate examples of where eye clinics have managed to cope well with the challenges they are facing.29 While this is likely to contribute to better commissioning of eye health care services and increased efficiency we believe that a higher level of sight loss prevention can only be achieved if funding is at least sustained in real terms at the current level. Transition from Health to Social Care 7. Good practice in eye health requires services that allow patients to transit smoothly from health to social care. This is essential for those who do not respond to treatment and for those whose eye condition cannot be treated either because there is no treatment available or because they have presented late for treatment. At present this smooth transition from health to social care is far from guaranteed since few PCTs commission hospital eye clinics to provide a service to signpost patients to available support. 8. So-called Eye Clinic Liaison Officers (ECLOs) who provide this support have been recognised by the Royal College of Ophthalmologists as an essential part of an effective service for patients with age-related macular degeneration (AMD) and in some areas ECLOs are being funded jointly by Social Services, PCTs and third sector organisations. 9. There is growing concern that the cuts to Social Services budgets announced by the Government will lead to a discontinuation in the funding for these posts especially where health and social care budgets are not integrated. Current Challenges in the Area of Social Care for Blind and Partially Sighted People and the Impact of Funding Cuts 10. Even without any cuts in Social Services budgets blind and partially sighted people are affected by the increasing rationing of social services. In many cases their support needs are not recognised as significant enough. They are often assessed as having only low or moderate needs and as a result they rarely benefit from the personalisation agenda that the Government has rightly promoted in the past few years. Where blind and partially sighted people have accessed personal budgets they have welcomed the opportunity to put together a care package that meets their needs and have seen great benefits from doing so.30 12. Given the current problems facing blind and partially sighted people in relation to access to social care the proposed funding cuts present an enormous threat to their wellbeing. Already: — 20% of blind and partially sighted people say they do not recall receiving any visit from social services in the year after they registered with Social Services. — Services vary significantly across the country: The percentage of people reporting that they received a visit from social services within six weeks of being referred to Social Services ranged from 88% for the best local authority to 14% for the worst. — 17% of people that register with their council reported that they received no help or information at all in the year following registration.31 13. If funding cuts are implemented across the board this situation can only get worse. 29 30 31 For a discussion of capacity issues in AMD services see: Amoaku, W. (2009): Royal College of Ophthalmologists: Maximising Capacity in AMD Services. available at: http://www.rcophth.ac.uk/docs/scientific/Maximising Capacity in AMD Services - December 2009.pdf and Amoaku, W. (2009): AMD Services Survey. Royal College of Ophthalmologists. Available at: http://www.rcophth.ac.uk/scientific/amd-services-survey Kaye, A (2009): Lost and Found. RNIB, available at: www.rnib.org.uk Douglas, G, S Pavey and C Corcoran (2008): Access to information, services and support for people with visual impairment. Visual Impairment Centre for Teaching and Research (VICTAR), University of Birmingham. Please note that the figures regarding local authorities are unweighted. Health Committee: Evidence Ev w41 Indirect Impact of Social Care Cuts on Health Spending 14. If social care funding is cut and more blind and partially sighted people receive no support at all it is likely that the fall-out from this lack of support will be felt most acutely by carers and the health service itself. 15. This is because sight loss is associated with an increased risk of depression32 and an increased risk of injurious falls33, 34, 35, 36 and there is evidence that it also leads to extended average length of stay in hospitals resulting in late discharge into community care.37 Reduced support is likely to increase costs associated with these. 16. There is also strong evidence for the impact of caring on carers’ own health38 and less social care support is likely to increase that impact and the associated costs of an increased use of healthcare resources by carers. Society is already spending approximately £2 billion per year on the informal care for people with sight loss. Further reductions in social care support are likely to increase this figure as well as the figure of £2 billion spent on the direct costs associated with sight loss.39 Conclusions 17. The UK Government supports the World Health Organisation’s initiative to eliminate avoidable sight loss by 2020 and the UK Vision Strategy that was developed to achieve this aim. Whilst we recognize that the efficiency of eye health services can be further improved we have little doubt that the proposed spending cuts in social care and the decrease in NHS funding threaten to undermine efforts to improve the eye health of the population. Without adequate funding for early detection and treatment the number of people with sight problems is likely to increase from 1.8 million to almost four million in 2050. We strongly question the merits of salami-slicing spending cuts across all areas of NHS spending and would welcome a thorough, evidence-based debate on priority setting that takes account of new developments in eye health care and the impact of Social Care funding cuts on people with sight loss and those who care for them. October 2010 Written evidence from the UK Commissioning Public Health Network (COM 21) Background Information about the UKCPHN 1. The UKCPHN is a professional network of senior public health doctors and other practitioners working for the NHS either in primary care trust commissioning or specialised commissioning teams. 2. The group was first established in 2002 and now has 230! members. These members are drawn from all 10 England specialised commissioning teams and the majority of PCTs in England. As such the membership represents a significant proportion of public health practitioners actively working in commissioning. 3. The Group’s particular interest is priority setting and has, amongst its members, individuals that are recognised as having specialist knowledge and experience in this field. Equity and Excellence: Liberating the NHS 4. The UKCPHN has a number of concerns about the direction that the reforms are taking Society and the NHS. 5. The reforms purport to promote patient centred care, which our group would support. However the rhetoric and the overtones point to the NHS being taken towards a “patient as consumer” model of health care. Some of the evidence for this includes: — The promotion of direct accountability between the GP as budget holder and the patient. The Secretary of State has stated that he would like the GP to act as the patient’s “friend” while at the same time having greater and full accountability for scarce resources. One of the Ministers has also stated that the “democratic accountability” will therefore be in the consulting room—not between Citizen and the State. — The stated policy position that it is the GP’s duty to provide what their patients demand—even if this is ineffective healthcare such as homeopathy. 32 33 34 35 36 37 38 39 Evans, J R, Fletcher, A E and Wormald, R P (2007): Depression and anxiety in visually impaired older people, Ophthalmology, Volume 114, Issue 2, International Centre for Eye Health, London, pp. 283–288 Legood R, Scuffham P A and Cryer C (2003): “Are we blind to injuries in the visually impaired? A review of the literature”. Journal of Visual Impairment Research Thomas Pocklington Trust (2007): Lighting the homes of people with sight loss: an overview of recent research Scuffham et al. (2002): The incidence and cost of injurious falls associated with visual impairment in the UK Access Economics (2009): Future Sight Loss UK (1): the economic impact of blindness and partial sight in the UK population. Available at: www.rnib.org.uk Morse et al. (1999): Acute care hospital utlization by patients with a visual impairment HM Government (2008): Carers at the heart of 21st-century families and communities. Chapter 5: Health and Wellbeing. Available at: http://www.dh.gov.uk/prod consum dh/groups/dh digitalassets/wdh/wen/documents/digitalasset/dh 085338.pdf Access Economics (2009). See Footnote 40. Ev w42 Health Committee: Evidence — The introduction of the rule of rescue (which is the term that has been used to provide substantial resource to attempt to “rescue” someone from a grave situation even if the chances of survival are negligible) into the NHS in the form of the Cancer Fund. The aim of the fund is to give access to cancer drugs on demand. It is worth noting that the NHS has about £100,000 per person to spend throughout their life—namely cradle to grave care which has to secure primary prevention, all primary and secondary care, medication, community nursing, rehabilitation, nursing care etc. 6. There are two predictable consequences of continuing with such a philosophy. First is that inequalities and inequities will become even worse than they are now and second is that the NHS will provide less valuefor-money. Worsening Inequalities 7. Tudor-Hart first coined the term “the inverse care law” over two decades ago to describe the fact that those with the best health also received a greater share of the healthcare. 8. The Department of Health and the NHS has largely (neglectfully if not disgracefully) ignored this dimension of equity of access to healthcare. However we know the phenomenon is still prevalent within the NHS. Supporting evidence for this includes: — The fact that NHS budgets still do not reflect need. PCTs such as Bradford are 6% under-funded while Richmond and Twickenham continue to receive 20% above their allocation. — Studies reported in the Health Service Journal found that GPs that overspent their budget generally served more affluent areas while those that under spent their budget served poorer communities. Furthermore, using Patient Reported Outcomes Measures it would appear that middleclass patients tend to access treatments at a lower threshold than those from poorer backgrounds. This suggests amongst other things that GPs & clinicians may not be able to resist demands from middle class patients or that there might be a systematic bias in clinical decision making in favour of the middle classes. — The attached recent study of bone marrow transplantation is equally disturbing. This suggests that the poorer survival in those from lower socioeconomic backgrounds for a particular type of cancer may be contributed to because they are not accessing standard treatment. Repeating similar exercises in any service is likely to yield a similar picture to a greater or lesser degree. 9. Rather than address this inequity one can be confident that the reforms will worsen the situation because in systems where a consumer model of healthcare provision dominates those that have the best health manage to secure the best access to healthcare and there is a tendency to over treat and provide rule of rescue treatments. Reduced Value for Money 10. The second consequence of the move towards a “demand” rather than a “needs” based system is that the NHS will become less efficient. It has been stated that one of the aims for the reforms is to secure better value for money for the taxpayer with a plan to focus more on health outcome measures than process measures as a means of monitoring the performance of the NHS. At the same time the NHS is being asked to fund more treatments of limited or poor value. The two policies are contradictory. Throwing the Baby out with the Bathwater 11. There are also many problems and risks associated with such large scale reorganisation of commissioning which reflects, in our view, insufficient understanding of the range of functions which strategic bodies such as PCTs and health authorities before them have to carry out. (Even though a list of functions is available this does not necessarily translate into deep understanding of those functions). It is hard to see how these can simply be handed over to GP consortia without significant management and administrative support. The proposals outlined in the reforms are also born out of insufficient understanding of the task of commissioning which is a very time consuming process. PCTs and specialised commissioning teams do not, at present, have sufficient resource to commission everything well—at best it is possible to commission some of the services well for some of the time. It seems odd that a lack of resource and capacity has not been given proper consideration as a reason for suboptimal performance. So rather than further developing and building on existing systems there is a danger that substantial capacity— manpower, skills and experience—will be lost only for the NHS to then have to spend the next 10 years rebuilding it again. It is an inconvenient truth to both politicians and to Society that commissioning is skilled and resource intensive task if it is to be done well. Health Committee: Evidence Ev w43 Failure to be “Upfront” about Priority Setting 12. What has been very disappointing about the reforms and the rhetoric accompanying their announcement is that once again politicians have demonstrated little courage or leadership in the priority setting debate. It is a myth (but a nice story sold to a willing audience) that the NHS can provide everything by becoming more efficient. The Committee however would be hard pushed to find a single commissioner, manager, clinician or public health practitioner who truly believes that health service cuts can be avoided in the coming years. 13. PCTs trying to manage their budget have already come under fire from the Minister in relation to both homeopathy (which is not effective) and IVF (which is but is not necessarily seen as a priority). We are also getting some sense that capacity cannot be taken out of the NHS. It seems that the “new” interpretation of “comprehensive” is that the NHS should provide everything—or a bit of everything (with no help provided, of course, of where the line should be drawn). Pretending that everything can all be funded from within budget is at best denial and at worst dishonest. Recommendations: 14. That the population based perspective, through which resources might more fairly be distributed and with greater effect, is retained in commissioning and that patient centred care is not implemented as patient as “consumer”. 15. The preference of this group would be for integrated health care systems to develop based on programme budgeting and management. This is an alternative way to have clinical engagement. 16. The Department of Health and the NHS should pay greater attention to inequities in healthcare within England and less on comparison with Europe with a view to improving inequalities in health outcomes through addressing inequities in healthcare. 17. The Department of Health should address inequities in funding and also be careful that risk sharing schemes across GP practices and consortia do not lead to the poor subsidising the better off. 18. Politicians should demonstrate honesty and leadership by engaging the public and the NHS in priorities for funding. 19. Any major reform should be piloted in a realistic way—namely with both GPs who are keen and not so keen on the reforms and with a management budget which is related to the actual budgets GP consortia are expected to operate. Using preferential funding arrangements or financial incentives for the pilot schemes is disingenuous and will not provide the necessary evidence base for sound policy making. October 2010 Written evidence from Central London Healthcare (COM 22) 1. Introduction 1.1 Central London Healthcare (CLH) is a “not for profit” community interest company, bringing together 23 GP Practices in the City of Westminster to commission services on behalf of 130,000 registered patients. The organisation was formed over three years ago and has been successful in developing General Practice through providing innovative solutions to healthcare needs and managing demand while maintaining quality. The resulting hospital savings have been used to develop further services for patients. 1.2 CLH welcomes the White Paper because it will enable us to continue the journey we have begun to deliver services which meet the needs of patients through locally based GP and patient led commissioning. We therefore hope that as a result CLH will be able to move more quickly and have more impact on delivering outcomes for patients by being free of the constraints and limitations of Practice Base Commissioning, under which the organisation currently operates. 1.3 We have only responded to those questions raised by the Committee where we believe our experience or expertise as a well developed consortium of GP commissioners can be of value. 2. Clinical Engagement in Commissioning How will commissioners access the information and clinical expertise required to make high quality decisions about the shape of clinical services? 2.1 In answering this question we are drawing on the wealth of experience gained by over 200 clinicians, both doctors and nurses, across 23 GP practices, many of whom have an interest or background in a particular clinical speciality or aspect of health care. CLH also has strong relationships with secondary care clinicians as well as those working in community services. 2.2 Typically, when looking at a particular element of healthcare we will form a Clinical Reference Group led by a Primary Care Clinician, supported by clinicians from secondary and community care as appropriate. These groups bring together the local clinical expertise as well as looking further afield for evidence nationally and internationally. Ev w44 Health Committee: Evidence 2.3 CLH often operates through a combined Clinical Reference Group, with a non-clinical Project Executive Group ensuring that the clinical and administrative processes of the care pathway operate in an integrated manner to deliver high quality, effective clinical care with seamless easy access to that care. 2.4 We fully involve our patients in the design and delivery of services, and seek to improve clinical quality and patients’ experience of the services based on feedback received from patients. 3. How will Commissioners Address Issues of Clinical Practice Variation? 3.1 We see developing practices as a key element of CLH’s role with the objective of all practices delivering excellence in general practice. CLH has already achieved success in changing GP behaviour and reducing variation through through pro-active GP engagement and strong clinical leadership. 3.2 Examples of elements of our work which have enabled CLH to work successfully to combat issues of clinical practice variation are: A set of quality standards that practices must meet to be members of Central London Healthcare. All referrals to secondary care through our Patient Referral Service are peer reviewed by clinicians from other CLH practices. The provision of educational opportunities for GP and practice staff, as well as the opportunity for practices to share learning. Each practice also has a “buddy” practice to provide mutual support. A range of information provided to practices to allow them to compare their practice with peer practices. The adoption of a consortium approach to certain services thus enabling a particular practice to choose not to deliver a particular enhanced service but to offer instead that service to patients through a nearby GP practice within the consortium. 4. How will GPs Engage with their Colleagues within a Consortium and how will Consortia Engage with the Wider Clinical Community? 4.1 Engagement is key to both ensure GPs and practice staff are well informed and to ensure the consortium is aware of the needs of individual practices and those of their patients. CLH’s size means that as well as formal communications we can also maintain individual relationships across the consortium. We are concerned that if consortia are forced to be substantially larger than CLH, the collegiate spirit, peer comparison and collective responsibility may be lost. 4.2 Within the consortium CLH holds a number of forums which meet regularly for GPs, Practice Nurses, Practice Managers and Senior Administrative Staff. We have an annual multi disciplinary awayday, lunchtime clinical education sessions, various Clinical Reference Groups. We also provide newsletters for all staff and have active email exchanges on areas of interest. 4.3 CLH has a Management Board which is elected by all practices consists of GPs, Practice Nurses, Practice Managers, a Senior Manager from Social Care and the Chair of the User Panel. The User Panel brings together patients from across the consortium who are also engaged with their GP practices. 4.4 To engage with the wider community, CLH Clinicians sit on a range of boards with colleagues from other consortia, secondary care and community services (including social care). As well as our clinical reference groups we meet regularly with Secondary Care and Community Care Providers, Mental Health Providers and the voluntary sector. 5. How Open will the System be to New Entrants? Will care providers be free to offer new solutions which offer higher clinical quality, better patient experience or better value? 5.1 In our experience the processes that have been implemented to meet competition and procurement rules have led to the development of overly detailed specifications dictating to providers how they should operate their services. These specifications are often developed without the involvement of those directly involved in front line delivery. This has removed the opportunity for providers to innovate. We hope in future, while ensuring that legal and best practice requirements are met with regard to competition and procurement, we can challenge providers to provide innovative solutions to patients’ needs identified by GP commissioners. 6. Will Commissioners be Free to Access New Commissioning Expertise? 6.1 With the small number of staff within CLH, we have ensured we have access to a range of expertise and experience from the NHS, the Third Sector and the commercial sector. We believe there is much the NHS can learn, in commissioning, contracting, procurement and performance management from outside of healthcare. GPs as managers of their own small businesses also bring expertise to this area of CLH’s work. We supplement this core expertise with access to specialists as and when needed. We hope that a market will develop to allow GP commissioners to have further choice in where they can purchase expertise. Health Committee: Evidence Ev w45 7. Will Potential New Entrants be Free to Offer Alternative Commissioning Models? 7.1 CLH believes that the challenges ahead will mean looking at new approaches to commissioning. We will need to commission in a much more integrated way both across health and social care and across the various care pathways. With an ageing population and the increase in co-morbidities very many patients interact with a range of different health and social care services. The current approach to commissioning can often seem an inefficient use of resources resulting in uncoordinated care for the patient, even though each provider may be meeting their individual contract requirements. Commissioning in partnership with patients will inform priorities and solutions for co-ordinating care. 8. What Arrangements will be made to Encourage the Third Sector both as Commissioners and Providers? 8.1 As GPs CLH views the role of the Third Sector as critical both in terms of providing access to information and evidence with regard to the needs of the groups of patients the organisations represent, and as service providers. For example, CLH already works closely with the Third Sector and is currently working with Sense on MMR immunisation of child bearing women from ethnic minorities as well as reaching parents who may be fearful about having their children immunised. We are also working with Marie Curie Cancer Care with regard to End of Life Care. CLH is also seeking a suitable Third Sector representative to join its Management Board. 9. Accountability for Commissioning Decisions How will patients make their voice heard or their choice effective? 9.1 CLH puts the patient at the heart of all we do. We have an active User Panel of 14 members drawn from our constituent practice and it is inconceivable that we would make any significant decision without the approval of the User Panel. The Chair of the User Panel is a full member of our Management Board and other members sit on each of the key project groups. The User Panel also conducts patient surveys, provides feedback and recommendations on strategic planning, commissioning and service design or redesign; leads on our innovation fund and determines which projects will proceed together with the GPs. 9.2 We are however aware that it is impossible for such a group to represent the full diversity of our patient population. Therefore the User Panel has links with patient groups and patients in their practices and the wider community. We also engage with Third Sector organisations which represent particular groups of patients. Where there is a particular need practices make use of link workers to engage with certain groups of patients. For example we have both older peoples link workers and Bengali community link workers. 10. Integration of Health and Social Care How will any new structures promote the integration of health and social care? 10.1 CLH already works closely with Social Care and has a social care representative on the Management Board. Within Westminster CLH and the PCT have undertaken considerable joint commissioning and we believe there is scope to go further in this process. We believe there are many opportunities to improve services for patients and increase productivity, particularly in regard to domiciliary care services, by jointly commissioning services from providers who can provide both health and social care services. 11. Who will Drive Innovation During the Transitional Period? 11.1 CLH believes it has already delivered innovation resulting in improvements for patients. CLH has a comprehensive commissioning plan to deliver significant change. We will only be able to proceed with this work and deliver benefits for patients if we have access to resources to both progress this work and prepare for the future of GP Commissioning. October 2010 Written evidence from the Society of Chiropodists and Podiatrists (COM 23) The Society of Chiropodists and Podiatrists (the Society) welcomes the opportunity to respond to the Health Select Committee’s inquiry into commissioning. About the Society 1. The Society of Chiropodists and Podiatrists is the Professional Body and Trade Union for registered podiatrists. Membership is restricted to those qualified for registration and the Society represents around 10,000 private practitioners, NHS podiatrists and students. 2. The Society monitors standards of undergraduate education and provides opportunities for continuing professional development through its four faculties which are: the Faculty of Undergraduate Education; the Faculty of Podiatric Medicine; the Faculty of Podiatric Surgery and the Faculty of Management. Ev w46 Health Committee: Evidence 3. Maintaining healthy feet is one of the most important healthcare interventions to keep people fit, active and happy. People with poor foot health can find it impacts on them negatively in a number of ways— making them less mobile, less independent and more susceptible to other general illnesses. Podiatry also plays a crucial role in the treatment of serious conditions such as diabetes and arthritis. Views on the Existing Standard of Commissioning 4. The previous Health Select Committee inquiry into commissioning highlighted major concerns over the quality, effectiveness and value for money of PCT management with regard to commissioning of services. 5. We have found that while lip service is often paid to the benefits of good podiatric provision, the lack of a mandatory requirement for commissioners to invest in podiatry means that it is an area that can be squeezed. Indeed, in many areas, there have been ever-tightening eligibility criteria for patients requiring podiatric care, without any assessment of need being carried out. 6. While budgetary concerns will always be at the forefront of commissioners’ thinking, early intervention services such as podiatry will always lead to savings further down the line. For example the International Diabetes Federation estimates that early intervention by diabetic foot care teams could prevent 85% of foot amputations. Any reforms to commissioning must allow for better communication between commissioners and providers of various services to ensure that sufficient provision is available. Pace of Change 7. There has been a great deal of concern raised about the pace of change proposed in the White Paper and the impact that it will have on service delivery and quality of care. The Society agrees with others that it is not helpful to be both consulting on and progressing major change simultaneously. For our members in both NHS and private practice, the constant re-organisation and changing of healthcare structures and processes is unhelpful, and impacts on service and business planning, joint working with partners and patients and confidence in the system. We would urge the Committee to recommend the Department of Health takes a more measured and steady approach to allow the huge number of questions and concerns of healthcare professionals to be ironed out. Clinical Engagement in Commissioning 8. We would very much hope that any future commissioners, whether sitting in GP consortia or elsewhere, would seek to engage fully with the wider clinical community, including Allied Health Professionals. When dealing with the full range of possible services, we believe it is extremely important that commissioners understand the value of different types of service. 9. Many respondents to this consultation will no doubt express concerns that their specific service may be poorly understood by GPs, given its complexity, rarity, misconception, or personal GP preference. We would echo this concern. 10. It is vital that commissioners understand the fundamental difference between a fully qualified, HPC regulated podiatrist and the growing number of Foot Health Practitioners (FHPs). FHPs, who may set up businesses on the high street or work through third sector organisations, are not regulated and should only provide basic services such as toe nail cutting. However, the Society understands that many go further, providing treatments that should only be carried out by regulated podiatrists. Due to a lack of training, they may also fail to pick up on telltale signs of further health complications which a trained podiatrist would be well attuned to. 11. GP consortia must understand the difference between podiatrists and FHPs, why their charges may be different, and the importance of only referring patients to a registered podiatrist. 12. This leads to the broader question of how information and best practice will be shared between GP consortia and how consistency will be measured. As the health service becomes more localised and fragmented, it will become increasingly difficult for organisations with a specific interest, such as the Society, to communicate with commissioners and providers across the country. It would be disappointing if standards were to drop because inexperienced commissioning bodies are not able to access the best and most up to date information. The NHS Commissioning Board 13. There are many unanswered questions about the role and scope of the NHS Commissioning Board. For the Society, the key concern is that the Board is not fully representative of the diverse range of healthcare professionals. We would strongly recommend that there is at least one person representing Allied Health Professionals sitting as a permanent member of the Board. To focus solely on doctors and nurses would severely limit the Board’s ability to understand the interface between different strands of healthcare delivery. Health Committee: Evidence Ev w47 Impact of “Any Willing Provider” 14. Again, there are many unanswered questions about how opening up provision to new entrants in the market will impact on planning and patient care. For example, what happens to NHS premises if an NHS provider of podiatric services does not win the service contract under the new model? Will the premises be retained or sold—and would that mean that they could not then bid for services in the future? 15. Most independent podiatrists run small practices and may be at a disadvantage to larger providers if bidding to provide services. This will be particularly significant if the CQC has to pre-approve any providers in advance of them being able to bid for business. The path to CQC approval must be proportionate to ensure that there is a genuine level playing field and open market. Delivering Innovative Services 16. The Committee is right to ask how innovation will be driven forward during the transitional period, but this question also applies when any new arrangements are in place. The Society has concerns that the proposed commissioning structures will make it more difficult for innovative models to be developed, as commissioning becomes more fragmented and has a narrower geographical base. 17. In recent years, joint working between podiatrists and other healthcare professionals has delivered impressive results. As an example, musculo-skeletal triage services have been greatly improved through structured joint working between local physiotherapists and podiatrists, reducing the need for consultant referrals and leading to patients returning to work more quickly. We would be keen to stress to the Committee that any future commissioning structures should encourage and promote local innovation and joint ways of working. October 2010 Written evidence from Benenden Healthcare Society (COM 24) Executive Summary — Benenden Healthcare Society (Benenden) is a mutual purchaser and provider of healthcare, and a not-for-profit friendly society, fully owned by its members. The experience of Benenden’s successful supporting role with the NHS demonstrates the valuable role that mutuals have to play in supporting the NHS model — Benenden cautiously welcomes the proposals that the White Paper makes on the issue of GP commissioning, and hopes that the reforms will have a positive impact on patient choice and experience, and better shaping local services to meet local needs. — GP consortia should be encouraged to work closely with Third Sector partners, and other health and care professionals where their values align with the principles of the NHS to design joined-up services that are responsive to patients and the public, and the Select Committee may wish to scrutinise how such partnerships could evolve. — Benenden would welcome the Select Committee looking further into the issue of how choice and competition will best be fostered through the proposals, and how open the system will be to new entrants. — Benenden would like to work with the Health Select Committee to ensure support for the creation and expansion of mutuals, and other Third Sector organisations, and in enabling these groups to have greater involvement in the running of public services. — A priority when considering the issue of commissioning will be to look at accountability, and how best a balance can be reached between local and central accountability, particularly in decisions related to clinical priorities. 1. Introduction 1.1 Benenden welcomes this opportunity to make a submission to the Select Committee’s inquiry into Commissioning, looking into the new government’s strategy for commissioning. The proposals outlined in the recent White Paper Equity and Excellence: Liberating the NHS, clearly make it a timely moment to follow up on the work of the previous Committee in looking into the effectiveness of commissioning in the NHS. 1.2 Benenden was formed in 1905, and is a mutual purchaser and provider of healthcare, and a not-forprofit friendly society, fully owned by its members, as distinct from, say, the employee-owned model of mutuals. Membership of the Society stands at around 944,000 and includes current or former public sector employees and their dependents, or employees of registered charities and other organisations whose aims and objectives are deemed compatible with those of the Society. Ev w48 Health Committee: Evidence 1.3 Although Benenden predates the NHS, it wholeheartedly supports it and the concept of free healthcare for all, at the point of need. Benenden and the NHS, since its creation in 1948, have enjoyed a strong and supportive relationship, and this experience demonstrates how such roles could be expanded in the future to enhance overall NHS standards. 1.4 As well as procuring healthcare for its members, Benenden also provides first-class healthcare through its ownership of Benenden Hospital in Kent. Benenden Hospital provides high quality medical care and surgical services to Society members and is accredited by the NHS to provide services to NHS patients under the Patient Choice Programme. 1.5 Benenden share some of the concerns raised in the conclusions reached by Health Committee in the last Parliament about the current process of commissioning, including with regards to the performance of PCTs, and welcome efforts to achieve more empowered and effective commissioning. 1.6 Benenden welcome the key proposals in the White Paper for putting local consortia of GP practices in charge of commissioning services to best meet the needs of local people, supported by an independent NHS Commissioning Board. However, it is important that there is not a reorganisation just for the sake of it, in order to create something “new”. The key principles have to be patient outcomes and the efficient use of resources. It is well known that we have seen repeated reorganisations of the NHS over the last twenty years, and, as the Health Select Committee notes, the various approaches taken over the past twenty or so years have demonstrated that it does not automatically follow that a restructuring within commissioning leads to a better approach. 1.7 This submission seeks to respond to some of the key issues raised in the Health Select Committee inquiry, with particular reference to the potential impact for, and involvement of, Third Sector organisations such as themselves. 2. Engagement with the Wider Clinical Community 2.1 Benenden broadly welcomes aspects of the recent white paper, and the desire to improve commissioning inherent within it. It is not, therefore, opposed to the proposal to develop GP consortia who would assume responsibility for commissioning (supported by an independent Commissioning Board). 2.2 There are a few potential issues that Benenden have identified that the Government will need to take into consideration when looking at how to ensure the effective operation of GP commissioners. This will include how to manage the transfer of the new responsibility to take decisions on what should be treated as “priorities”. Successful commissioning will clearly be dependent on the wider involvement of other health and care professionals, and this will need to be promoted and supported from the centre—this will, presumably, require the new Commissioning Board and/or the Department of Health to ensure that the necessary linkages and relationships are developed to ensure an effective and joined-up approach. 2.3 GP consortia should be encouraged to work closely with Third Sector partners, and other health and care professionals where their values align with the principles of the NHS to design joined-up services that are responsive to patients and the public, and thought should be given to how partnerships could evolve. 2.4 There is a danger that the multi-professional support network that GP consortia will require will end up looking and acting like PCTs in a different name. It is important to safeguard against creating a system that abolishes one bureaucracy, but simply creates another in its place through an expensive process. 3. New Entrants 3.1 The inquiry is looking at the issue of how open the system will be to new entrants, and also specifically what arrangements will be made to encourage the Third Sector’s involvement, and this is obviously an issue of particular relevance to Benenden. 3.2 A significant aspect of the government White Paper is the commitment to increasing patient choice, with the promise that patients will have the “choice of any provider, choice of consultant-led team, choice of GP practice and choice of treatment”, and the removal of unnecessary barriers to new provision. Benenden believe that greater patient choice is a very worthy aspiration, and it will be vital that GP consortia ensure that maximising choice and providing as short a waiting time is possible is paramount, and Benenden are keen to see that this is considered a priority within their responsibilities. 3.3 Benenden would suggest that mutual healthcare providers can be a mechanism in the provision of choice that should be utilised. There will be occasions when Third Sector providers will be able to offer solutions which offer higher clinical quality, better patient experience such as shorter waiting times, or better value, and it is hoped that new commissioners will welcome and encourage their involvement in such instances. Benenden and the NHS, since its creation in 1948, have had a strong and successful partnership to date, that can provide valuable experience when considering the role that mutuals have to play in supporting the NHS model. 3.4 This can be achieved through greater involvement of patients in their treatment, an area that the White Paper makes a number of key commitments on, and on the improved publication of data to enable patients to share in decisions made about their care and find out much more easily about services that are available. Benenden are supportive of this ambition, which will help to promote choice and accountability, and look forward to seeing the introduction of this. Health Committee: Evidence Ev w49 3.5 There is a need to be realistic, in understanding that NHS is always going to be the dominant provider, but it is also important to ensure that choice and competition can flourish despite this dominance. Benenden will be interested to see the detail on how the Government seek to support this and what arrangements will be made to encourage the Third Sector both as commissioners and providers. A key issue for existing and new participants in the market will be the Government and new Commission’s attitude to market failure. Where NHS and Foundation Trusts are dominating other “players” we will want to see a “level playing field”. Continued subsidisation of failing organisations will quickly bring any true market to collapse. 4. Developing the Mutual Concept 4.1 It is a time of change and radical reform, both for the NHS, and in the management of our public finances more generally, and there are significant opportunities for mutuals to play a greater role. If we, as a nation, want to create a health and social care system which provides high quality right across the board, we have to recognise that funding this entirely from taxation is going to be an increasingly difficult task. Benenden would like to work closely with the Government as they seek to “support the creation and expansion of mutuals, co-operatives, charities and social enterprises, and enable these groups to have much greater involvement in the running of public services”.40 4.2 The scope for a greater role for mutuals in healthcare is illustrated by the fact that of all European countries, the UK has the third highest proportion of public funding within total healthcare expenditure. It is worth drawing the Department’s attention to the examples of other European states, whose positive experiences demonstrate the part that mutuals can play in healthcare provision. 4.3 France has a national system which is funded by social insurance contributions (contributions paid as a percentage of salary) and taxation. Patients pay a contribution for most treatments and services and the proportion varies for different treatments and drugs. Most French citizens (90%) use complimentary insurance to reimburse these costs and 70% use a mutuelle. Mutuelles are provided for within the French legal system under their own “Code de Mutualite”. They are entrenched in French society and even after considerable amalgamations they number over 10,000. The contribution from complimentary insurance to total health expenditure is 12.8%. 4.4 The Danish model is also worth noting. All primary and specialist care in Denmark is provided on the basis of need with no need for patient contributions, but co-payments are required for services such as pharmaceuticals (above certain thresholds), physiotherapy, dental care and some optometry services. These co-payments account for around 16% of total healthcare expenditure in Denmark, with government tax funds covering the other 84%. 37% of the population (over two million people) purchase complementary insurance through the not-for-profit “Danmark” organisation, which reimburses patients for co-payment costs. 5. Accountability for Commissioning Decisions 5.1 Unlike with GP fundholding, it is welcome that this move toward GPs acting as purchasers is being introduced across the board, rather than on a voluntary basis so that there is a parity of approach. And, moreover, the fact that GPs will, as a result, have greater accountability for their own resources is likely to result in more cost-efficient decision making, given that previously the cost of referrals has not been a significant consideration to GPs. 5.2 It will be interesting to see how the Government manages to put in place proper financial constraints and mechanisms, so that individual consortia are conscious of the need to control costs in the wider locality. There is a concern that if this does not happen, the overarching oversight and control of the purse strings could be lost. 5.3 The issue of accountability for commissioning decisions is a significant one for the Committee to consider. The creation of an NHS Commissioning Board and GP consortia is a welcome move in many ways towards a more locally accountable agenda, giving greater power to the local community. However the reality is that there will remain the expectation that the centre should also remain accountable for decisions, and a balance therefore needs to be struck between the lines of accountability. 6. Role of Local Authorities in Public Health and Commissioning Decisions 6.1 Benenden welcome the commitment to give a greater role to local authorities in public health and commissioning decisions, as again it helps to ensure greater local accountability. Benenden look forward to further details on how this will be achieved, and welcome the announcement of the publication a White Paper on public health later in the year. 40 The Coalition: Our Programme for Government, p29 Ev w50 Health Committee: Evidence 7. Conclusion 7.1 In conclusion, Benenden is supportive of the proposals that the White Paper makes on the issue of GP commissioning, and hopes that this will have a positive impact on patient choice and experience, allowing the Third Sector to play a greater role in the provision of health services. Benenden hope that the Health Select Committee find this submission of interest, and look forward to the opportunity to discuss their views further. Especially as Benenden is in an excellent position to share its expertise as a mutual with groups seeking to create new mutual organisations within NHS health market, and hopes that there will be the opportunity to do so. October 2010 Written evidence from the Association of Directors of Adults’ Social Services (COM 25) Summary — Health and social care are inter-dependent and all commissioning should reflect this. — Commissioning should focus on transforming services for better outcomes more efficiently. This involves shifting care for many people away from acute and institutional care and closer to home, and power away from professionals to people to define for themselves how best their needs can be met. — There is a critical leadership role for local government and ADASS members, together with opportunities to integrate commissioning. We have a range of resource agreements, risks and rights activities, population based and development and reform programmes and infrastructure offers to bring to the table with GP consortia. — ADASS welcomes many of the proposals of the NHS White Paper but the scale of the changes in the context of the NHS and Local Government addressing both financial and quality agendas for the forthcoming period must not be underestimated. Implementation must be done carefully if the spirit of the programme is to be maintained. 1. Background 1.1 The Association of Directors of Adult Social Services (ADASS) represents Directors of Adult Social Services in Local Authorities in England. As well as having statutory responsibilities for the commissioning and provision of social care, ADASS members often also share a number of responsibilities for housing, leisure, library, culture, and community services within their Councils and for co-ordination with the NHS, the criminal justice system, voluntary agencies, private companies and other partners. ADASS members have leadership responsibilities to promote local access to services and drive partnership working to deliver better outcomes for local populations. They participate in the planning of the full range of council services and work with NHS commissioning colleagues through formal and informal arrangements. 2. Introduction 2.1 ADASS welcomes the opportunity to submit this statement in relation to commissioning and the NHS. This response does not seek to directly answer all the questions of the inquiry but to emphasise the interdependence of the NHS and Local Government in commissioning. 2.2 We recognise the significance of the timing of this Committee and its contribution to the debate about the implementation of policies for commissioning outlined in the White Paper Equity and Excellence: Liberating the NHS. We know that there are plans for White Papers relating to Public Health and Social Care due in the future and so submit this paper in that context. NHS reforms will not be effective without a thriving social care sector. 2.3 This submission focuses on aspects of the committee’s inquiry that most interface with the concerns of Directors of Adults Social Services which are: — the engagement of the public; — ensuring that the services, supports and treatments commissioned improve outcomes for people, are personal and safeguard their rights and wellbeing; — the interfaces with the wellbeing of local populations and the role of the local authority and public health; — tackling inequalities and ensuring that the needs of more vulnerable individuals and families, those with specialist needs and communities are addressed; — the interfaces of a whole system of health and social care and with other public and community systems; and — the effective use of resources in a challenging economic and demographic environment. Health Committee: Evidence Ev w51 2.4 We consider these alongside the proposed “building blocks of commissioning” including GP consortia, the strengthening of democratic legitimacy locally whereby “local authorities will promote the joining up of local NHS services, social care and health improvement” and the establishment of an NHS Commissioning Board. 2.5 The scale of the proposed changes for both the NHS and local government must not be underestimated. ADASS welcomes many of the proposals. Care will be needed in the delivery of other aspects in order to ensure that the spirit of the policy is delivered in a way that is manageable in the context of other critical changes that are underway. This is a significant re-organisation of both the NHS and Local Government and it is taking place at a time when both have key financial and quality issues to focus on. As well as potential benefits there are therefore risks. 2.6 ADASS welcomes the transfer of public health responsibilities to local authorities. We have a history of working with public health colleagues, not least in relation to strategic needs analyses, which are critical underpinnings to commissioning activity. Most councils have some form of joint appointment and all have histories of joint working. 2.7 We welcome the proposals to formalise councils’ responsibilities for health improvement and the coordination of health, well-being and social care. Reciprocal duties for GP consortia to engage would enhance this function. 2.8 ADASS also welcomes the creation of statutory boards (Health and Wellbeing Boards) within local authorities and oversight for local democratic accountability. We believe that there should be flexibility about how such boards are developed locally, dependent upon: — The configuration of GP consortia and their overlay with the council’s geographical boundaries. — Current partnership arrangements. These have developed differently and we believe councils and their partners are best placed locally to decide how this will work for their populations and places— not least in terms of how they overlay with other partnerships such as those for community safety and children and young people 2.9 We believe that there should be a statutory requirement for GP engagement in these Boards. 2.10 Such boards must simplify accountability and address the strategy and key commissioning and delivery decisions across the whole health and social care, and wider social systems. We do not want to reexperience the bureaucratic weight of the Joint Consultative Committees of the 80s and 90s which oversaw the proportionately tiny amount of expenditure represented through joint funding whilst virtually never reviewing critical mainstream decisions. We urge the requirement for local authority involvement in the sign off of GP consortia commissioning plans. 3. Engaging the Public and Patients in Different Levels of Commissioning 3.1 ADASS welcomes the proposals for the involvement of people in decisions about their care and in enabling patients to shape the NHS. Directors of Adults Social Services have considerable experience of engaging with people to contribute to this. In relation to commissioning, we see this as operating on a number of levels. 3.2 At an individual level, much has been done to support people to be in control of their social care through work on personalisation: using individual budgets for people needing financial support from local authorities and developing universal information and advice and some support and brokerage services to enable people to organise what they need. This individual commissioning resonates with the concept that “the headquarters of the NHS is in the consulting room”. Individual commissioning and information about outcomes and people’s experiences are critical means of driving up quality. Given real choices, people will not choose the service with high mortality, infection or pressure sore rates or where there are low levels of dignity, safety or safeguarding. 3.3 An adjunct to individual commissioning relates to work with families, in terms of support for carers and for families who have social and other difficulties and where there may be safeguarding concerns in relation to children or adults being at risk of abuse. 3.4 Commissioning is dependent upon developing markets to respond to personalised service needs and developing community capacity. Unless there are suppliers of a range of responsive, effective and safe services (which is critically dependent upon a workforce with the necessary skills who are rewarded economically and/or through social recognition) then funding is to no purpose. Public and patient involvement at this level will frequently need to engage with communities of interest based around specific groups of people—for example, people with mental health problems or parents of young children. 3.5 Finally there is commissioning for practice populations and communities. Local authorities are key leaders both in terms of their democratic accountability and in terms of their leadership of a range of partnerships focussed on improving outcomes in the broadest sense for their populations and places. Much joint commissioning has been in place for some time, informed by a number of local involvement forums. We welcome the inclusion of local HealthWatch in the local authority portfolio. Ev w52 Health Committee: Evidence 4. Commissioning for Outcomes 4.1 ADASS welcomes commissioning for outcomes. This is not simple, for example in relation to identifying the outcomes people want for themselves. Much has been done to develop strategic needs analyses. The challenge is now to extend evidence banks of what works and the costs of interventions. We welcome the principle of having standards rather than targets. Whilst a focus on outcomes is positive, the possibility of three outcomes frameworks for the NHS, Public Health and Social Care that pull parts of the system in different directions needs to be avoided. We advocate the need for whole life outcomes that drive joint effort from across local government and the NHS. Outcome frameworks should be developed nationally but outcomes should be owned locally to agree priorities for investment and action. 4.2 We believe that the proposed payments systems (including payments of premia to GP consortia to make a proportion of GP Practice income linked to the outcomes they achieve) require careful thinking through as there is the potential for these to become as significant drivers as targets. 4.3 ADASS also believes that unless the issues of under-doctored and under-resourced areas of high population need are addressed, payments for outcomes and quality will very possibly exacerbate inequalities. GPs in these areas frequently have high numbers of patients on their lists, possibly the least infrastructure and are perhaps least likely to be able to engage in commissioning. We believe that the payment of premia to encourage GPs to work in such areas should be considered. 5. Commissioning Purpose 5.1 Commissioning led through GP consortia and councils should have as its purpose to shift patterns of care and support to achieve both better outcomes and more effective and efficient services. There are key opportunities for closer integration of primary care and other services and more flexible, preventive and streamlined services for people with long term conditions and living in vulnerable circumstances. 5.2 Health and social care commissioning must complement each other and use joint commissioning as a bridge, developing services that reduce the need for costly acute and residential care. These services should support people to stay where they generally want to be, which is at home. ADASS and the Department of Health commissioned “Commissioning Care Closer to Home” this year. It addressed the commissioning of services that move away from an acute hospital focus and encompass a broader approach to people than treating a condition. These will include community wellbeing, social inclusion and health inequalities. As critical as commissioning new services is the de-commissioning of less effective services. 5.3 This requires a focus on all the public and community activity in a place. “The implementation of care closer to home could be reinforced if it is seen as a key component of the local ‘story of place’ and… a shared objective for all partners including politicians and the public”. 5.4 They concluded that wide ranges of partnering arrangements are in place and that the goal should be a “single community based support system focussed on the health and wellbeing of the local population”. 6. Integrated Health and Social Care Commissioning 6.1 The White Paper argues that NHS commissioning through PCTs has become both too remote from patients and from the clinical insight of GPs. 6.2 Directors of Social Services have a long history of working with health authorities, NHS Trusts, GP fundholders, PCGs, PCTs and practice based commissioners. We know that structure and process for commissioning are important but we also know that the interaction, behaviours, knowledge and skills of partners are essential to make things happen locally. 6.3 ADASS members are already engaging in a range of discussions, nationally and locally to ensure that new commissioning is as effective as possible. Involvement is broader than just GPs. We believe that the Royal College of GPs, ADASS, the Association of Directors of Children’s Services, the Association of Directors of Public Health and NHSConfed can work together as professional organisations to deliver the agenda. 6.4 Given this experience we are very concerned that this NHS transformation is undertaken carefully. Replacing 152 PCTs with a yet unknown number of GP consortia will put GPs in a pivotal position. It will potentially break the co-terminosity of PCT and council boundaries and weaken the ability to commissioning jointly. There needs to be strong professional input to counter this and an understanding that commissioning will need to flex up to the footprint of regions for some services and down to neighbourhoods for others. We recognise that there is a risk of fragmentation and the potential benefit and risk of consortia taking very different approaches. We believe that GPs have mixed views of the proposals. 6.5 Our challenge is to make offers to consortia to support effective health and social care commissioning. The offers we can make are based in our experience in involving people, addressing the needs of populations, working with communities and markets and of commissioning jointly both with the NHS and with other statutory partners. We are also exploring what and how we can offer commissioning support, particularly in the areas where we are critically interdependent. Health Committee: Evidence Ev w53 6.6 We are concerned initially to ensure that locally partners are clear about what they want to achieve (better care at individual, family, practice, community and population levels) their priorities and that pooled budgets with adult social care and children’s services and safeguarding are sustained. We have identified the following for Directors to bring to the table early with GP consortia: — Resource agreements: such as continuing care, reablement and rehabilitation, equipment and telecare investments and joint commissioning. — Risks and rights activities: such as Mental Health and Mental Capacity Act work, safeguarding children and vulnerable adults, interfaces with the criminal justice system and complaints, inquiries and CQC investigations. — Population based programmes such as Joint Strategic Needs Assessments, emergency and civil contingencies, prevention, public engagement, and public and school health. — Development and reform programmes: including personal budgets, social capital and volunteering, carers, dementia and autism. — Infrastructure such as assets, commissioning, procurement, HR and information management. 6.7 We are likely to be able to increase efficiency by sharing overheads and infrastructure, knowledge and skills. 7. NHS Continuing Healthcare 7.1 ADASS believes that future arrangements for the delivery and governance of NHS Continuing Healthcare must be robust. Eligibility for this has been a source of confusion, controversy, ombudsman investigations, litigation and media attention. In 2007 a national framework was introduced which provided a single process for determining eligibility and did much to improve fairness and consistency across England. In 2009 the framework was updated and PCTs, SHAs and local authorities have clear statutory responsibilities. We believe there is an urgent need for the risks and challenges inherent in this to be fully considered in discussions between PCTs, emerging GP consortia and local authorities to ensure that transitional arrangements run smoothly and that statutory functions are assigned to new organisations once the PCT’s and SHA’s are abolished. 7.2 ADASS proposes that the following could be put in place to mitigate risks: — The NHS Commissioning Board is given powers and responsibilities to ensure the fair application of the National Framework for NHS Continuing Healthcare and that the DH retains policy responsibility for the Framework. — The NHS Commissioning Board should have powers to hold GP consortia to account for the fair application of the Framework. — Plans are made so that the Independent Review Panel arrangements (required by Directions) continue to operate as joint local authority and NHS arrangements at a regional level, ensuring independent arbitration where an individual appeals against a decision not to provide them with NHS funded care. This could be a responsibility of the NHS Commissioning Board delegated to regional arrangements. — Health and Wellbeing Boards/partnership arrangements between local authorities and GP consortia are established in a way that facilitates: — a joint approach to assessment for NHS CHC eligibility; — governance and system management of NHS CHC processes across local authorities and clusters of GP consortia; and — a joint approach to commissioning care for people in receipt of NHS CHC and for people who have high levels of need but do not necessarily meet the criteria for fully funded NHS care. — In order to ensure fairness, transparency and to maximise personalisation, ADASS proposes that arrangements should be made for reporting nationally on the number of individuals in receipt of NHS CHC who are supported to live at home as a percentage of those in receipt of NHS CHC in the local population. 8. Regulation, Inspection and Local Co-ordination and Accountability 8.1 Some of the White Paper’s proposals, such as the proposed inter-relationships of CQC, Monitor, the NHS Commissioning Board, local partnership arrangements and HealthWatch and the extension of the National Institute for Health and Clinical Excellence to Social Care (NICE already works with the Social Care Institute for Excellence to jointly produce quality standards, for example the recently acclaimed work on dementia)together with commissioning are, at least at this stage, confusing. 8.2 They may be equally confusing for the public. We would welcome further exploration and clarification. Ev w54 Health Committee: Evidence 9. Resource Implications 9.1 There are financial and resource implications for councils from the White Paper proposals which are as yet unquantified but which will impact on commissioning. Key concerns for us are: — The level and nature of public health budgets and staffing transfer arrangements. — The costs of Boards and local Health Watch and the short-term implications for LINks as existing contracts expire. — Arrangements for joint commissioning and pooled budgets. — Financial accountability arrangements for GP consortia and practices—including overspending. — The NHS, flexibilities and place based budgeting. — The funding of reablement services. October 2010 Written evidence from 2020 Public Services Trust Information and Technology Group (COM 26) 1. Over the course of the past year the 2020 Public Services Trust (2020 PST), an independent think tank and registered charity based at the RSA, has published a series of papers that attempt to recommend the characteristics of a new public services settlement appropriate for the future needs and aspirations of citizens, and the best practical arrangements for its implementation. One of our areas of work addressed the future of information and communication technology in public services in a report called “Online or In-line”.41 2. Compiled by the 2020 Public Services Trust Information and Technology Group, our report concluded that: “ICT is critical to unlocking the efficiency gains required to deliver high quality public services at a time of fiscal restraint. We therefore call for much stronger flows of information between service users and providers [and] greater use of online services…”42 3. These information flows are critical for high quality commissioning, the purpose of which is to achieve four things: (a) Effective and appropriate distribution of resources. (b) High and improving quality of care. (c) A good and improving patient experience. (d) Low and reducing costs. 4. For this systemic reform of commissioning to succeed, it is crucial that timely, accurate information is available to the key stakeholders—commissioners, patients and the public—in a form that allows them to make informed choices, take control of their use of the health services and to hold the system to account. In summary: 1. The absence of accurate data on performance, spending and costs leaves commissioners and the public blind when crucial decisions have to be made about investment in, or closure of, services. The public has no information on how PCT spending aligns with disease prevalence, meaning that GP Commissioners cannot be held to account for meeting local health needs. Crucially, the almost complete absence of cost and productivity data in community services means that the hypothesis that shifting care out of hospitals will provide a better, low cost NHS, is simply an idea based on a limited number studies in other health systems. 2. Patients and the public cannot get the answers to simple questions like, “How good or bad is my local GP?” or “Which local provider organisations provide the best care?” This means that they can neither make informed decisions about where to get care, nor can they make an informed contribution to local health discussions such as the merger or closure of services. 3. Neither patients nor GPs can get access to routine patient experience data, to inform commissioning or choice decisions. 4. Neither the public nor commissioners have an understanding of what services cost, either absolutely or in relative terms. Without cost, outcome or satisfaction data they cannot assess the value for money of services they commission or use. 5. Each of these questions can be answered, but only via more comprehensive intelligence and transparency within the NHS. This submission to the Health Select Committee enquiry sets out our recommendations for the better use of information in commissioning high quality, cost-effective healthcare. 41 42 Alldritt, C, Coulthard, J, Crabtree, J, Kelsey, T, Lucas, B, Shaw, J, Swindells, M, Taylor, L, “Online or In-line: The future of information and communication technology in public services” (London, 2020 Public Services Trust: 2010: 11) Note that the principles of “Online or In-line” align closely to the three pillars of information in healthcare proposed by the British Computer Society, namely: transparency, interoperability and self-service. Health Committee: Evidence Ev w55 6. Our recommendations are structured in four parts: (a) Data collection: Data needs to be collected to be able to inform commissioners, patients and the public on the quality and value of their health service. (b) Data quality: Data quality needs to be of a high standard. (c) Transparency: The data needs to be made available to commissioners, patients and the public in a variety of forms that will allow interrogation for decision making and accountability. (d) Comparison: Data should be benchmarked against UK and international comparators to create an environment of competition and striving for excellence. Section 1: Data Collection 7. There are significant gaps in knowledge around NHS commissioned services. While we know that mortality rates in hospitals vary from below 29% of the national average to 31% above it,43 we lack similar insight on episodes in primary care. Some of the underlying data exists, but it is not routinely collected. 8. There is very little data on quality or efficiency for most “out of hospital” services (especially community-based services), the quality of data in social care is very poor (eg there is no standardised outcomes data on nursing homes or hospices) and there is virtually no useful measurement of outcomes in maternity services. Stripped of its patient identifiers, this type of data is critical to the development of quality measures and to the future development of measures across whole pathways. 9. While the coalition is correctly focused on reducing the burden of data collections on local services, it would be a mistake to confuse this agenda with a reduction in the need for relevant, quality data. One of the reasons that the NHS is administratively expensive is that data has not been robustly collected in many areas and standards have not been defined. This has meant that every time someone wants to understand NHS performance they have to collect the data as a separate, bureaucratic process. An example of this is the UNIFY 2 database at the Department of Health (DH), onto which hospitals load performance data such as waiting times and healthcare acquired infection data, despite the fact that this is also collected automatically through the Information Centre (IC) Hospital Episode Statistics (HES) submission or on local pathology systems. The quality of HES data (the official national record of hospital activity) is considered to be of too poor for management purposes. 10. However, enhancing existing data collection mechanisms could help to address some data gaps almost immediately. For example, including a “present on admission flag” for coding of diagnoses in Secondary Uses Service (SUS) data would increase the value of this data enormously at relatively little cost. 11. The NHS must ensure it has the information commissioners and the public need. This means standard data sets defined nationally, collected once and used for many purposes. It is only by improving the intelligence gap that inequalities will start to be reduced and variation in outcomes narrowed. Recommendations: 1. Standardised national data sets need to be developed urgently for episodes in primary care and community services, similar to the routine data set on episodes of hospital activity. These should be done incrementally so that that striving for “perfect” does not extend the existing delay of many years. 2. The NHS Information Centre should act as a hub ensuring that a single dataset is created and managed that meets the needs of the Commissioning Board, regulators, the professional bodies and Health Watch. Their remit should be to identify a minimum core dataset that is managed as licensing provision for all NHS providers, including GPs. 3. The NHS Information Centre should be required to publish a comprehensive roadmap for publication of primary care data within three months, to begin collecting skeleton data from 1 April 2011 and evolving to a comprehensive dataset in 12 months. 4. A key responsibility of the new NHS Commissioning Board should be to produce to a sixmonthly report for parliamentary scrutiny highlighting its proposals for closing intelligence gaps and developing modern measures of outcome in all areas of NHS activity. Section 2: Data Quality 12. The NHS is in a self fulfilling cycle of failure with regards to data quality. The quality of data routinely collected as a by-product of providing care is poor or absent. Therefore, it is not used for management purposes and a costly parallel bureaucracy has been created to gather management data. The poor quality of routinely collected data is used as an excuse not to share the data with the public. Therefore, it is never exposed to scrutiny and there is no drive to improve it. 13. If the gaps in data collection are addressed, as described in section 1 above, three things need to happen to ensure that those data sets are populated with high quality data. 43 Dr Foster Intelligence, “The Dr Foster Good Hospital Guide; How safe is your hospital?” (Dr Foster Intelligence, 2009) Ev w56 Health Committee: Evidence (a) Individual clinical responsibility 14. Transparent clinical data at the level of individual clinician has been shown to improve quality and productivity in initiatives such as the New York Cardiac Surgery programme, which publishes risk-adjusted performance data on individual surgeons and has recorded a 41% reduction of mortality in three years. Recommendations: 1. It should become a legal duty of all providers who are funded by the NHS—including individual clinicians—to collect standardised, high quality data on their individual patient activity and outcomes to meet the national standards. 2. Commissioners should have the power to require addition local data access and suspend providers’ NHS funding or referral of patients for failure to comply. 3. The Information Centre should check that its clinical audit databases (eg SUS) are being completed accurately—currently it funds many clinical audit datasets where completion rates are so low that the resulting data is of limited value. 4. Software suppliers should be required to provide regular, routine extraction from their databases to avoid this data collection becoming a bureaucratic overhead. (b) Patient access to records 15. For the Coalition’s health strategy to work and the information revolution to be real, there must be a cultural change in the relationship between patients and the NHS. Patients must become intelligent consumers of services, not simply their passive recipients. This will require patients to have access to information about providers and their own record. Choice of provider is illusory if any decision other than your current GP and local hospital will require a full history on the patient to be created from scratch. 16. Direct patient access to their record will drive data quality, allowing the patient to be an auditor of data quality. It is already possible for patients to access their record from home in some practices, such as those in South London and Hyde in Manchester, but few practices have activated or publicised this capability. Recommendations: 1. All GPs should provide quick and simple online access to patient records within 24 months. 2. NHS Choices should show from April 2011 which GPs can currently offer their patients access to their clinical record from home to enable patients to choose a GP that offers this service. 3. From April 2013, the Commissioning Board should withhold a proportion of the capitated payment from GPs who fail to offer this service. (c) Open access to the same single datasets 17. If data quality is to receive the management attention that it requires, the disconnect between data gathered for bureaucratic processes and data gathered for patient care and service management must be resolved. Recommendations: 1. The Department of Health should require that all contractual activity and quality management will be undertaken from the same transparent datasets. This would mean that the HES activity data would be used for payment and made available to the public for scrutiny. 2. The IC should identify, rationalise and make available all data sets collected from the NHS, including those held by other government departments. This should not increase centralisation. Datasets such as disease registers should continue to be managed by a variety of organisations. 3. The IC, Office for National Statistics and other organisations holding public data sets should have clear rules and processes to ensure timely access to data for external organisations. There should include a commitment to respond to request for data within a reasonable time frame, rules for access to anonymised data and for handling applications for identifiable data (making use of the public interest oversight provided by the National Information Governance Board). 4. Organisations such as the Commissioning Board, Care Quality Commission or Monitor must use existing sources wherever possible and only collect additional data where demonstrably necessary, making the data they collect available as part of the distributed national dataset. Health Committee: Evidence Ev w57 Section 3: Information Transparency 18. The new White Paper will see the NHS held to account for its performance by the public and commissioners rather than the Department of Health. A crucial element to enabling this is breaking the virtual state-monopoly on the publication of NHS performance data. A market must be created in data analysis so that commissioners and the public have the information they need. At present this market is held back by the refusal of the NHS to give access to the data. Without such transparency the NHS can return to cosy self regulation and quality will suffer. 19. There should be a general principle that any data that the Information Commissioner would approve for release under a Freedom of Information request should be routinely placed in the public domain as it is created. The specific set of actions below should start the process: 20. There is huge variation is primary care prescribing across the NHS causing harm to patients and unnecessary waste of resources. For instance, more than 2,000 patient a year die prematurely because they are inappropriately prescribed antipsychotic drugs by their GP,44 yet we do not know which GP practices are responsible, nor why. Recommendation: Data on prescribing needs to be published at GP practice level so that providers, commissioners and patients have transparency around prescribing behaviour on an appropriately risk-adjusted basis.45 21. The NHS already collects a wide range of data, but “The problem is that this data is not widely available for analysis by other interested parties—whether in the private or third sectors, or by citizens themselves. For example, data on primary care is collected but is not routinely available. This means that citizens, private or third sector bodies cannot benchmark the quality of GPs or community service providers.” (Online or In-line, 2020 PST, 2010: 23) Recommendations: 1. The DH should open up to public scrutiny all the performance databases that it holds, appropriately anonymised. 2. Data on all healthcare provider outcomes need to be published routinely to the entire community so that commissioners and the public can be better informed. 22. Greater patient engagement helps to create a culture of self-management, including increased selfservice and the exercise of choice. A culture of self-management is crucial for the modernisation and indeed survival of the NHS in its current form, free at the point of need.46 However, there is no standard for collecting or analysing the data that is needed to judge how far this culture of self-management is progressing, and patient experience data is not readily available to the public in a comparable format. Recommendation: All providers should be required to produce routine data on patient experience, standardised to commissioner requirements. We would expect that this would mean at least biannual data on comprehensive patient experience to inform commissioning decisions. 23. Data on costs of health services—despite a commitment to maintain real spending in the NHS over the next parliament, the organisation will need to find 20% productivity savings if it is to meet rising costs and increased demand for health services over the next five years. Transparent data and information are critical for increasing cost-efficiency. 24. Commissioners need to know that it is possible to commission better quality at lower cost; “Similar hospitals in London can vary by 25% in their costs and that the hospital providing the best outcomes in the South East is 10% cheaper than the one providing the lowest quality care.”47 The public needs to know that there is no direct correlation between spend and quality, and hold providers and commissioners to account for the value of the healthcare they are buying for their money. Recommendation: The Department of Health should make reference cost data publicly available. The Commissioning Board should create a comparative index of cost and quality for all the services it commissions and the providers of those services. Section 4: Performance Comparison 25. The scale of quality and productivity variation within the NHS is enormous. Driving the poorest performers towards the standard of the best will save lives, reduce waiting and reduce cost. This is the key prize in the financial challenge that public sector faces. It is therefore crucial that robust comparison can be made at hospital, community and primary level; covering public and private providers of NHS care. 26. Release of comparative data has been held up for years, in part by concern that unfair comparison will be made if the data is not adjusted to allow for variations in the complexity of the patients. This argument has allowed unjustifiable variation to continue unchallenged. The Department of Health needs to address the 44 45 46 47 Department of Health, “National Dementia Strategy” (DH, 2009) If necessary, release of prescribing data at GP practice level should be subject to our “public good test” to assess whether the social benefit of publishing this data outweighs private contractual/privacy concerns. See, Alldritt, C et al., “Online or Inline”, 2020 PST (2010:25). Wanless, D, “Securing Good Health for the Whole Population” (HM Treasury/DH, 2004) Alldritt, C et al., “Online or In-Line”, 2020 PST (2010: 24) Ev w58 Health Committee: Evidence need for robust risk adjustment methodologies, without allowing this to be a block to all progress. It should also endorse at a national level particular outcome measures that the NHS expects organisations to use while recognising that this list of metrics will change over time as improvement to data and risk models allow. 27. Furthermore, if the best organisations in the NHS are to improve, they, commissioners and the public need to have access to international outcomes so that they can aspire to world-class excellence. Recommendations: 1. The DH programme to create risk standardised outcome measures needs to be accelerated and the outcomes placed in the public domain to be used by any organisation. 2. All organisations publishing comparative “league tables” with proprietary risk adjustment should be required to publish their methodology or have it kite marked in advance by the NHS Information Centre (as a way to protect their intellectual property). 3. Each hospital, as part of its Foundation Trust status, should be required to publish international comparators of outcome. The Information Centre should publish guidance on the best practice in such publications. 4. In due course, international benchmarks should become a standard part of all quality reporting by providers (including out-of-hospital providers) in the NHS. 5. The DH should use NHS Choices as a route to publish “official” comparisons, without attempting to make this the only source of comparative data. October 2010 Written evidence from the Audit Commission (COM 27) Summary Clinical Engagement and Accountability for Commissioning 1. The government’s proposals for commissioning through GP consortia are different from earlier policies that had similar aims. Nonetheless, previous experience offers relevant lessons for making the changes more likely to succeed. We have reviewed the findings from Audit Commission studies into GP commissioning published over the last 15 years and recent audit reports on current arrangements in ten PCTs. In our view, the key areas for action are: — adequate management allowances and financial incentives to participate with be essential to overcoming previous barriers to GPs’ capacity and willingness to engage in commissioning; — previous GP commissioners have been strong on planned care but less strong on emergency care, mental health, working with local authorities or involving patients in commissioning decisions— time will be needed to develop GP commissioning capability; — information on activity and finance available to PCTs and GPs has often been inadequate—a major development programme will be required; and — putting in place governance arrangements that make clear the respective roles and responsibilities of the Commissioning Board and GP consortia, as well as helping to avoid any conflicts of interest within consortia. Integration of Health and Social Care 2. The Commission’s study, Means to and End (2009), is the most recent authoritative review of joint financing arrangements by any organisation. Key points are: — the relatively slow development of pooled funding and other resources over many years (currently only 4% of NHS and social care funds are pooled), despite the complete flexibility offered by the legislation; — perceptions about the difficulty of integration and the important role of individuals; — misalignment of financing systems and timetables, and of information provision; and — the impact of personal budgets on joint financing and other arrangements. Transitional Arrangements 3. The Commission’s key points are: — maintaining strong financial management, where the NHS has an improving track record, will be essential; and — managing the costs and potential disruption of restructuring. Health Committee: Evidence Ev w59 Clinical Engagement in and Accountability for Commissioning 4. GP Consortia will be different from previous policies aimed at getting greater GP involvement in commissioning. Several different approaches have been adopted since GP fundholding (GPFH) started in 1990. Firstly, multifunds—where separate fundholders pooled their resources and commissioning power— and then Total Purchasing Pilots—which extended the services covered by fundholding. Both were developed directly by GPs. These arrangements were replaced by primary care groups and, initially, primary care trusts before practice based commissioning offered another solution. 5. Since 1995, the Audit Commission has published several studies into the different approaches, drawing on audit work and field research. Auditors have also reviewed local arrangements as part of their statutory responsibility for satisfying themselves that health bodies have proper arrangements for value for money ie securing economy, efficiency and effectiveness in their use of resources. We have reviewed the studies and the ten most recent local audit reports to identify common experiences and themes that must be addressed if GP consortia are to be successful. They are grouped into four broad categories: — GP capacity and willingness to engage in commissioning; — development of commissioning capability; — information on activity and finance; and — governance arrangements. GP Capacity and Willingness to Engage in Commissioning Activities 6. Our studies of GP Fundholding (GPFH), Primary Care Groups (PCGs), and Practice Based Commissioning (PBCs) have all highlighted the difficulty of GPs having enough capacity to engage properly with commissioning. None was universally successful in addressing this issue. Exhibit 1 shows the results of our 2007 survey of PBCs. A minority of GPs considered they had sufficient capacity to manage an indicative budget and to monitor activity. Adequate management support will be essential to undertake commissioning and contract management as well as, for example, financial management and data analysis. Exhibit 1 PBC CAPACITY TO MANAGE A BUDGET AND MONITOR ACTIVITY Practices views on whether they had sufficient capacity to manage an indicative budget and to monitor activity To manage an indicative budget To monitor activity 18% 17% Yes 39% No 44% 44% Partly 38% Source: Practice based commissioning survey 2007. Audit Commission 7. Pooling management allowances is a way of maximising their value through reducing duplicated effort and increasing efficiency. It also brought small practices into the GPFH scheme through multifunds. They varied considerably in size. There was also little correlation between the list size of the multifund and the amount of management allowance contributed to central office costs, as Exhibit 2 shows. Ev w60 Health Committee: Evidence Exhibit 2 MANAGEMENT COSTS FUNDING ARRANGEMENTS FOR MULTIFUNDS 8. Consortia will need to address the question of how much responsibility to devolve to individual practices for monitoring budgets and activity and how much freedom to give them. Such devolution will be essential if practices are to adjust their own clinical behaviour and see the advantages of doing so. However, the greater the devolution, the greater the management demands on individual practices. 9. Alongside management support, another common issue was adequate incentives for GPs to manage a budget successfully. Use of savings, and conversely responsibility for overspends, has always been a difficult matter. Failure to provide suitable incentives through use of savings bedevilled the early development of PBC. This in part accounted for our finding that, although nearly all GPs received a payment for PBC activities, only about two thirds reported themselves as “actively engaged”. Many GPs also focused more on how to develop provision in primary care than on better commissioning of secondary care more widely. Health Committee: Evidence Ev w61 Development of Commissioning Capability 10. Although there is much experience of GPs having direct control of budgets, there is no experience of GPs taking active responsibility for commissioning all of secondary care. Even the Total Purchasing Pilots in the 1990s—perhaps the nearest cousin to GP Consortia—focused on a limited number of areas. Exhibit 3 shows the median PBC budget was only 40% of the PCT total. Exhibit 3 SCOPE OF PBC INDICATIVE BUDGETS Percentage of PCT’s overall budget for 2006/07 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Median PCTs Source: Audit Commission 11. The most popular focus for Total Purchasing Pilots was Accident and Emergency, but the pilots covered only some 8% of practices. There is relatively little experience of GPs using budgets to commission and manage emergency care, an area where PCTs have also struggled. GP commissioning has been much stronger on managing planned care and developing alternative services to secondary care. Our Practice Based Commissioning (PBC) research showed that 55% of practices surveyed reported there had been a positive impact on referrals and almost all had worked to reduce referral activity. Improvements in the cost and quality of GP prescribing were also often reported. 12. GP commissioners also have limited experience of commissioning mental health services or those for other vulnerable groups. Few, if any, total purchasing pilots actively commissioned mental health services. Nor have practice based commissioners. However, our 2006 study, Managing Finances in Mental Health, identified more general weaknesses in arrangements for commissioning mental health services, stemming in part from the quality of information made available by providers. Previous GP commissioning arrangements have also not shown significant success in involving patients and the public in commissioning decisions. 13. However, it is clear the different versions of GP commissioning have had success, within their more limited scope. In GPFH and PBC, these were mostly tactical, not strategic. They paid close attention to some individual care pathways but few secured radical changes in services. 14. The important points here are that realistic expectations should be set about what new GP commissioning arrangements are likely to deliver, especially in the early years. Also, commissioning capability will need development, particularly in those areas where there has been little experience of or enthusiasm for commissioning some services. Relationships will also need to develop with local authorities, not just because of the change of personnel and boundaries. Our PBC research showed that very few practices were working with local authorities to plan and deliver services. Information on Activity and Finance 15. A lack of reliable and prompt information on finance and activity has been a major inhibitor to GP engagement in commissioning, including driving innovation. A major development programme will be needed to go from the current position for PBCs to what will be required for GP consortia. It is still the case that a PBC may not have an indicative budget until halfway through the year and have no regular, frequent monitoring information. Ev w62 Health Committee: Evidence Governance Arrangements 16. GP consortia will have much freedom to decide their governance arrangements. We draw out three points from our previous work on GP commissioning that will be relevant. 17. First, unclear roles and responsibilities between GPs and PCTs, caused by lack of prescriptive national guidance and local tensions, had a negative impact on the progress of PBCs. Greater clarity of roles and responsibilities than has previously been achieved will be vital if GP practices, GP Consortia and the National Commissioning Board are to work together successfully. This is particularly true for the provision of primary care and the impact it can have on the overall success of commissioning. 18. Second, there has always been concern about potential conflicts of interest when GPs act as both commissioners and providers. Different approaches have been used to resolve these. The proposed division of responsibilities between the NHS Commissioning Board for commissioning primary care and GP consortia for commissioning secondary care, and the proposed requirements for consortia to tender services should substantially address the issue. However, the rules governing the use of GP consortia funds will need careful definition and monitoring, especially if consortia pay individual practices through incentive schemes, or for service delivery. Scrutiny of business cases will also be important. Independent audit, which goes beyond audit of the financial statements, should be part of the overall arrangements for ensuring the proper functioning of consortia. 19. Third, management of financial risks has challenged GP commissioners in the past. The NHS has experience of managing such risks, including for relatively small organisations. But these have usually been limited in commissioning either to the “stop loss” mechanism for GPFH that limited the cost that individual practices could incur for individual patients or crude forms of pooling, including top-slicing. There is little experience of managing such risks through insurance. Integration of Health and Social Care 20. The Committee is also interested in greater integration between health and social care. The Commission has studied joint financing arrangements between the NHS and local government. Our report, Means to an End (2010), is the most recent and authoritative review from any organisation. The Commission welcomes the drive for further integration. New structures, such as the proposed Health and Well-being Boards, may help to bring this about. But structures alone are not a guarantee of success of improved services. Softer issues such as relationships between the partners, leadership and a focus on outcomes rather than process are also important. Other points also need attention. 21. NHS and local authorities have been able to transfer funds and staff between each other since 1998. But there has been only a slow growth of pooled funds and other joint resources since then. As exhibit 4 taken from our report shows, only around 4% of all health and social care spending is currently pooled. This is mainly for learning disability and mental illness services with very little for elderly peoples’ services, shown in exhibit 5. Health Committee: Evidence Ev w63 Exhibit 4 JOINT HEALTH AND SOCIAL CARE EXPENDITURE AS A PROPORTION OF TOTAL OUTURN 2007–08 Adult social care net spend £13.1 billion NHS net outturn £86.4 billion Joint expenditure on health and social care (formal) £3.4 billion Source: Audit Commission (data from DH Departmental Report 2009, PSSEX1 2007/08, DH notification register 2008, Audit Commission pooled fund survey 2008) Exhibit 5 RANGE OF POOLED FUND ARRANGEMENTS Source: Audit Commission survey 2008 Ev w64 Health Committee: Evidence 22. Our report, Means to an End found the perceived complexity of the arrangements, coupled with inadequate understanding of the legislation and its detailed requirements have contributed to the slow growth in pooled funds and other formal joint arrangements. In addition: — NHS bodies and councils often perceived their different financial regimes to be a barrier to greater use of joint financing mechanisms; — Integrated services require joint approaches to data collection, information-sharing, record keeping and management information to inform commissioning and expenditure decisions; and — Neither NHS bodies nor councils felt that joint working had been reflected in practice by central departments (particularly the Department of Health and CLG). For example, participants in our research referred to numerous sets of joint commissioning guidance issued at similar times by different departments and other national organisations. 24. The impact of personal budgets and direct payments on pooled funds is also significant. Such funds will need to be separated as a personal budget is incompatible with a joint local authority and NHS fund used to contract health and social care from providers. In time, development of personal health budgets, which are currently being piloted, may resolve this problem. But the pace of change in social care is much quicker. Transitional Arrangements 25. Finally, the Committee has sought views on transitional arrangements. From the Commission’s perspective, there are several key points. 26. Maintaining good financial management will be essential while the NHS undergoes significant structural change. This includes achieving most of the £15–20 billion savings expected by 2014. 27. Our forthcoming report to be published on 14 October on PCT Use of Resources in 2009–10 will show that PCTs have continued to improve their financial management. They are in a much stronger position than, say, three years ago. Fuller details will be made available to the Committee after the report is published. 28. Auditors of PCTs appointed by the Commission will continue to review the financial and risk management arrangements of PCTs over the next two years. This is part of their statutory responsibility to satisfy themselves that PCTs have proper arrangements for securing economy, efficiency and effectiveness in their use of resources. Given the financial challenges the NHS faces, the Commission will focus auditors’ work on the financial resilience of PCTs, including their ability to achieve cost improvements. The transition to GP consortia and the separation of PCT provider arms will inevitably increase the risks for PCTs in managing their finances and delivering service improvements through their own commissioning. As in all previous restructurings, there will also be increased costs arising from abolition of PCTs and SHAs, for example through severance payments, that will need to be specifically managed and monitored and subject to audit. 29. A new audit regime for GP Consortia will need to be developed. The Commission is discussing with the Department of Health how best it can contribute its expertise and knowledge to developing arrangements for GP consortia and make a smooth transition made from the old to the new. 30. Finally, there is likely to be a significant impact on pooled budgets and other PCT arrangements with local authorities. All pooled budgets and other formal joint arrangements will need unpicking and putting back together—if wanted—with GP Consortia. Personal relationships will also need to develop between new partners. Our Means to an End report found that such relationships together with clear leadership are critical to effective joint working. October 2010 Sources Nationally Published Research All the following reports are available to download in full from the Audit Commission website. http://www.audit-commission.gov.uk/nationalstudies/health/pages/default.aspx — Audit Commission (1995) Briefing on GP Fundholding. — Audit Commission (1996) What the Doctor Ordered: A Study of GP Fundholders in England and Wales. — Audit Commission (2000) The PCG Agenda: Early Progress of Primary Care Groups in “The New NHS”. — Audit Commission (2001) A Healthy Outlook: Local Authority Overview and Scrutiny of Health. — Audit Commission (2004a) Transforming Primary Care: The Role of Primary Care Trusts in Shaping and Supporting General Practice. — Audit Commission (2004b) Quicker Treatment Closer to Home: Primary Care Trusts’ Success in Redesigning Care Pathways. Health Committee: Evidence Ev w65 — Audit Commission (2006a) Early Lessons in Implementing Practice Based Commissioning: Key Areas to Focus on for Success and Key Questions for Primary Care Trusts’ Board to Consider. — Audit Commission (2006b) Managing Finances in Mental Health. — Audit Commission (2007) Putting Commissioning into Practice: Implementing Practice Based Commissioning Through Good Financial Management. — Audit Commission (2009) Means to an End: Joint Financing Across Health and Social Care. — Audit Commission (forthcoming) Auditors’ Local Evaluation and Use of Resources Scores 2009/10: Summary Results for NHS Trusts and Primary Care Trusts. Local Audit Reports Auditors have issued a number of local PBC reports where improvement themes and/or Key Lines of Enquiry (KLOEs) for Use of Resources work at PCTs highlighted relevant risks. The most recent reports from 2009–10 and 2010–11 are listed below: South West Essex (May 2010) Warwickshire (November 2009) East Riding of Yorkshire (June 2010) Devon (August 2010) West Sussex (June 2010) East and Coastal Kent (April 2010) Suffolk (April 2010) Nottingham City (February 2010) Gloucestershire (July 2009) Hull (February 2009) Written evidence from National Children’s Bureau (COM 29) 1.0 Summary 1.1 NCB welcomes the opportunity to provide evidence to the Committee on health commissioning as it pertains to children and young people. We urge the Committee to: — challenge the government to ensure that any changes to the structure and mechanisms underpinning health service commissioning be implemented with a strong focus on improving commissioning for children’s health. — recommend that a single body at the local level—the health and well-being board—be responsible for overseeing the commissioning of the majority of services for children and young people, including health services. — seek assurances from government that health and well-being boards and their functions will be placed on a statutory footing, with clear statutory responsibilities for children’s health and wellbeing. — recommend that the Department of Health, with the Department for Education, develop frameworks for providing support on commissioning children’s health services, as part of its transition strategy. — seek assurances from government that GP commissioning consortia and the NHS Commissioning Board will be subject to the Children Act 1989 duty to comply with requests for support and services for children in need, currently placed on Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs). — recommend that government put in place measures to ensure that the implementation of its commissioning proposals does not disadvantage looked after children. — seek assurances from government that it will transfer children’s safeguarding and well-being duties, currently placed on PCTs and SHAs, to the new commissioning bodies. — seek commitment from government that it will put in place mechanisms to ensure HealthWatch can effectively engage children and young people, particularly the most vulnerable and those with complex needs. — recommend that government put in place measures so that voluntary sector organisations delivering effective health services are not disadvantaged by the proposed health reforms. NCB would welcome the opportunity to provide oral evidence to the Committee. Ev w66 Health Committee: Evidence 2.0 About NCB 2.1 NCB’s mission is to advance the well-being of all children and young people across every aspect of their lives. As the leading national charity which supports children, young people and families, and those who work with them, across England and Northern Ireland, we focus on identifying and communicating high impact, community and family-centred solutions. We work with organisations from across the voluntary, statutory and private sectors through our membership scheme, and through the sector-led specialist networks and partnership programmes that operate under our charitable status. 2.2 NCB’s has a history of working to promote the health of children and young people and to enable them to influence the quality and choice of health services they receive. As a Department of Health strategic partner, NCB’s Voluntary Sector Support (VSS) Programme provides information and practical support to voluntary organisations providing health services to children and young people. NCB has an established programme on health that works across the range of settings where children and young people live, learn and play, including schools, care, custody and supported housing. Activities include the development of policy and practice, improved partnership working and the participation of children and young people themselves in order to improve their health outcomes and service experiences. 3.0 Child Health and the NHS White Paper 3.1 While the NHS White Paper set out significant reforms to the commissioning and provision of NHS services, which will undoubtedly have an impact on children and young people, it included a surprising lack of clarity about the implications for children and their families. The Department of Health’s recent publication, Achieving equity and excellence for children (2010), has provided some insight. However, key questions still remain: — How will commissioning responsibilities for children’s health be divided between the NHS Commissioning Board, GP consortia and the local authority-led “local health and well-being board”? — How will new commissioning bodies develop and secure the knowledge and skills they need to commission for child health effectively? — How can we ensure the measures proposed in the White Paper do not disadvantage those young people with complex health needs, including disabled and looked after children and young people and those in custody? — How can we ensure a strong voice for children and young people, and those who work with them, in the commissioning process? These questions will be explored in our submission. 3.2 For children and young people’s health, the status quo has not served us well. Despite areas of good practice, there has been a lack of integration across service delivery and a lack of accountability and transparency in the planning for and delivery of child health services. Professor Sir Ian Kennedy’s review of children’s NHS services1 identified a number of challenges, including: — Low priority afforded to children and young people’s care. — GPs having insufficient training and experience in paediatrics. — Failures within the NHS to provide children with a safe environment. — A lack of coordination across children’s health services, and with other services, which can be particularly difficult for those with complex needs. 3.3 We urge the Committee to challenge the government to ensure that any changes to the structure and mechanisms underpinning health service commissioning be implemented with a strong focus on addressing these challenges and improving commissioning for children’s health. 4.0 Commissioning Responsibility for Children’s Health Services 4.1 NCB believes that the maximum range of services for children and young people—including the majority of children’s health services—should be coordinated by a single body at the local level. Services should be commissioned in a coordinated way to ensure they operate seamlessly across: health, social care, education and other services; NHS and non-NHS boundaries; and universal, targeted and specialist levels. 4.2 NCB believes that the local health and well-being board, proposed in the Department of Health’s NHS White Paper2, would be best placed to take on this commissioning coordinating role. With the participation of GP commissioning consortia, the NHS Commissioning Board, local authorities and other partners, the health and well-being board should have responsibility for setting a local commissioning strategy across children’s health, education, social care and other services. NCB believes that such an approach would help to secure seamless provision to children, young people and families through effective partnership structures. 4.3 Effective interventions for children and young people’s health are often delivered through services that are not health-specific. For example, the National Evaluation of Sure Start found that a child with access to a Children’s Centre (formerly Sure Start Local Programmes) had more immunisations and fewer Health Committee: Evidence Ev w67 accidents than young children living in other areas3. School health initiatives can have a positive impact on pupils’ health and behaviour, and can be particularly effective in improving young people’s knowledge of health issues4. 4.4 Having a single accountable body responsible for children’s education, childcare, recreation and health services, bringing together the range of lead commissioners for those services, would help ensure consistent approaches to the commissioning and delivery of integrated, early intervention services. It would also provide a framework through which a single body can be held accountable to the public, through the local authority, for ensuring that the Healthy Child Programme 0–19 is available to all children and young people. 4.5 In order to deliver for children’s health and well-being, the health and well-being board and its functions must be placed on a statutory footing. Furthermore, government must put in place mechanisms and incentives to ensure that the local boards prioritise children’s health and well-being. In such a partnership there is always the danger that children’s health and well-being will be marginalised. This must be avoided. 4.6 We urge the Committee to recommend that: — the local health and well-being board be responsible for overseeing the commissioning of the all services for children and young people, including health services; — the health and well-being board and its functions be placed on a statutory footing; — government put in place incentives and mechanisms to ensure that children’s health and well-being is prioritised within the health and well-being board; and — consideration is given as to how to engage children’s services that commission health services directly, such as early years settings and schools. 5.0 Developing the Knowledge and Skills of Commissioners—Managing the Transition 5.1 If government does implement its proposal to transfer responsibility for aspects of health commissioning to GP consortia, with the NHS Commissioning Board leading national and specialist commissioning, the transition must be well managed. This is particularly important for children and young people’s health. Professor Sir Ian Kennedy’s review of NHS services for children found that many GPs lack knowledge and experience of paediatrics1. Evidence also suggests that GPs are not sufficiently aware of the range of services available to children and families. For example, a survey of parents using children’s centres found that, although best practice would see health professionals signposting parents to children’s centres, only 4% were signposted by their GP5. 5.2 In order to be effective, the work of GP commissioning consortia, the NHS Commissioning Board and the local health and well-being boards must be informed by: — a thorough understanding of children’s health, including: the wider determinants of health; the impact of broader children’s services on health outcomes; and supporting children with complex needs, such as disabled children, those living in care and those with mental health problems; and — the best available evidence of what works to improve health outcomes, including examples of validated good practice, provided to commissioners in an appropriate and accessible format. 5.3 To achieve this, government must ensure that a move away from centrally-directed targets and regional advice and support, is accompanied by impetus and resources for the development of sector-led models of support to commissioners. This cannot be left to chance. We urge the Committee to recommend that the Department of Health, with the Department for Education, develop frameworks for providing support on commissioning children’s health services, as part of its transition strategy. 6.0 Children and Young People with Complex Needs—Looked After Children 6.1 NCB has concerns about the impact of proposed commissioning arrangements on children and young people with complex and specific needs, for example disabled or looked after children and young people and those in custody. Primary Care Trusts and Strategic Health Authorities have a duty under the Children Act 1989 to comply with requests from the local authority to help them provide support and services to children in need6. We urge the Committee to seek assurances from government that GP Commissioning and the NHS Commissioning Board consortia will be subject to: — a duty to comply with requests from relevant local authorities for support and services for children in need; — public sector equality duties introduced under the Equality Act 2010; and — a requirement to conduct equality impact assessments of their commissioning frameworks across all equality streams, including disability and age. 6.2 Our work with looked after children, through the Healthy Care Programme, and more recently Healthy Outlooks7, revealed a severe lack of effective arrangements for delivering care to this vulnerable group of children. Looked after children are particularly vulnerable to health risks and problems often due to their experience prior to entering care and the subsequent challenges they face in the care system itself. Ev w68 Health Committee: Evidence — 45% of looked after children and young people aged five to 17 were assessed as having at least one mental health disorder, compared to 10% of the general child and young person population.8 They exhibit high rates of self-harm and high-risk behaviour, particularly in secure accommodation.9 — Two thirds of all looked after children were reported to have at least one physical health complaint—most commonly eye and/or sight problems, speech and language problems, difficulty in coordination and asthma.10 — Some studies have shown higher levels of substance misuse, including smoking, among looked after children and young people, when compared to the non-care population, however research in this area is limited.11 6.3 While some health outcomes for looked after children have improved in recent years, there have been persistent difficulties, particularly in relation to partnership working across health bodies and local authorities at the strategic level, and arrangements for securing health services for children placed out of authority12,13. 6.4 Looked after children and young people are often highly mobile: nearly a third are placed outside their local authority area, and over 10% experience three or more placement moves in a single year14. This can often lead to confusion about which local body in which areas has responsibility for commissioning and delivering health services to these children. This is despite the introduction of regulations15 which assign responsibility for secondary health care to the PCT for the area where the child originally lived. The introduction of GP commissioning consortia will undoubtedly lead to changes to, and a possible increase in, commissioning boundaries, which could cause greater confusion and further disadvantage to children in care. 6.5 We urge the Committee to recommend that government put in place measures to ensure that the implementation of its commissioning proposals does not disadvantage looked after children. Government should: — clarify where responsibility for commissioning health services for looked after children will sit. This includes services to help them overcome barriers in accessing universal services as well as targeted and specialist services; — place a duty on the new GP commissioning consortia to have regard to statutory guidance on promoting the health of looked after children16. In 2009, the former Department for Children, Schools and Families and the Department of Health published revised guidance, and made it statutory for Primary Care Trusts and Strategic Health Authorities for the first time (under sections 10 and 11 of the Children Act 2004). The momentum resulting from the publication and new status of that guidance must not be lost; — facilitate the provision of training and support to GP commissioning consortia on the health needs of looked after children, as an early priority, and clarify the future of the roles of designated doctor and nurse; and — clarify what arrangements local authorities and commissioning bodies will be expected to establish for commissioning services for looked after children and young people who are placed outside their “home” authority or who move across health commissioning boundaries. 7.0 Local Cooperation and Safeguarding General Duties 7.1 In carrying out their functions, including those for commissioning, Primary Care Trusts and Strategic Health Authorities are under a duty to have regard to the need to safeguard and promote children’s welfare, and to cooperate with the local authority and local partners to promote children’s well-being17. PCTs and SHAs are also statutory members of Local Safeguarding Children Boards (LSCBs)18. In its recent publication on child health, the Department of Health confirmed that it intends the introduce new duties for GP commissioning consortia that “fully replicate those that current apply to PCTs and SHAs under the Children Act 2004”19. 7.2 We urge the Committee to seek assurances from government that it will transfer children’s safeguarding and well-being duties, currently placed on PCTs and SHAs, to the new commissioning bodies. Government should: — place a duty on each GP commissioning consortium to cooperate with all the local authorities it covers to improve children’s well-being; — place a duty on the NHS Commissioning Board to cooperate with all relevant partners to improve children’s well-being; — place a duty on GP commissioniing consortia and the NHS Commissioning Board to carry out its functions with a view to safeguarding and promoting children’s welfare; and — require GP commissioning consortia to be members of all relevant LSCBs operating in their commissioning area. Health Committee: Evidence Ev w69 8.0 A Strong Voice for Children and Young People and those who Work with them 8.1 NCB welcomes proposals in the NHS White Paper to strengthen the voice of patients and the public in decisions about health care commissioning and their own care, through national and local HealthWatch. However, past experience shows that services put in place to engage all members of the public will rarely engage effectively with children and young people, unless there is a specific requirement to do so. The experience of Patient Advice and Liaison Services (PALS) and Local Involvement Networks (LINks) suggests that children are often an after-thought. 8.2 It is vital, therefore, that as the national and local HealthWatch plans are implemented, government ensures that HealthWatch staff have the knowledge, capacity and skills to engage children and young people, and that there are strategies in place to do so. Staff will also need to understand the value of working with both children and young people and their parents and carers, recognising that listening to one perspective does not conflict with listening to another. Furthermore, any efforts to engage children and young people in the work of national and local HealthWatch must include specific action to involve those who are least likely to be engaged and those with complex health needs. This involves additional and specific resources and tools. 8.3 It is proposed by government that HealthWatch support the involvement of patients in strategic decisions about local services (currently the role of LINKs) and provide information and advocacy to support patients to exercise choice and make complaints (currently the role of PALS). However, NCB’s work with LINks and PALS suggests that they will need additional support, tools and resources in order to effectively involve children and young people in their work. 8.4 A current NCB project aims to build the capacity of LINks to engage with voluntary organisations working with children and young people. Early research has given a mixed picture of the level of engagement of children and young people within LINks.48 Those that failed to involve children and young people said this was due to: a perception that this was not part of the LINks remit; lack of capacity; and limited resources. 8.5 Research with PALS found that 75% were not actively involving children and young people in their service, because they did not have the necessary resources, skills and support from managers20. Consultations with children and young people reveal that most did not know what PALS are, but thought it could be really useful, once the service was explained to them21. Through our PALS project, NCB has provided training to 174 of the approximately 500 PALS in the country, many of whom have since reported increased involvement of children and young people.22. 8.6 The effective engagement of children and young people through HealthWatch can be achieved by building on existing participation mechanisms and resources, such as: the PALS and LINks projects referred to above, Participation Works23, school councils and youth councils, children in care councils and Parent Partnership Networks. There are also specific resources to support children’s engagement in commissioning, including How to involve children and young people in commissioning, published by Participation Works24. 8.7 Ensuring the engagement of local voluntary and community sector (VCS) organisations within the work of HealthWatch will also be key to securing commissioning decisions that reflect the views and the needs of the most marginalised. VCS organisations often work with the most excluded and vulnerable members of society, those who are often reluctant to engage with statutory services. Commissioners must be required to work in partnership with these VCS organisation when assessing local need and engaging service users/providers. 8.8 We urge the Committee to seek commitment from government that it will: — put in place mechanisms to ensure HealthWatch receives support so that they are able effectively to engage children and young people; — provide incentives to ensure that HealthWatch engages in effective outreach work to involve the most marginalised groups of children and young people and those with complex needs; — ensure GP commissioning consortia and local health and well-being boards have the necessary support and incentives to work with the voluntary sector to engage marginalised service users; and — help to develop the capacity of the voluntary sector to bring their clients’ voices to the commissioning process. 48 12% of LINks who responded to our survey said they had not involved children and young people in their work via voluntary organisations. The percentage of children and youth organisations as a proportion of LINks’ members ranged from 1 to 90%, with an average of 30%. Ev w70 Health Committee: Evidence 9.0 Commissioning the Voluntary Sector 9.1 Voluntary and community sector organisations are well placed to provide health services directly to children and young people, particularly to those for whom access to mainstream health services is a challenge. The voluntary organisations we consulted expressed concerns about: — the sector having a lack of capacity or resources to demonstrate their impact, a real concern if we are to move towards greater use of payment-by-results models. Some voluntary organisations also struggle to access the patient information held by commissioners, which they will need in order to demonstrate service outcomes; — GP commissioners having insufficient appreciation of the importance of “soft” outcomes—such as improved confidence and self-esteem—that are often the focus of voluntary sector interventions; and — the effect of proposals to make greater use of payment-by-results on voluntary organisations where the impact of their work may not be measurable for many years, especially for those working with young children. This could lead to voluntary organisations struggling to compete with larger private providers, which may work less effectively particularly with marginalised communities. 9.2 We urge the Committee to recommend that government put in place measures so that voluntary sector organisations delivering effective health services are not disadvantaged by the proposed health reforms. This should include: — assessing the potential impact of proposals on the voluntary sector, and introducing measures to ensure that voluntary organisations providing health services can compete effectively; — putting in place mechanisms to provide health and well-being boards, GPs and the voluntary sector with knowledge, support and incentives to ensure they engage with each other as part of the needs assessment and commissioning process; — addressing voluntary organisations’ concerns about access to patient information held by commissioners, as part of the forthcoming NHS information strategy; and — ensuring the NHS Commissioning Board, when developing payment-by-results models, considers how it will measure outcomes in a meaningful way where the real impact of some interventions may not be apparent in the short-term. October 2010 References 1 Sir Ian Kennedy (2010) Getting it right for children and young people: overcoming cultural barriers in the NHS so as to meet their needs. 2 Department of Health (2010) Equity and excellence: Liberating the NHS. 3 The National Evaluation of Sure Start (NESS) (Institute for the Study of Children, Families and Social Issues, Birkbeck, University of London) (2008) The Impact of Sure Start Local Programmes on Three Year Olds and Their Families. 4 Lister-Sharp D, Chapman S, Stewart-Brown S, Sowden A (1999) Health promoting schools and health promotion in schools: two systematic reviews Health Technology Assessment HTA NHS R&D HTA Programme. 5 DCSF (2009) Sure Start children’s centres—survey of parents. 6 Section 27, Children Act 1989. 7 www.ncb.org.uk/healthyoutlooks. Health Outlooks connects people who work with children and young people “most in need” to networks which can support them. 8 Department for Education and Skills (2007) Care Matters: Time for Change. Cm 7137. 9 Richardson, J and Joughin, C (2000) Mental Health Needs of Looked After Children. London: Gaskell. 10 Meltzer and others (2003) The Mental Health of Young People Looked After by Local Authorities in England. London: The Stationery Office. 11 Meltzer and others 2003 op. cit.; Williams, J and others (2001) “Case-control study of the health of those looked after by local authorities”, Archives of Disease in Childhood, 85, 280–85; Department of Health (1997) Substance Misuse and Young People. London: Department of Health. 12 Mooney, A, Statham J, Monck E, Chambers H (2009) Promoting the Health of Looked After Children: a Study to Inform Revision of the 2002 guidance Research Report DCSF-RR125 London: The Stationery Office. 13 Ofsted (2008) Safeguarding Children: The Third joint Chief Inspectors’ report on arrangements to safeguard children www.safeguardingchildren.org.uk 14 Care Matters: Ministerial Stocktake report 2010. Health Committee: Evidence Ev w71 15 The National Health Service (Functions of Strategic Health Authorities and Primary Care Trusts and Administration Arrangements) (England) (Amendment) Regulations 2007. SI 2007 No 559. 16 Department for Children, Schools and Families/Department of Health (2009) Statutory Guidance on Promoting the Health and Wellbeing of Looked After Children. 17 Section 10 and 11 of the Children Act 2004. 18 Section 13 of the Children Act 2004. 19 Department of Health (2010) Achieving equity and excellence for children, para 4.27. 20 Pobi S (2007) PALS: Getting it right for children and young people—A report on the results from NCB’s PALS survey in July 2007 http://www.ncb.org.uk/default.aspx?page%605 21 Pobi S (2007) PALS: Getting it right for children and young people—Consultations with children and young people http://www.ncb.org.uk/default.aspx?page%605 22 The PALS resources are available at: http://www.ncb.org.uk/resources/free resources/pals project.aspx 23 www.participationworks.org.uk 24 www.participationworks.org.uk/resources/how-to-involve-children-and-young-people-in-commissioning Written evidence from Dr Corinne Camilleri-Ferrante (COM 30) Background I am a medically qualified Consultant in Public Health Medicine with many years’ experience of commissioning, screening, teaching and training. Prior to that, I trained in Paediatrics. I present these as my own views on the White Paper Liberating the NHS. They do not necessarily reflect the views of the organisations for which I work. Equity and Excellence: Liberating the NHS 1. I welcome the concept of commissioning for outcomes. 2. Safeguarding the health of the population requires the joint efforts of all elements of the health service: primary care, secondary care, public health and many others. It also extends beyond the NHS. The only real possibility for success lies in joining up these disparate parts into coherent programmes of care, which consider entire patient pathways from prevention through to tertiary care and, ultimately, end of life care. Commissioning for wants, not needs, makes this far more difficult and tends to increase inequities and health inequalities. In addition, it requires the coordinated efforts of all participants: this is best organised through a strong Director of Public Health function. 3. I have concerns about the concept of taking the NHS towards a consumer model of health care. This is suggested by: — The promotion of direct accountability between the GP as fund holder and clinical decision maker, and the patient. The Minister would like the GP to act as the patient’s “friend” while at the same time managing scarce resources. These roles cannot be reconciled in such a direct relationship. — The promotion of the idea that is it the GP’s duty to provide what his or her patients demand, even if this is ineffective health care such as homeopathy. — The introduction of the rule of rescue into the NHS in the form of the cancer drug fund. 4. Most disappointingly, for a Government which prides itself on being able to take tough decisions and tackling the economic crisis, there is no evidence that this Government is willing to tackle seriously the issue of priority setting in the NHS. There are two predictable consequences of continuing with such a philosophy. First, inequalities and inequities will worsen. Second, the NHS will provide less value for money. 5. The NHS has largely ignored the problem of inequalities: — NHS budgets still do not reflect need. PCTs such as Bradford are 6% under-funded while Richmond and Twickenham continue to receive 20% above their allocation. — A recent study reported in the Health Service Journal found that those GPs that overspent their budget generally served better off areas while those that serve poorer areas were generally underspent. Furthermore, middle class patients tended to access certain treatments at a lower threshold than those from poorer backgrounds. This suggests one of two forces operates within the NHS: either both GPs and clinicians cannot resist demands from middle class patients, or there is systematic bias in decision making in favour of the middle classes. Rather than address this situation, the reforms will worsen it. In a consumer based model of health care provision the following happens: — those that have the best health always manage to secure the best access to health care; and — there is a tendency to over treat. Ev w72 Health Committee: Evidence 6. The second consequence of the move towards a demands rather than a needs based system is that the NHS will become less efficient. It has been stated that one of the aims for the reforms is to secure better value for money and to focus on health outcomes rather than process measures as a means to monitor the performance of the NHS. Yet at the same time the NHS is being asked to fund treatments which either have no effect or poor effect. 7. It is disappointing that there is no evidence of leadership in the priority setting debate, with little thought or consideration being given to the consequences of funding health care services on demand. There is no discussion of what will necessarily be displaced if doubtful wonder treatments are funded. Opportunity costs remain a very real issue which is not addressed. 8. A number of concerns also arise in terms of the reorganisation of care. Firstly, I believe that there is insufficient understanding of the range of tasks undertaken by the PCT which simply cannot be handed over to GP consortia without major support. And secondly there is insufficient understanding of the task of commissioning, from strategic planning to procurement. Good commissioning is based on a thorough understanding of the needs (not wants) of the population and of the service, as well as the ability to manage service delivery. There is a danger that substantial capacity, manpower, skills and experience will be lost during this very major reorganisation, only for the NHS to have to spend 10 years rebuilding what it has lost. 9. Training of the next generation of public health practitioners is paramount to the success of the NHS. This will be threatened if the current implicit suggestion that public health can be safely fragmented is maintained. While I applaud the concepts of closer working relationships with Local Authorities, and the setting up of a National Public Health Service, I believe it is imperative that the public health workforce is essentially kept together, with outposts into other parts of the system. Recommendations 1. Integrated health care systems should be developed based on programme management. 2. The Department of Health and the NHS should pay greater attention to inequities in health care which contribute to inequalities in life expectancy and quality of life. Promoting six-star services for the few rather than a five-star service for all is ethically questionable. 3. Politicians should demonstrate honesty and leadership by engaging the public and the NHS in the debate about priorities for funding. 4. Any major reform should be piloted in a geographic region in a realistic way, namely with GPs both keen and not so keen on the reforms and with a management budget which it is anticipated will be available nationally to implement the reforms (ie there should not be preferential funding arrangements or financial incentives for the pilot scheme). 5. Public health needs to be accepted as integral to all the elements of the NHS, not just health promotion and health protection. 6. A strong Director of Public Health, with an independent voice and responsibility for the health of an entire population, is essential. October 2010 Written evidence from Terence Lewis, Lewis Governance (COM 31) I am a Chartered Secretary. Governance is a board level activity. My business is to identify the causes of poor corporate performance and to correct these through effective governance. Central to this is ensuring a proper prioritisation of stakeholder interests within the board governance structures. Many performance failures within the NHS that affect the patients experience of care can be traced to poor commissioning of services. This is largely due to the commissioning process receiving little input from the “customer” and is compounded by the almost total absence of any NHS trust board level accountability to this stakeholder constituency for quality, choice or the patient experience. Hence, poor governance. Even in the area of clinical governance, post Bristol and Shipman, there have been too many examples of governance process failures—with severe consequences for the patient—culminating in Mid Staffs. My following first-hand experience within the Department of Health and the NHS informs this submission: 2001–06 PCT non-executive director. 2004–07 Non-executive director, directorate level, Department of Health. 2006–07. White Paper Task Group member, Our Health, Our Care, Our Say. 2007–09 Deputy Chair, Commission to Review Mental Health Services in the North West. 2008–09 Next Stage Review Since 2000, a major focus to secure delivery of the NHS Plan, along with value for money from the investment being made and committed, was to be the commissioning process. Health Committee: Evidence Ev w73 Significant policy points in policy development to improve commissioning were Shifting the Balance of Power, Commissioning a Patient Led NHS, World Class Commissioning and the Next Stage Review. Each of these policy initiatives had at its centre the creation of a service that would be patient centred and locality sensitive, and commissioning was intended to secure these objectives. World Class Commissioning established 11 competencies that were required of Primary Care Trusts. These were: 1. Locally lead the NHS. 2. Work collaboratively with community partners. 3. Engage with the public and patients. 4. Collaborate with clinicians to inform strategy, service design and resource utilisation. 5. Manage knowledge and assess current and future needs. 6. Identify and prioritise investment requirements and opportunities. 7. Stimulate the market to meet demand and secure outcomes. 8. Drive continuous improvement in quality and outcomes through innovation. 9. Secure procurement skills that ensure providers have appropriate contracts. 10. Performance manage. 11. Manage finances. In the three years since WCC became operational as policy, performance reviews have been undertaken by Strategic Health Authorities. These have revealed poor levels of performance. The most recent, published last month, again shows disappointing performance and against competency 3 little progress at all. Competency three requires PCTs to: Proactively seek and build continuous and meaningful engagement with the public and patients, to shape services and improve health. Why do PCTs need this competency in order to become world class commissioners? PCTs are responsible through the commissioning process for investing public funds on behalf of their patients and communities. In order to make commissioning decisions that reflect the needs, priorities and aspirations of the local population, PCTs will have to engage the public in a variety of ways, openly and honestly. They will need to be proactive in seeking out the views and experiences of the public, patients, their carers and other stakeholders, especially those least able to act as advocates for themselves. No where has the letter or spirit of this competency been delivered. Consequently, the services improvements and changes identified by patients and the public and incorporated into Our Health, Our Care, Our Say were frustrated. The public consultation around this White Paper was the most comprehensive ever. Competency 3 was seen as having a significant role in securing local leadership, close working between social care and health, innovation, market stimulation, more 3rd sector services, contract delivery and compliance and VFM. In much the same way as the customer influences similar domains in the private sector. The failures to truly engage patients in commissioning choices and the measurement of service quality are acknowledged in the current WP Equity and Excellence Liberating the NHS. Indeed, the value of several of the competencies of WCC, together with Lord Darzi’s recognition that the patient experience must be one of the three key measures of service quality, are to be found in White Paper. Equally, it is recognised that those at present holding responsibility for the delivery of commissioning competencies, and the audit of quality outcomes, have fallen short. Key competencies have not been abandoned but accountability for their delivery has been made clear and placed in other hands. The following extracts from the WP and commissioning consultation document illustrate these points: Nothing about me without me. — ..compared to other sectors, healthcare systems are in their infancy in putting the experience of the user first, and have barely started to realise the potential of patients as joint providers of their own care and recovery. Progress has been limited in making the NHS truly patient led.16 We intend to put that right. — The new NHS Commissioning Board will champion patient and carer involvement, and the Secretary of State will hold it to account for progress. — Information generated by patients themselves will be critical to this process, and will include much wider use of effective tools like Patient-Reported Outcome Measures (PROMS), patient experience data, and real-time feedback. At present, PROMs, other outcome measures, patient experience Ev w74 Health Committee: Evidence surveys and national clinical audit are not used widely enough. We will expand their validity, collection and use. The Department will extend national clinical audit to support clinicians across a much wider range of treatments and conditions, and it will extend PROMs across the NHS wherever practicable. — We will also encourage more widespread use of patient experience surveys and real-time feedback. We will enable patients to rate services and clinical departments according to the quality of care they received, and we will require hospitals to be open about mistakes and always tell patients if something has gone wrong. ….. patients will be at the heart of everything we do. So they will have more choice and control, helped by easy access to the information they need about the best GPs and hospitals. Patients will be in charge of making decisions about their care. Commissioning Consultation Document Patients and the public 6.1 One of the principal aims of GP commissioning is to make decisions more sensitive and responsive to the needs and wishes of patients and the public. Good communication and engagement with the public will, therefore, be vital. Both GP consortia and the NHS Commissioning Board will need to find and evolve efficient and effective ways of harnessing public voice so that commissioning decisions are increasingly shaped by people’s expressed needs and wants. This is the central theme of NHS commissioning—understanding the health needs of a local population or a group of patients and of individual patients; working with patients and the full range of health and care professionals involved to decide what services will best meet those needs and to design these services; creating a clinical service specification that forms the basis for contracts with providers; establishing and holding a range of contracts that offer choice for patients wherever practicable; and monitoring to ensure that services are delivered to the right standards of quality. For the past decade, commissioning responsibilities have largely rested with primary care trusts (PCTs) and to some extent the primary care groups that preceded them. The previous Government made belated attempts to strengthen PCT commissioning through its programme of “world class commissioning”. But the weaknesses of the system have lain much deeper than the capacity of staff working in PCTs. Commissioning has been too remote from the patients it is intended to serve. Our proposals for GP commissioning and the NHS Commissioning Board mark a fundamental break with this past. Most commissioning decisions will now be made by consortia of GP practices, free from topdown managerial control and supported and held to account for the outcomes they achieve by the NHS Commissioning Board. This will push decision-making much closer to patients and local communities and ensure that commissioners are accountable to them. As can be seen from WCC and the Next Stage Review, the commitment to the accountability of the NHS to the patient for commissioning decisions, and the quality of services, has grown stronger. Yet little has changed in terms of patient input or influence. The causes of failure in this part of the “business” are significantly rooted in the absence of significant consequences for the trust. Consequently performance in this domain is of little importance to the board. It is my experience that the disconnection between policy and practice can occur when policy is “interpreted” by stakeholders before being implemented by the Service. Those occupying senior positions within stakeholder groups will frequently have followed a similar career route through the NHS and it would, perhaps, be surprising if they were not to share a preference for “company solutions” when deciding these questions. This interpretation of policy, and the timescale for its implementation, can take place in a range of ways The exchanges involved can occur in places and ways that do not include patients and carers, or where they have only a token presence; by this I mean, lacking the resources and support to have an equal and authoritative voice. This is a most unsatisfactory situation. If the unambiguous commitments made to patients by the Government in the White Paper are to be kept, then the patient must be enabled to support the Government in achieving the service modernisation and improved outcomes it wishes to see. First, this will require enabling patients to make an informed and authoritative contribution to commissioning decisions. Secondly, it will require making the Commissioning Board accountable to patients through the SoS for patient involvement in commissioning. Thirdly, the CQC, GPs and service providers will be responsible to patients for the quality of commissioning and service outcomes. With the demise of SHAs there will be no other stakeholder to monitor these matters. These measures would have the effect of making the priorities of the patient stakeholder as significant as those of others. If it is clear to an organisation that the patient experience is as important to the determination of its performance as, say, balancing the books, governance to achieve these objectives will follow. To develop this point may I make the following comments? Good governance ensures an organisation secures sound performance in those areas that will affect its standing in the judgement of stakeholders. Loss of this confidence can affect an organisation’s survival. A key part of this process, in both public and private sectors, is ensuring that, de facto, the customer/patient Health Committee: Evidence Ev w75 is an ever presences at board meetings, because confidence in the organisation in this group of stakeholders is key to its success. The NED has a pivotal role in this, but in my view boards of foundation trusts have been constructed with too strong a business and financial bias at the expense of patients. This model has been replicated in many PCTs. I believe the consequences of this are evident from the allocation of responsibilities in the White Paper. In my view, it is imperative that NHS boards contain, as well as a range of other expertise, NEDs who “know that business”, understand, value and espouse the public service ethos and whose responsibility it is to secure the confidence of the patient stakeholder group in the Trust. This would not undermine the efficient running of the Service, but would ensure the interests of all stakeholders are given equal value in the decisions made about services and their delivery. My interest is primarily in the field of mental health, but I believe my experience there and the conclusions I have reached, hold true in other parts of the system. It has long been my belief that DH writes good policy that reflects the priorities of a government that has won the right to act in our name. However, as I have indicated, this is not the end of the story. Good policy before being implemented is often interpreted by key stakeholders—a process from which patients can be excluded. The interpretation of policy, and the timescale for its implementation, will take place within and between the Department of Health, the NHS, regulators and organisations representing other stakeholders, and they will take place in ways and places from which service users and carers can be excluded or have only a token presence. If this situation persists, not only will users of services continue to be discriminated against, but will once again see policy “watered down”. As serious, will be the dilution of dynamic policy intended to increase the influence of patients in the commissioning and provision of services; and to enable them to hold to account—the role of the “customer” in all parts of the private sector. To address this key issue, an organisation to represent users and carers needs to be funded and established at national level. Such an organisation would replicate for patients and families the ability to establish the professional skills and knowledge to represent their interests and equal to that at the disposal of other stakeholders in advocating for their constituencies. I would suggest that Healthwatch be established in this way. The disadvantage at which patients presently find themselves in this respect, enables the potential for policy such as WCC, HQCfA and now the White Paper, to improve services and re-align the prioritisation of stakeholders, to be frustrated, Instead a “company solutions” is developed without the challenge such a patient body would provide.. These solutions often require less “stretch” for organisations in terms of ways of working, innovation, identifying new providers, being absolutely clear about VFM and ensuring the quality of the patient’s experience is at the heart of governance to assure quality services. In the private sector solutions to meet the need for change, and the challenges this presents, must have the interest of the “customer” at their heart. In the process, a significant degree of impact on the interests of other stakeholders may have to be accepted. In the public sector, there often is poor first focus on the patient’s interest due to lack of impact on the organisation arising from a poor patient experience. Regulation has a significant role to play on behalf of the patient, but regulators must be clear about that they are measuring the quality of performance with a significant focus on those outcomes important to patients. It is to be welcomed that the CQC annual “health check” is to be discontinued and instead inspections will be in response to “real time” intelligence from patients and families on the quality of services and their experience of them. The situation revealed in the Francis report makes clear that dynamic and informed patient participation must be secured. Systems are already in place to make this possible. October 2010 Written evidence from the Kidney Alliance (COM 32) The Kidney Alliance (KA) is an umbrella organisation formed in 1998 by The National Kidney Federation, The British Renal Society and the Renal Association with an aim to bring together the patients’ voice and professionals committed to kidney care. The organisation aims to promote prevention and early identification of kidney disease and high quality treatment for all patients at risk from or identified with kidney failure on an equal and uniform basis throughout the UK. Current member organisations: British Renal Society Renal Association British Transplantation Society British Kidney Patient Association Kidney Research UK National Kidney Federation British Association of Paediatric Nephrologists Renal Nutrition Group Ev w76 Health Committee: Evidence Royal College of Nursing, Nephrology Nursing Forum Association of Renal Managers Association of Renal Industries The following comments represent a consensus opinion from all member organisations. Summary Points — We are concerned that GP Consortia will need to commission a wide range of services within renal care on which the level of knowledge will be understandably variable. We would like to see specialist advice made available to Consortia, without creating conflicts of interest with potential providers, to ensure that decisions are not only appropriate for local need but also appropriate for the needs of patients throughout the care pathway. — We would like to see the views of patients built into commissioning decisions in specific therapy areas by utilizing the specialist expertise of local patient groups. — We are concerned that the proposed local systems to scrutinize decisions are complex and may discourage patients from engaging with them. — We would like to see clear systems of accountability and responsibility established at local and also at national level where services are commissioned nationally. — We would like to see quality standards include minimum service standards that should be common to all GP consortia and all providers. — We would like to see all dialysis services continue to be commissioned as a national specialized service and we are concerned that any move away from this could put at risk the lives of patients. This is particularly important for children’s renal services as kidney disease in children is rare and provision of services will need to take into consideration the critical mass required for clinical effectiveness. 1. Clinical Engagement and Commissioning 1.1 Renal care requires the commissioning of a wide variety of services. These vary from basic lifestyle and dietary advice to specialized services such as dialysis, organ transplantation, cancer treatments and end of life care. This huge range of services needs to be carefully integrated for renal patients and to be supported by vital ancillary services. 1.2 The consequence of this wide range of services on commissioning is that it is likely that many patients will be simultaneously receiving services that have been commissioned via different routes (eg locally commissioned services and those commissioned as national specialized services). 1.3 This places a great deal of pressure on the commissioners in GP Consortia to make appropriate decisions across diverse areas of service involving many different components, but always with renal care at the centre. In our view, this is likely to be at odds with the understandable inclination to commission a specific service component in the same way for all its potential uses in order to try to achieve maximum efficiency. We therefore believe that GP Consortia commissioners will require significant specialist renal care support to ensure that their decisions relating to services in this field are appropriate. 1.4 If such support comes from Trusts that are likely to be commissioned to provide the care, this creates a potential conflict of interests. However, we do not believe that adequate expertise on all aspects of renal services will exist within GP Consortia and we would be concerned if commissioning decisions were to be made without such input. 1.5 In our view, GP Consortia will require access to independent, specialist advice. In addition, quality standards will be very important and should set out the services that are considered essential (including ancillary services that support treatment such as dialysis). 1.6 The views of patients are crucial in shaping services. It will be far more effective (as well as constructive) to have local patients involved in shaping services, not just holding the Consortia to account. Local patient groups have valuable specialist knowledge that would be vital in informing commissioning decisions and GP Consortia should be encouraged to involve them in relevant commissioning decisions and service planning. In the adult and paediatric settings, parent/patient reported outcome measures would be useful in ensuring positive experiences and improving choice. 1.7 The development of renal networks is essential. These would act to link the pathway and involve the multi-disciplinary team together with patients and carers. 1.8 The Chronic Kidney Disease pathway from diagnosis to treatment in Primary care through to specialist clinics, renal replacement therapy including home therapies and transplantation requires a high degree of integrated care across primary and secondary care and social care by local authorities. Putting commissioning in the hands of primary care will not help to integrate this, which is why we have always supported specialised commissioning for advanced CKD, which will progress to end stage renal failure. Even under the current system there are perverse incentives between social care and secondary care whereby NHS Trusts have both a healthcare and financial incentive to discharge patients as soon as they are fit with Health Committee: Evidence Ev w77 appropriate care packages in place while social care agencies have an incentive to place barriers to discharge in order to delay/avoid funding a care package. Any new commissioning structure must have integration at its heart. 2. Accountability for Commissioning Decisions 2.1 We believe that there is a distinction to be made between patient opinion on the choice of services and expert patient opinion on what those services should consist of. The former is about the local community exercising its choice on local priorities, whereas the latter is aimed at ensuring that the provision of those services chosen is appropriate to meet the needs of patients. 2.2 As stated under section 1, we would like to see greater emphasis placed on consultation between GP Consortia and local patient organizations. We believe these interactions should be transparent so that the extent to which patient views have been included in commissioning can be scrutinized. 2.3 We believe that the NHS Commissioning Board should have a role in reviewing the commissioning decisions of all GP Consortia, identifying and challenging anomalies. Also we agree that the NHS Commissioning Board should have responsibility for commissioning specialized services (see later section). 2.4 Health Watch should be the watchdog for local commissioning. However, this will place upon it similar pressures to those of the commissioners themselves because it will naturally focus across the local situation and priorities, but in addition it should scrutinize local services in specific disease areas on a topto-bottom basis. The latter will require specialist knowledge and insight that may or may not be available locally. 2.5 The processes by which Health Watch will fulfill its role require more detailed explanation. The way in which the role of Health Watch integrates with that of its parent organization, the Care Quality Commission, needs considerable clarification—particularly the degree to which the regulator will influence the watchdog. 2.6 Where commissioners face hard choices, there must be adequate facilities for independent appeals to be made. This should include specialized services that are commissioned at national level. However, it is not only the choice of services and treatments that should be subject to appeal, but in a similar way, the processes by which the choices available are developed should also be open to appeal. This includes not only existing NICE processes (taking into consideration the development of Quality Standards) but also the definition of tariffs—especially pathway tariffs by Monitor. 2.7 No matter how management of the NHS is configured, we remain clear that the ultimate responsibility lies (and should continue to lie) with the Secretary of State for Health. 3. Integration of Health and Social Care 3.1 We understand the concerns regarding the interests of providers—particularly as the proposals open up the possibility of the involvement of a much broader group of providers. However, we would be concerned if the desire to achieve a more balanced situation between the commissioners and providers were to impede the availability of specialist advice and information on services, because it would be unrealistic to expect commissioners to be expert in all therapy areas. 3.2 We believe that quality standards will be helpful in guiding commissioners, but that more help will be required, including access to independent expert advice. For example, it would be theoretically possible for a provider to offer kidney dialysis at a lower cost by excluding ancillary services such as patient counseling to save money. However, patient counseling has a direct benefit on concordance with dialysis and excluding it would increase the risk of patients under-dialyzing, leading to serious (and potentially costly) complications. 3.3 It would be helpful for quality standards to include clear minimum acceptable standards. If services fell below these, this would trigger immediate, automatic intervention by the NHS Commissioning Board and/or Care Quality Commission. 3.4 We have concerns regarding service reconfiguration and local decisions of a similar nature. The proposed system of local monitoring and scrutiny is fragmented and complex. We are concerned that this will have a detrimental effect on team working and co-operation making it more difficult for such decisions to be made. We are also concerned that the resulting culture will not safeguard examples of good practice, which would often come from interdisciplinary cooperation. 3.5 Whilst the White Paper places great emphasis on outcomes, with which we agree, we also believe that the retention of a few key process measures is vital, for example the goal for 85% patients on dialysis to have vascular access provided through a fistula or a graft within a defined period of starting dialysis—which is likely to have a direct outcome on patient mortality and experience. Such measures may help to move forward changes to services and guide what changes are necessary. We believe they will also play a useful role in encouraging innovation during the interim period. However, we have serious concerns over the absence of appropriately developed overarching indicators to support many of the outcomes domains. We understand that such development takes time, but our concern is that by the time they have been developed and have begun to produce useful data, many of the important decisions regarding the review of the NHS will already have been taken. Ev w78 Health Committee: Evidence 4. Resource Allocation 4.1 Resource allocation based on the headcount within a GP Consortium would seem to provide a sensible basis for building budgets. However, there will be some services that will require a more strategic view in the allocation of resources. The focus of national specialized commissioning will tend to be on rare conditions. However, we would not agree with the view that national specialized commissioning and commissioning of services for rare conditions are one and the same. There are some specialized treatments that should be commissioned at national level despite being widespread in their use. Kidney dialysis is one such example. 4.2 By commissioning dialysis services at national level, the use of budgets will be much more efficient and this will help to maintain value for money. Commissioning at a national level would allow for: (1) Efficiency in provision of facility. (2) Maintain a consistent approach to the patient pathway. (3) Be cost effective by setting universal quality standards, offering choice, of therapy and encouraging a holistic approach to renal replacement therapy. (4) Conversely, GP consortia may deprioritize dialysis services due to small patient numbers requiring renal replacement therapy and the high cost; this would be exacerbated in paediatric services, where the condition is already extremely rare. 4.3 We do not think that risk-sharing arrangements between multiple GP Consortia would meet the requirements of dialysis commissioning. For example, the provision of dialysis must be maintained whatever the circumstances (for example if a GP Consortium were to get into difficulty) since the lives of patients depend on regular access to this treatment. The loss of dialysis service by even a day can put lives at risk. 4.4 Risk sharing between consortia would be fraught with difficulties because different consortia would be likely to have different levels of risk, making it harder to reach agreement. For example, clinical practice suggests that rural PCTs are likely to have a lower requirement for renal replacement therapy compared with inner city PCTs. 5. Specialist Services 5.1 The national definition set for national specialized services is under review. The prevalence of a disease and the frequency with which a service would be utilized is commonly regarded as a crucial factor in determining a specialized service. However, when this factor was placed into the existing national definition set, it was intended to be used as a guide and not as a prescriptive definition on which to rule in, or out, any specific service. The Kidney Alliance is concerned that this situation is about to change so that only services for rare conditions would be included in the definition set. 5.2 The scope of the NHS Commissioning Board’s remit for specialised services needs to be clearly defined. It is very important that the incidence of conditions requiring low volume services be accurately identified. In the Alliance’s view, the only credible basis for doing so is the current edition of the Specialised Services National Definitions Set. This should be in its entirety, though subject to regular revision. 5.3 We have set out our reasons for maintaining dialysis as a national specialized service in section 4. We believe that the continuity and consistency of service required by kidney patients who rely on dialysis cannot be achieved through local or regional commissioning and we are firmly of the opinion that any move away from national commissioning will place lives at risk. 5.4 We would therefore like to see commissioning of dialysis services remain at national level and for these services to be funded independently. 5.5 We would like to see more detail on the proposed arrangements for commissioning national specialized services. We would also like to see the new Advisory Group on National Specialised Services (AGNSS) establish close links with relevant patient organizations and for them to be involved in the Group’s decision-making processes. 5.6 We would also like to see established processes at national level by which disputes over decisions on national specialized services could be taken up and resolved and also by which proposed changes to the national definition set could be scrutinized. This may be a role for Health Watch at national level, but such detail needs to be clarified as a matter of urgency. October 2010 Health Committee: Evidence Ev w79 Written evidence from Shire Pharmaceuticals Ltd (COM 33) Summary Points — Currently commissioning for rare conditions takes place at national level, and is overseen by the National Specialised Commissioning Group (NSCG). This arrangement is widely regarded as effective, efficient and appears to be viewed as a model of good practice for the commissioning for rare conditions by other EU nations. — The extremely low prevalence and frequently uneven distribution of very rare conditions means that GP Consortia are unlikely to be able to make effective decisions regarding services and treatments for these conditions and we believe that commissioning of such services and treatments should take place at a national level, as currently. — The uneven distribution of very rare conditions places significant and disproportionate financial risk on any given GP Consortium. This risk is such that commissioning by clusters of consortia or at regional level would not significantly diminish it. Top-sliced, national funding is required to support national commissioning of services and treatments for very rare conditions. — There remain significant issues relating to the proposed arrangements for national commissioning and these proposals require urgent, detailed clarification and public scrutiny in terms of: — Responsibility and accountability. — Prioritization versus other services and treatments. — Assessment of services and treatments. — Patient involvement. — National safeguards and complaints procedures. 1. Clinical Engagement and Commissioning 1.1 The National Institute for Health and Clinical Excellence (NICE) has proposed the definition of an ultra-orphan condition as one with a prevalence of less than 1 in 50,000 (this matches the criterion used by the National Specialist Commissioning Advisory Group of a condition that affects less than 1,000 across the UK). 1.2 If one assumes that a GP consortium would, on average, cover around 250,000 people, the incidence of very rare conditions means that it is virtually impossible for any consortium to access meaningful information on the required services. 1.3 Even where several consortia come together, they are likely to be dealing with around 20 patients or less. 1.4 There are a number of risks in this situation, including: — The extremely low patient numbers mean that they may be considered too small to register on the Government’s proposed system of indicators and thus lose out to more prevalent conditions. — It will be difficult for any GP Consortium to acquire the knowledge and experience needed effectively to commission services, which already resides within the national commissioning body (NSCG). — There is a significant risk that cases will come to the attention of GP Consortia as cases for exceptional funding, which will be inefficient and time-consuming. 1.5 The underlying cause of most conditions that sit within the ultra-orphan definition is genetic. This means that in addition to their low prevalence, they are unlikely to be distributed uniformly across the country. Small clusters are likely to form due to familial association. 1.6 This clustering has a number of potential consequences. For example, this means that even fewer GP Consortia would be likely to have experience of the particular condition. This would represent variations in clinical practice, making it even harder for consistent decisions to be made regarding services. In addition, treatment costs would be unevenly distributed between GP Consortia. This would represent a significant financial risk for any consortium. 1.7 In our opinion, it is highly unlikely that GP Consortia would be able to make high quality decisions regarding services for people with very rare conditions. Experience has indicated that ultra-orphan conditions are so rare that they require a different approach even when commissioned at national level. We therefore believe that commissioning via groups of consortia or by regional commissioning would be ineffective and that the only viable option would be to deal with them as national specialized services. 1.8 Since the majority of rare diseases are genetic disorders that affect children, there is the additional risk that any moves to commission services and treatment at local level could disadvantage children—a group that already tends to be marginalized in health care. Ev w80 Health Committee: Evidence 2. Accountability for Commissioning Decisions 2.1 We believe that there is a great deal of essential detail that needs to be communicated in relation to proposed future arrangements for commissioning specialized services at national level and we would urge the Government to make this known as a matter of urgency. 2.2 The White Paper—Liberating the NHS, states that the NHS Commissioning Board will be responsible for commissioning national specialised services and we are aware that a new organization, the Advisory Group on National Specialised Services (AGNSS) is being formed. Although the group has already met, the future interaction between it and the NHS Commissioning Board remains to be seen. 2.3 Whilst we agree that local accountability for commissioning decision is important, we believe that it is equally important to apply the same level of accountability for nationally commissioned services. 2.4 Patient organizations have played a vital role in informing decisions made by the National Specialised Commissioning Group (NSCG) and we believe that it is crucial that this close relationship should continue with the AGNSS because this has been the only way to ensure that the voices of patients with very rare conditions can be heard. 2.5 The NSCG had undertaken a number of strands of work. This included development of proposals for a system to assess new treatments for ultra-orphan diseases. We are given to understand that the intention is to take forward this work, however details on the precise nature of the assessment that will be undertaken are not available. We are in favour of evidence-based processes of assessing ultra-orphan treatments where they can be shown to make a constructive contribution to commissioning decisions. We believe that the significant challenge in doing this for rare conditions needs to be recognized so that appropriate, dedicated assessment processes are developed rather than existing ones being adapted for the needs of treatments for rare conditions. We therefore believe that it is important for AGNSS to clarify its intentions on the development of an assessment process and, if it is to continue, to make known the detailed process so that it can be carefully scrutinized. 2.6 We believe that it will be important to have adequate processes at national level to deal with disputes over decisions made by the NHS Commissioning Board in relation to national specialised services. It is far from clear if, or how, individual patients would be take up complaints against national specialized services or commissioning decisions. 2.7 In our view, disputes over decisions made at national level in the commissioning of specialized services should be dealt with by Health Watch at national level. Involving local Health Watch would be ineffective as their level of specialist knowledge would be insufficient. However, for a patient to engage with such a national body as Health Watch could be a daunting experience and we would like to see Health Watch develop a simple, user-friendly process for dealing with complaints regarding national specialized services and commissioning. 2.8 Similarly, we would like to see clearly established accountability for national specialized commissioning decisions. Ultimately we would see this lying with the Secretary of State as part of his role in holding to account the NHS Commissioning Board. Integration of Health and Social Care 2.9 As a consequence of the way in which the NHS is being structured, with greater emphasis on local decision making, it is our belief that the highly specialized nature and infrequent occurrence of very rare conditions places people suffering from them at a disadvantage and we therefore believe that they should be considered as a vulnerable group. 2.10 The system of indicators by which, when they are developed, the performance of the NHS will be measured, is likely to be more heavily influenced by conditions that are more prevalent. For example indicators that relate to heart disease or diabetes will have greater influence on overarching indicators such as mortality amenable to healthcare. Conversely, performance for small groups of people with very rare conditions are not likely to have any visible impact. 2.11 At local level, where the focus will be on delivering quality standards and contributing to improvement indicators, whilst at the same time demonstrating a good service for the local population, it is likely that individual rare conditions would not be seen as a priority. This would be unfair to people with rare conditions who could be discriminated against on the basis of the low incidence of their condition. 2.12 We believe that the solution to these potential issues is to remove commissioning decisions on rare diseases from the local environment and to commission them as specialised services and treatments at national level. Resource Allocation 2.13 As mentioned under 1.6, the distribution of very rare conditions can typically result in a small number of small clusters of patients. This would make resource planning difficult for GP Consortia. 2.14 The duplication of effort that would result from local commissioning of services and treatments for rare conditions would be not only ineffective, but also highly inefficient. Health Committee: Evidence Ev w81 2.15 The costs of developing treatments for very rare conditions are at least as high as those for developing treatments for more prevalent conditions. Indeed, the difficulty and cost of conducting adequate clinical trials can often increase costs beyond average. 2.16 Given the small number of patients for whom the treatment would be effective, the cost per patient of treatments for rare conditions is generally much higher than for other drugs. Moreover, these are generally highly specific treatments and therefore not effective in other indications. 2.17 Balanced against the high cost per patient is the small number of patients with whom the treatment would be used. This means that the total cost to the NHS at national level is relatively small. In contrast, the financial risk to a GP Consortium is considerable; if a cluster of just a few patients occurs within a consortium, it can have a major impact on local budgets. 2.18 Risk sharing by pooling budgets would go some way to overcoming the difficulties described above. However, it would require significant resource to administer. Added to this it would be a time consuming and challenging process to gain consensus from all GP Consortia on a specific rare conditions—particularly because, as we have already said, the level of specialist knowledge does not exist locally. It is worth noting that the consortium approach to commissioning has been tried in the past but its ineffectiveness led to the development of the current national commissioning arrangements for rare conditions. 2.19 We believe that the most efficient and effective way of allocating resources is to create a separate, topsliced, national budget and to fund nationally commissioned specialized services and treatments from this. 3. Specialist Services 3.1 The needs of people with rare conditions can often be very different from to those of other group of patients and require a different management approach. For example, the genetic aetiology of many rare conditions mean that not only the presenting patient but also the whole family (particularly the children) needs to be seen. 3.2 This means that “standard” services are seldom appropriate for rare conditions, requiring highly specialized knowledge, very specific patient support and access to specifically developed treatments, plus the allocation of resources to provide all of this. 3.3 We would like to see the commissioning of treatments for rare conditions treated as nationally commissioned specialized services so that this can be guided by appropriate expert knowledge and decisions can be made nationally in order to gain maximum benefit form a strategic approach to these illnesses. 3.4 We believe that such an approach would most likely be in line with other responses being formulated by European Member States in response to the European Directive: European Action in the field of rare disease (COM(2008)0726—C6-0455/2008—2008/0218(CNS)). 3.5 We would like to see the challenges in developing treatments for rare conditions recognized in the way that access is provided to such drugs. In particular, we would like to see adequate allowance made for the relatively low volumes of clinical data that it is possible to generate, the relatively high cost per patient balanced against the low impact on overall NHS budgets and the highly specific nature of these treatments rendering them effective in a very narrow clinical indication. 3.6 The unique characteristics of specialized services for rare conditions strongly suggest that they should be kept separate from other services, once they have been defined. Consequently, those services for rare conditions that are commissioned at national level should also be funded at national level with no impact on any individual GP consortium since the presence of a cluster of patients is not a factor of poor public, or other, healthcare. 3.7 We believe that AGNSS has a key role to play and that it should develop strong relationships with patient organizations, which should be fully engaged in decision-making processes. 3.8 We believe that future planning of commissioning and resourcing for rare conditions should be the responsibility of AGNSS on behalf of the NHS Commissioning Board and that this should be informed by an effective horizon scanning process in which manufacturers should be encouraged to participate. October 2010 Ev w82 Health Committee: Evidence Written evidence from Better Value Healthcare (COM 34) Why is it we know to the nearest £ what we spent in every health centre and hospital and not to the nearest hundred million what we spend on bi-polar disorder or rheumatoid arthritis? Why is that even we know we know we spend about £1 Billion on asthma we do not know what value is derived or what value could be derived from £900 Million expenditure? The Eternal Verities of Healthcare This is my 22nd reorganisation but few have made much significant difference. Furthermore rheumatoid arthritis existed before the first of my organisations and exists now. Over the last 30 years I have seen some developments in Programme Budgeting and Systems, for examples in cancer, renal services and stroke but some of these have been determined by the need for capital investment. Most of the Health Service still resembles a Brownian Motion namely the random movement of patients, clinicians, blood samples and reports. The Need to Focus on Value What is needed is firstly to appreciate that value is the most important criteria not quality. Obviously quality improvement increases value but to maximise value it is necessary not only to do things right but to do the right things. The value derived from Health Service is measured by the relationship between cost and outcome. The Need for Planning, Programming and Budgeting PBB was introduced in the US Defence Department in the 1960’s. Instead of continuing to fund separate requisitions from Army, Navy and Air Force Robert S McNamara introduced the concept of Programme Budgeting, how all the Military Services had to work together. The United Kingdom is fortunate in that we have the best Programme Budgeting information in the world set out in Table 1 below: Table 1 Estimated England level gross expenditure by Programme Budget 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Infectious Diseases Cancers and Tumours Disorders of Blood Endocrine, Nutritional and Metabolic Mental Health Disorders Problems of Learning Disability Neurological Problems of Vision Problems of Hearing Problems of Circulation Problems of the Respiratory System Dental Problems Problems of Gastro Intestinal System Problems of the Skin Problems of Musculo Skeletal System Problems due to Trauma and Injuries Problems of Genito Urinary System Maternity and Reproductive Health Conditions of Neonates Adverse effects and poisoning Healthy Individuals Social Care Needs Other Total Gross Expenditure 2008–09 £000s 1,410,980 5,134,948 1,253,786 2,526,152 10,415,840 2,916,182 3,683,873 1,664,102 417,167 7,420,201 4,247,325 3,087,416 4,097,920 1,794,226 4,212,469 3,299,792 4,000,641 3,100,821 1,101,470 955,442 1,908,832 3,156,039 24,836,323 96,814,987 The first step is to review the allocation by programme both nationally and by commissioner. To help this every Primary Care Trust in England was sent a Health Investment Pack in September 2010. However before switching resources from one programme budget to another it is far more important to engage clinicians with patients and debating the use of the resources they already have. Health Committee: Evidence Ev w83 Within Programme and Within Systems Analysis The Health Service of the 21st Century should be run not on the basis of Institutions, which will continue to be necessary, but on the basis of Systems, Networks and Pathways and the definition of these terms given below. A SYSTEM is a set of activities with a common set of objectives (also known as a service). A NETWORK is a set of individuals and organisations that deliver the system’s objectives (a team is a set of individuals or departments within one organisation). A PATHWAY is the route patients usually follow through the network. A PROGRAMME is a set of systems with a common knowledge base and a common budget. Thus when looking for increased investment in the management of chronic obstructive pulmonary disease, for example, the first place to look is within the lung disease programme budget and within that in the systems budget for chronic obstructive pulmonary disease. The development of this approach will engage clinical and patient organisations. Before campaigning for more resources for their particular priority such communities of interest need to look within their whole programme budget to see if the innovation could be funded by reducing waste. This is what commissioners should require them to buy commissioning programmes and systems, not primary and secondary care. October 2010 Written evidence from Allied Health Professions Federation (COM 35) This submission is provided by Richard Evans, Chief Executive Officer, The Society and College of Radiographers on behalf of the Allied Health Professions Federation (AHPF). 1. Summary 1.1 The White Paper proposals on commissioning represent a high-risk strategy. 1.2 The existing system has been slow to implement and achieve high standards but that does not imply failure of the system or the need for radical change. 1.3 There is a lack of evidence that the proposed system will provide improvement. 1.4 There are concerns that effective workforce planning including education for professions will be further damaged by the proposals. 1.5 GP consortia will require considerable input from a number of clinical professional groups if they are fully to grasp the breadth of issues of service provision. 1.6 Contestibility has not increased quality or innovation in health care delivery. 1.7 The current proposals provide no reassurance that there will be more robust attention paid to clinical quality or workforce standards in the plural provider system. 1.8 Consortia of General Practitioners may have difficulty in accepting the role to ration health care provision. 1.9 It is difficult to see how effective patient/public advocacy will be promoted in practice. 1.10 It is difficult to see how integration of health and social care is facilitated through the proposals. 1.11 There is a lack of clarity over how small scale and highly specialised clinical services will be assured. 2. Commissioning 2.1 In common with other groups of healthcare professionals, the AHPF believes that the white paper proposals for change in the model of commissioning predict severe disruption to the delivery of health care, are likely to introduce additional costs at a time of financial constraint and are uncertain to deliver improvement to care provision. 2.2 We agree that there are imperfections in the current system and understand frustration that the separattion of purchase from provision in the NHS has not produced a stronger commissioning model. However, the current pressures to continue to expand capacity within fixed financial provision are placing services under unprecedented strain. We are very concerned that experimenting with commissioning at the present time is unnecessary and risks severe damage to patient services. 2.3 There is a lack of evidence that the model of GP consortia operating an “any willing provider”approach will succeed in raising standards of health care and in achieving the admirable objective of improving health outcomes. The proposals do not apparently allow for testing of the model or indicate a process for actively supervising the project to spot failure and allow for intervention to change direction. 2.4 We are concerned that the proposals are motivated by political dogma rather than by a genuine concern to improve health care delivery in England. Ev w84 Health Committee: Evidence 2.5 The challenges of workforce planning to ensure sustainability of services and to support innovation and change in delivery are very significant and are another feature of the commissioning task that is yet to become clear. 3. Clinical Engagement 3.1 The AHPF supports the involvement of clinical professionals in the commissioning process. 3.2 General Practitioners and their teams in primary care have a unique role and perspective on the healthcare needs of the population. However, it is clear that, even through a consortium this does not translate into management expertise to embrace the complexity of commissioning. Neither does it confer expertise in depth about the services that will be required to be provided through the commissioning process. 3.3 Experience has shown that clinical engagement across the purchaser-provider relationship has been problematic. This must be overcome in future and in particular, if the white paper proposals go ahead, must inform a consortium based commissioning model from the outset. 3.4 The requirement to adopt a plural approach to provision challenges clinical team working and places pressure on commissioners to ensure quality and sustainability in services they cannot hope fully to understand. Commissioners require advice and support from and dialogue with clinical experts if they are to avoid some of the commissioning errors that were made, even by the Department of Health and SHAs during the last decade. 4. Competition 4.1 Plurality of provision of services has been shown to work in some parts of the NHS over recent years. There have also been some spectacular and costly failures, within established NHS providers and within the independent sector that demonstrate that the assumption that competition drives up standards and innovation is insecure. 4.2 The “any willing provider” ethic would perhaps be less worrying if it were “any suitable provider” or “any capable provider”. It is necessary for there to be much more reassurance ove r service quality and how this will be guaranteed. 4.3 Experience has shown that the ability of small independent providers to “cherry pick” non-complex procedures and deliver them cheaply and quickly can damage secondary care providers that are left with a less flexible workforce and a case load of more complex, resource-intensive work. It will be important that commissioners see the “bigger picture” and understand the full implications of their commissioning decisions. 4.4 Under any circumstances, commissioners must be able to satisfy themselves that providers will be able and willing to work together to provide the integrated high quality services that are required in any care pathway. Continuity of the medical records, pathology and PACS systems are obvious requirements but so too are clinical team working and accountability. 4.5 The success of multidisciplinary clinical team working in delivering improved care and outcomes and in reducing costs must not be lost. However, it is self evident that preserving this excellent practice will be more challenging within a context of multiple providers. The AHPF fears that fragmentation of provision is potentially damaging to care pathways and that commissioners will require particular focus and expertise in ensuring overall service quality across multiple providers in the face of strict financial constraint. 4.6 There is an impressive record of development of advanced and consultant practice amongst AHPs in recent years. This has delivered very high quality services at low cost. It is true to say that this sort of service innovation is not generally seen within independent sector provision. We are concerned that the drive towards further plurality will stifle professional development and innovation, marking a return to less efficient, labour intensive and costly models of provision. 4.7 Examples of innovation amongst AHPs that have improved care for patients but that have challenged traditional hierarchies include self-referral to AHP services, supplementary prescribing and image interpretation. All are well evidenced and make a massive contribution to efficient and effective care. The AHPF is concerned that, because of conservatism in the independent sector and the inherent medical bias in the commissioning model, plural provision may not support these innovations. This will be a detriment to patient care, restrict patient choice and introduce serious challenges to the development, recruitment and retention of the workforce. 4.8 The AHPF is glad to see reference to the expectation that all providers will take part in funding the education and training of the healthcare workforce. Commissioners will have an important role in ensuring that the workforce within their area is appropriately educated, trained and developed. This is a feature of the commissioning role that is currently missing from the white paper proposals but that cannot be overlooked. Diversity of provision will make the task even more complex. 4.9 Plural provision of services brings issues of workforce supply that are of concern to the AHPF. The movement of healthcare professionals between different employers is likely to become much more widespread. Whilst this might bring opportunities for professionals to develop their careers in innovative ways, there are also dangers. These include breaking of lines of clinical supervision, developmental support Health Committee: Evidence Ev w85 and professional networks. It is also clear that the process of local, regional and national workforce planning will be made much more complex in a plural system of provision. It is not at all clear how commissioning consortia can possibly get to grips with this vital activity sufficiently quickly and comprehensively so as to avoid calamitous workforce deficits in the (relatively) near future. 5. Accountability 5.1 The expectation that GP consortia will be able to handle the large financial responsibility that is implied in the proposals is fundamental to the success of the model. 5.2 Experience with the “fund-holding” experiment in the past demonstrated that individual GPs responded very differently and whilst there is clearly no expectation that all GPs will become involved in the commissioning activity of a consortium, there is an implication that the GP community will work together effectively to manage the budget. The role as rationers of care is a different perspective for many GPs. 5.3 The proposals seem to struggle with the basic concept that a medically—led commissioning model is ideal for the NHS as against a desire to control primary care itself. As commissioning for primary care is to be centrally conducted, it is not at all clear how consortia will deal with influencing quality or outcomes at what is the entry level for the majority of patients. As it is inconceivable that all GPs will be fully supportive of the new arrangements, this weakness in the ability of commissioners to affect outcomes could be a serious challenge. 5.4 Although patient choice remains clearly evident in the white paper and receives some reference in connection with commissioning, there is little within the proposals to indicate how consortia will be able to demonstrate their responsibilities to patients and the public as the key stakeholders in health and social care. 5.5 A culture and mechanisms are required to promote listening to patients, public, a range of professionals and professional bodies as well as social care service commissioners and providers. 5.6 Consortia must be clearly accountable to patients and the public with demonstrable penalties for failure to deliver agreed outcomes. 6. Integration of Health and Social Care 6.1 Although integrated working across the health and social care boundary is a clear objective within the health white paper, there is little detail in the commissioning proposals that indicates that any consideration has been given to how this will work in practice. 6.2 Experience in health over the past ten years has shown that a competitive market has tended to drive providers apart and introduce tension between commissioner and provider. The already (in many cases) uneasy relationship between the health and social cate sectors requires particular attention, encouraging a spirit of collaboration. This should not be absent from the commissioning proposals and we are concerned that individuals whose care is organised across boundaries will suffer a deficit through implementation. 7. Specialist Services 7.1 Some AHP groups are particularly concerned with the delivery of low-volume specialist services.The proposal that consortia should have the “freedom and responsibility to decide for themselves” about levels of commissioning will effectively allow these services, and the patients who rely on them, to fall through the commissioning net. 7.2 In the context of immense complexity that will be facing consortia, low-volume services are very likely to be categorised as “too difficult” or just be overlooked entirely. 7.3 The National Commissioning Board could take responsibility for nominating lead consortia to deal with these services on a regional or supra-regional basis and should call on the expertise of professional bodies and patient groups to inform the criteria for service provision, workforce and educational planning that will be required. 7.4 There is a clear indication that some very specialised services will be commissioned at national level. Clarity over which services will be included is required and is of interest to the AHPF. 7.5 Cancer services in particular receive no reference within the commissioning proposals but are of enormous public interest. October 2010 Ev w86 Health Committee: Evidence Written evidence from Independent Midwives UK (COM 36) Executive Summary Independent Midwives UK (IM UK) welcomes this opportunity to contribute to the committee’s inquiry into how to resolve the issues which have undermined the effectiveness of commissioning in the NHS. However, if the policies for commissioning outlined in the government’s White Paper Equity and excellence: Liberating the NHS are to succeed in the maternity services, midwifery must be at the centre of commissioning and midwives should be the lead professionals who are commissioned, preferably through maternity networks such as those proposed by the NCT, to provide individualised, woman centred care. A comprehensive referral system to enable the midwife to access obstetric and other specialist support services through a seamless care pathway will ensure appropriate individualised care is targeted where it is needed. Women with multiple risk factors will receive the level of care they require but for the majority of healthy women who become pregnant, they will be much more likely to enjoy a positive, empowering and safe normal birth if they are able to access caseload midwifery—one to one midwifery based on continuity of carer. “Every pregnant woman needs a midwife and some will need a doctor too”. 1. Introduction 1.1 IM UK, whose members have been providing safe, high quality caseload midwifery privately since 1985, established a social enterprise in 2008 with the objective of bringing their model of care into the NHS. Increasing the current range of providers available within the NHS will extend maternity choice, improve public health and help solve some of the issues around recruiting and retaining midwives by offering them an alternative way of working. 1.2 In April 2010, the organisation was awarded a significant grant by the DH Social Enterprise Investment Fund (SEIF) to enable it to begin to develop the necessary infrastructure required for contracting in. This work includes creating clinical governance frameworks, IT processes and template midwifery contracts and is well underway. IM UK has a register of over six hundred midwives wishing to work under this model and is currently in the process of developing partnerships with NHS midwives interested in exploring the right to request to set up neighbourhood midwifery practices, based in the communities they serve. 1.3 IM UK have maintained a database of detailed statistics on all aspects of our care since 2002i. Our data matches and conforms with the existing evidence that continuity of carer and caseload midwifery consistently deliver better outcomes for women and their babies(i), (ii), (iii). IM UK has a 15% C/S rate (NHS average 25%) a 76% normal birth rate, (NHS average 40%) and a breastfeeding rate of 69% at six weeks (NHS average 45%). Because it has such good outcomes, this type of care saves money; it doubles the rate of normal, uncomplicated birth and makes a significant contribution to public health by increasing breastfeeding rates, reducing childhood obesity, asthma, eczema and neonatal readmissions. 1.4 Within our model of care, a woman chooses her own midwife to provide personalised care throughout her pregnancy, labour and the early days of parenthood. The care is predicated on a relationship between a woman and her midwife, meaning families receive care tailored to their individual needs from a clinician they trust. Currently, this style of care is usually only available outside the NHS, via independent midwives. However, it is a fully costed, clinically effective model of care that women value highly and a significant proportion of midwives across all sectors want the opportunity to offer. 2. Barriers to Effective Commissioning of Alternative Midwifery Service Providers 2.1 Indemnity insurance for midwives is not currently available from the insurance market. Any alternative providers of midwifery care are therefore unable to access cover and so are effectively barred from having their services commissioned. 2.2 A recent review, chaired by Finlay Scott, was undertaken to examine the feasibility of mandatory indemnity/insurance being linked to healthcare professionals registration. It has recognised that there are groups for whom no insurance is available but whose services are highly valued and effective. The review recommends that, if the government agrees these services are of value, it should help to facilitate a solution. 2.3 The current market failure to provide insurance cover means that the most likely solution in the short term is to invite alternative providers of healthcare to access the NHSLA Clinical Negligence Scheme for Trusts (CNST). Although the legislation to enable this is contained within the Health and Social Care Act 2008, the consultation process and enactment have yet to happen. 2.4 IM UK understand there is an issue about the way in which CNST functions in that there is no “continuing cover” available to members who leave. If a contract ends and is not renewed the organisation is then automatically outside of the scheme and therefore not covered, even for events which happened while they were members. This would be deemed inadequate indemnity for a healthcare professional. 2.5 While a number of PCTs have expressed interest in commissioning neighbourhood midwifery services they are unable to do so because of the lack of insurance. This has been a source of frustration to them, especially in those areas where the current provider—usually the acute Trust, is not providing the full range of local, flexible services where there is clearly a demand for them. Health Committee: Evidence Ev w87 2.6 IM UK experience so far reflects the widely held view that there is an imbalance of power between commissioners and the big providers who operate in effect a monopoly and so can dictate all the terms. We have found that PCTs are not only unable to commission our services directly but cannot even wield any real influence over their local maternity providers to work collaboratively with us to ensure a more reliable and expanded home birth service. In one instance the PCT maternity commissioner concerned worked hard on a proposal which would have involved the local NHS acute Trust offering IM UK midwives an honorary contract to solve the lack of insurance (something which was commonplace a few years ago). Senior managers would not agree the plan and so local women were denied the opportunity to have an expanded, more reliable service provided by experienced midwives, willing to work under local guidelines. 2.7 As a small organization, currently offering a high quality, valued service to private clients, IM UK has been trying unsuccessfully for years to expand the numbers of women who could benefit from our model of care by offering our member’s services to the NHS. We have been unable to make any headway, despite overwhelming evidence that this model of care works and numerous policy documents recommending its adoption on a much wider scale within maternity service reform. Our experience to date mirrors the conclusion of James Gubb, Director of Civitas in his recent report “Refusing treatment. The NHS and market-based reform”:(iv) “By and large, the ‘NHS family’ has successfully broken competitive, lower-cost and higherquality alternatives, keeping the benefits of innovation and accountability limited. …Existing NHS providers use their muscle and connections to keep providing services even when faster, higher quality care is on offer elsewhere… The NHS market for secondary care is yet to have its intended impact on providers and bring about the anticipated benefits on any meaningful and systematic scale”. 2.8 There is another difficulty, with major safety implications, when NHS Trusts do not allow access to independent midwives to deliver babies in their hospitals. Because of litigation fears and a skills deficit, women with high risk pregnancies, such as those carrying breech babies and twins, are increasingly told that a vaginal birth is not an option within the NHS. Hiring an independent midwife, who is skilled in these births, is often their only option if they wish to try and avoid a caesarean section but they are then forced to choose a high risk birth at home. IM UK have argued for some years now that they should be able to support these women in hospital. More collaborative commissioning arrangements would enable this much safer option to be available to women who want to make different choices and to the midwives willing to support them. 2.9 To date in our view, the frequently reiterated desire to bring in innovative ideas and flexible, responsive, transformative models of care from alternative providers has never extended beyond rhetoric, it looks good written in policy documents(v), (vi) but the inertia on the ground has not shifted an inch and nothing changes for the women seeking genuine choice and the midwives wanting to provide it. 3. Maternity Networks and the Proposed NHS Commissioning Board 3.1 Strong, national commissioning arrangements for maternity provision, which enable all providers to contract in their services with indemnity cover, will make a significant contribution to the public health agenda and will reduce many of the strains within the current maternity service. 3.2 IM UK welcome the White Paper’s proposal to include the commissioning of maternity care as part of the agenda for the new NHS Commissioning Board. We strongly support the draft proposals from the NCT for maternity networks which would be contracted or accredited to provide services to those expecting a baby. 3.3 The networks could use a number of systems/bodies to provide care but the accredited provider would receive payment when a woman chooses them as her care giver. This is more like a private sector model or the model proposed by IM UK. Each woman attracts a fee to cover their total care which could be for baseline midwifery care with additional payments for risk factors and referrals etc. 3.4 We welcome the proposals in the White Paper on the plans to link payments to quality of care and outcomes: “implementing a more comprehensive, transparent and sustainable structure of payment for performance so that money follows the patient and reflects quality” (pg 25). The maternity episode of care would be an ideal opportunity to pilot a personal budget scheme, it is time limited and the client group are predisposed to actively participate in their care and to make informed decisions about the choices available to them. 3.5 For many years now, women have been given the illusion of choice through policy commitments but the majority have not experienced it in practice.(vii) By commissioning caseload midwifery through IM UK it will be possible to make genuine choice a reality. Ev w88 Health Committee: Evidence 4. Ensuring Accountability through Commissioning 4.1 Midwives who work as independent practitioners are self-employed, autonomous, confident professionals. They are self managing, often in small practices or partnerships and, because of the relationship they develop with the women they care for there is always a high level of awareness of their own accountability for any decision making and actions taken, underlined by the requirements of their regulatory body, the Nursing and Midwifery Council (NMC). 4.2 One of the problems with large, bureaucratic, impersonal institutions, which is what the NHS has become, is that accountability and personal regulation often get lost in what is known as the “tick box culture”. A growing criticism of CNST is that the ever burgeoning numbers of standards and protocols are becoming counter-productive because they reduce the individual’s use of clinical judgement. This is particularly worrying in midwifery when rapid decision-making in an urgent situation can mean the difference between a good and a poor outcome. A skilled, competent and confident midwifery profession should be the solid foundation of any maternity service but midwives are concerned that their skills and competencies are being gradually undermined and underused by the current system. 4.3 One of the government’s five priorities for the NHS is to empower health professionals to use their clinical judgement. A caseload model of care, delivered through neighbourhood midwifery practices will provide the framework which enables midwives to deliver care in a flexible, individualised way, using their skills, experience and clinical judgement to ensure intelligent decision making. Evidence shows that midwives leave the profession because they are frustrated with working in a system of fragmented care based in bureaucratic ‘baby factories’ with high intervention rates. Midwives empowered to use their clinical judgement within a meaningful relationship with their clients will lead to improved quality, safety, satisfaction and accountability in the service they provide. 4.4 There is little, if any, evidence that CNST is delivering on its primary aim—to reduce the costs of litigation within the NHS and especially within the maternity service which currently accounts for about 60% of the overall cost. This despite the ever increasing workload involved in trying to achieve CNST level 3 and then maintain it. 4.5 Improved continuity of carer, which leads to the developing of a close relationship between the midwife and the woman in her care tends to be a protective factor in reducing litigation claims. When a woman is more involved in the decisions about her care, she is much less likely to decide to sue where there is a poor outcome. Any reduction in the ballooning litigation costs currently being borne by the NHSLA is to be welcomed, both for the human cost involved in long and distressing legal battles and because more money can then be directed at increasing and improving front line services. 4.6 IM UK is currently developing the processes, infrastructure, corporate and clinical governance, as well as the contract which each member will sign up to if they wish to offer their services through IM UK. We will ensure that our governance is robust, transparent and meets the requirements of all and any regulatory bodies, such as the NMC, CNST and CQC. Because we will hold the contract for the provision of services and sub contract the work out to our members, we will guarantee to the commissioners that we will deliver what we promise. 5. Public Health Agenda 5.1 There are major short and long term health benefits attached to increasing the percentage of normal birth, reducing intervention and improving breastfeeding rates for women. Good quality midwifery care ensures the best start in life for new babies and makes a fundamental difference to families in the long term. UK wide infant feeding surveys have shown that nine out of ten women who stop breastfeeding within six to eight weeks of birth would like to continue but need consistent information and support from health professionals to do so. The recent survey on postnatal care(viii) demonstrated just how lacking this crucial service is, with 59% of first time mothers feeling unsupported. Commissioning IM UK to deliver our caseload model through neighbourhood midwifery practices will provide that support through extended postnatal care as an integral part of the care pathway. 5.2 IM UK, as a flexible, responsive social enterprise, is able to help commissioners target socially vulnerable women in their communities, offering individually tailored midwifery care through children’s centres and outreach work, we can ensure those women and their families who will benefit most from continuity of carer are able to access it. 6. Recommendations 6.1 To develop robust, streamlined commissioning processes which support and enable alternative providers to deliver care on a level playing field with current providers. 6.2 Maternity networks to be developed in collaboration with the National Commissioning Board which will have a multi-disciplinary and stakeholder membership but will ensure that the role of the midwife is paramount and that she/he is the lead professional in both providing and co-ordinating care, in line with Midwifery 2020 recommendations.(ix) Health Committee: Evidence Ev w89 6.3 To commit to solving the problems around lack of indemnity for independent midwifery and to finding the solution needed to make insurance cover available for all maternity/midwifery providers. This will enable the development of sustainable, high quality, safe midwifery services fit for the 21st century. October 2010 7. References (i) Milan M MIDIRS Midwifery Digest vol 14, no 4, Dec 2004 pp548–554. (ii) Johnson and Daviss Outcomes of planned home births with certified professional midwives. BMJ 2005, 330,1416 (18 June). (iii) Milan. M MIDIRS Midwifery Digest vol 15, no 4, Dec 2005 pp 439–449. (iv) Brereton L, Gubb J Refusing treatment. The NHS and market-based reform, Civitas 2010. (v) Dep’t of Health, Changing Childbirth, Report of the Expert maternity Group. HMSO 1993. (vi) Dep’t of Health, Maternity Matters: Choice, access and continuity of care in a safe service. HMSO 2007. (vii) Gibson R, Dodwell M. An investigation into choice of place of birth. London: NCT; 2009. (viii) Bhavnani V, Newburn M left to your own devices: The postnatal experience of 1260 first-time mothers. London NCT 2010. (ix) Department of Health, Midwifery 2020: Delivering expectations Midwifery 2020 Programme. Written evidence from the National Osteoporosis Society (COM 37) Executive Summary — Osteoporosis causes fragile bones and can lead to painful and disabling fractures. Bone protecting treatments, recommended by NICE and available on the NHS, have been shown to reduce a person’s chances of fracture by up to 50%. Fracture Liaison Services (FLSs) ensure that those at risk are identified and offered treatment. However, only a third of local areas in England offer access to an FLS, leaving many patients without NICE recommended treatments. This is putting them at risk of unnecessary fractures and without access to follow-up services which may be necessary to reduce their risk of falls. — At present, the commissioning process is not working effectively enough for patients with or at risk of fractures. Guidance on commissioning comprehensive falls and fracture services has been produced by the Department of Health (DH) for Primary Care Trusts (PCTs) and local authorities as part of the Prevention Package for Older People. The guidance must now be implemented. As the restructure of the NHS takes place, it is crucial that GPs are provided with support they need to play their part in commissioning comprehensive, integrated falls and fracture services. Under the White Paper proposals, this will require the inclusion of fragility fracture prevention indicators in the new NHS Outcomes Framework. This should be followed by the formulation of a Quality Standard on the management of fracture risk. — The NHS, the public health service and social care must all work closely together to ensure that comprehensive, integrated care is commissioned and provided. Ideally, a single health outcomes framework, applicable to all three, should be put in place. Patients and the public must be empowered to provide their views on how services are organised. The newly proposed structures, including health and wellbeing boards and HealthWatches, have potential to ensure that this occurs. Osteoporosis and Fragility Fractures 1. Osteoporosis causes fragile bones, which can lead to painful and disabling fractures. It is a long-term condition which affects 2.3 million people in England.49, 50, 51 In the UK, 1 in 2 women and 1 in 5 men will fracture at some point after the age of 50, mainly because of poor bone health. 300,000 fragility fractures (fractures which result from a fall from standing height or less) occur every year in the UK. 49 50 51 Calculated using mid-2007 population data59 and osteoporosis incidence from60 National Statistics Online, 2007. Available for download from: http://www.statistics.gov.uk/statbase/Product.asp?vlnk%15106. Accessed on 19 January 2009. Kanis J A, Johnell O, Oden A, Jonsson B, De Laet C, and Dawson A, 2000. Risk of hip fracture according to the World Health Organization criteria for osteopenia and osteoporosis. Bone 2000; 27, pp 585–590. Ev w90 Health Committee: Evidence 2. Hip fractures which result from osteoporosis are extremely serious: 10% of patients die within one month of their injury; 30% die within a year. Over 80,000 hip fractures occur annually in the UK. £2 billion is spent every year treating and caring for UK hip fractures.52, 53, 54, 55 3. Yet fractures which result from osteoporosis are not inevitable. Bone protecting treatments, recommended by NICE and available on the NHS, have been shown to reduce a person’s chances of fracture by up to 50%. Fracture Liaison Services (FLS) 4. The occurrence of a fragility fracture is often the first sign that an individual has osteoporosis and is at a higher risk of sustaining a future fracture. It is a fact that half of all hip fracture patients have suffered previous fragility fractures.56, 57, 58, 59 5. It is, therefore, vital that every person who suffers a fragility fracture in any part of their skeleton is identified. This should be following presentation at a hospital or through their GP. Each fragility fracture patient should also be offered a future fracture risk assessment. Where appropriate, this should lead to advice and treatment to ensure that their future risk of falling and fracturing is reduced. 6. These important steps are recognised in a number of national policy documents in place for England, which advocate osteoporosis and falls assessment for older people who suffer fragility fractures: — National Service Framework for Older People, Section 6: Falls. March 2001. — NICE Clinical Guideline 21, November 2004. — NICE Technology Appraisal 161, October 2008. — Directed Enhanced Service (DES) on osteoporosis and fragility fracture prevention, 2008–10. — The Prevention Package for Older People, July 2009. 7. Despite this, a number of recent studies show that, worryingly, the majority of patients with fragility fractures are simply slipping through the net. Most are not receiving the assessment and treatment they need to prevent a further (or “secondary”) fracture, as recommended by NICE.60, 61 Assessment rates are better amongst hip fracture cases (75% of hip fracture patients in England, Wales and Northern Ireland are currently prescribed bone-strengthening medication, are being assessed or are awaiting assessment).62 However, further work is still needed to ensure that fragility fracture patients over the age of 50 receive appropriate investigations and treatments for osteoporosis where necessary. 8. Overall, most of the readily identifiable patients at high risk of future hip fracture are being consistently missed by the NHS. This is leaving those who are most vulnerable to hip fracture without the treatment they need. 9. The way to ensure that every fragility fracture patient over the age of 50 receives the assessment and treatment they need is through the implementation of FLSs throughout England. These should be linked to every hospital that receives fracture patients. 52 53 54 55 56 57 58 59 60 61 62 Figures in62 updated using mid-2007 population data63 and the Hospital and Community Health Services (HCHS) pay and price inflation 06–077. Torgerson D, Iglesias C and Reid D M, 2001. The economics of fracture prevention. In—The Effective Management of Osteoporosis. Edited by D H Barlow, R M Francis and A Miles, pp 111–121. National Statistics Online, 2007. Available for download from: http://www.statistics.gov.uk/statbase/Product.asp?vlnk%15106. Accessed on 19 January 2009. NHS Finance Manual, 2009. Available for download from: http://www.info.doh.gov.uk/doh/finman.nsf/Newsletters. Accessed on 19 January 2009. Gallagher J C, Melton L J, Riggs B L, Bergstrath E, 1980. Epidemiology of fractures of the proximal femur in Rochester, Minnesota. Clin Orthop Relat Res;150: pp 163–171. Lyles K W, Colon-Emeric C S, Pieper C et al, 2006. The Horizon Recurrent Clinical Fracture after Recent Hip Fracture Trial (RFT) Study Cohort Description. Abstracts of the 28th Annual Meeting of the American Society for Bone and Mineral Research. 2006, ASBMR 28th Annual Meeting in Philadelphia, Pennsylvania, USA. Abstract SA405. Available for download from: http://www.abstractsonline.com/viewer/?mkey%%7BFC197A55%2DD8DD%2D4F3D%2D9994%2D290B64584CCB%7D. Accessed on 14 October 2008. Edwards B J, Bunta A D, Simonelli C, Bolander M, Fitzpatrick L A, 2007. Prior fractures are common in patients with subsequent hip fractures. Clin Orthop Relat Res;461: pp 226–230. McLellan A R, Reid D M, Forbes K, Reid R, Campbell C et al, 2004. Effectiveness of Strategies for the Secondary Prevention of Osteoporotic Fractures in Scotland (CEPS 99/03). NHS Quality Improvement Scotland. Available for download from: http://www.nhshealthquality.org/nhsqis/qis display findings.jsp?pContentID%2755&p applic%CCC&pElementID%0&p MenuId%0&p service%Content.show&. Accessed on 14 October 2008. The Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, 2007. National Clinical Audit of Falls and Bone Health in Older People. Available for download from: http://www.rcplondon.ac.uk/clinical-standards/ceeu/Documents/fbhop-nationalreport.pdf. Accessed on: 14 October 2008. Hippisley-Cox J, Bayly J, Potter J, Fenty J and Parker C on behalf of QRESEARCH and The Information Centre for Health and Social Care, 2007. Evaluation of standards of care for osteoporosis and falls in primary care. Available for download from: http://www.qresearch.org/Public Documents/Evaluation%20of%20standards%20of%20care%20for%20osteopoorosus%20 and%20falls%20in%20primary%20care.pdf. Accessed on 14 October 2008. The National Hip Fracture Database. 2010. National Report. Available to download from: http://www.ccad.org.uk/nhfd.nsf/NHFD%20National%20Report%202010.pdf. Accessed on 23 September 2010. Health Committee: Evidence Ev w91 10. FLSs are usually provided by a dedicated nurse specialist, working under the guidance of a specialist in bone health. The nurse specialist is responsible for establishing systems of care to ensure that every fracture patient over 50 years (excluding high trauma and road traffic accident victims, whose fractures are unlikely to have been caused by osteoporosis) is identified, recorded and offered a “one-stop-shop” fracture risk assessment. 11. The FLS bridges the existing care gap between different areas of health and social care and provides seamless and efficient patient care. It also ensures that the patient does not have to manage all the different parts of the NHS themselves—the presence of an FLS means that the NHS does this on behalf of the patient. 12. FLSs are proven to be effective in UK settings. Glasgow has had a city-wide FLS since 2002, which has operated in parallel a falls prevention service. The FLS was expanded to include the neighbouring Clyde region in 2009. Studies on hip fracture incidence in the Greater Glasgow area show that between 1998 and 2008, the number of recorded hip fractures in the region decreased by 7.3% from 1,377 to 1,276.63 In comparison, hospital admissions for hip fracture in those aged 65 and over in England have increased by approximately 2% per year during the years 1998–99 to 2008–09.64 The Glasgow data provides an indication of the outcomes that can be achieved when a comprehensive secondary fracture prevention service is put in place in a UK setting. 13. The case for FLSs is further strengthened by data which shows the success of the Kaiser SCAL system in the United States. In 2009, the actual number of cases of hip fracture sustained by individuals aged 60 and over was recorded as 47.8% lower than the number that would have been expected, had the system not been in place.65 14. There are some excellent examples of FLSs operating in the NHS in England. The Ipswich FLS team have published on practical aspects of setting up and running their service with a view to support likeminded colleagues wanting to establish an FLS in their own areas.66 Other exemplary services include the Newcastle Fracture Clinic Service and the falls and fracture service in Greenwich, London. 15. Despite this compelling evidence, the proportion of hospitals in England with access to an FLS is shockingly low. An organisational audit of falls and fracture services by The Royal College of Physicians and the Healthcare Quality Improvement Partnership (HQIP)67 published in 2009, found that: — just 24% of NHS and Health and Social Care Trusts in England, Wales and Northern Ireland employ a Fracture Liaison Nurse; — 31% of Trusts have the assessment and management of fracture patients co-ordinated by a Fracture Liaison Nurse; and — just 23% of Trusts have a written local commissioning strategy for bone health. 16. These results highlight a significant health inequality in terms of the future fracture risk that those patients who have and have not had their care co-ordinated by an FLS are exposed to. 17. Under the proposals contained in the Health White Paper, the NHS Board will need to ensure that it retains an overview of national audit data. This will be necessary in order for it to decide how to focus its resources on tackling variations in clinical practice and health inequalities. Where GP consortia are not meeting their obligations to reduce inequalities, the board should hold the power to intervene to improve GP commissioning activity where necessary. 18. In order to make informed decisions about commissioning comprehensive and integrated falls and fracture services, GPs consortia will need to take account of local results derived from national audit data such as that described above. The Prevention Package for Older People 19. In July 2009, DH published the Prevention Package for Older People. This provides guidance for PCTs and local authorities on commissioning comprehensive falls and fracture services. The Package includes: — a template care pathway; — assistance on conducting a Joint Strategic Needs Assessment (JSNA); 63 64 65 66 67 Skelton A & Neil F, 2009. NHS Greater Glasgow and Clyde Strategy for Osteoporosis and Falls Prevention 2006?2010: an evaluation: 2007?2009. Available for download from: http://library.nhsggc.org.uk/mediaAssets/OFPS/NHSGGC%20Strategy%20for%20Osteoporosis%20and%20Falls%20P revention%202006-2010 An%20Evaluation Skelton%20and%20Neil%202009.pdf. Accessed on: 23 September 2010. Hospital Episode Statistics. 2010. Dell R, 2010. Kaiser’s Healthy Bones Programme. Clunie G and Stephenson S, 2008. Implementing and running a Fracture Liaison Service: An integrated clinical service providing a comprehensive bone health assessment at the point of fracture management. J Ortho Nursing 2008;12: pp 156–162. Royal College of Physicians and the Healthcare Quality Improvement Partnership, 2009. National Audit of the Organisation of Services for Falls and Bone Health of Older People: Public Report: March 2009: England, Wales and Northern Ireland. Available for download from: http://www.rcplondon.ac.uk/clinical-standards/ceeu/Current-work/Falls/Documents/National-Fallsand-Bone-HealthPublic-Audit-Report-March-2009.pdf. Accessed on 25 March 2009. Ev w92 Health Committee: Evidence — guidance on exercise training to prevent falls; and — a health-economic impact assessment, providing projections of: — the financial costs and savings associated with a comprehensive falls and fracture service for a PCT and local authority(s); over a five-year period, an FLS will cost £234,181 to set up and maintain; in the same period, it will save £290,708 in treatment and care costs from averted fractures; this represents a net saving of £56,527; — the fractures prevented by a comprehensive FLS for a population-size typically served by a PCT: a comprehensive FLS serving a PCT population of approximately 320,000 people will prevent 33 fragility fractures over a five-year period. 20. The guidance is based upon peer-reviewed evidence and provides local areas with the tools they need to provide patients with access to NICE-recommended treatments and care. Though its implementation, local communities can deliver evidence-based, patient-centred services, helping them to meet the demands set out in the NHS Constitution. 21. The charity was represented on the expert task group which advised the DH on the content of the Prevention Package. 22. The NHS Board should use resources which have already been produced (such as the Prevention Package) to form the national framework of quality standards, model contracts, tariffs and commissioning networks to assist GP commissioners. The board should also share examples of commissioning best practice. The overall framework of support must be maintained and kept up to date as new data becomes available and new models of service provision are developed. 23. When facing difficult choices, we call upon commissioners to prioritise those services which evidence shows will have the greatest health and economic benefits for both patients and the NHS. Integrated falls and fracture services are proven to be both effective at preventing fractures, in addition to being cost-saving. They should be put in place in every local community in England. Commissioning Fracture Services 24. The majority of patients do not have access to services which would ensure that they receive NICE recommended treatments for fracture prevention. This shows that, for the majority of those at risk of fractures, the commissioning process is not operating correctly across England. 25. Commissioning strategies are vital to the provision of comprehensive services. All parties involved in a local falls and fracture service must be jointly involved in drafting a strategy. As an example, these should include: — commissioners; — health professionals (working in both primary and secondary care); — managers at acute NHS trusts; — intermediate care; — local authority social care services; — the local ambulance trust; and — patient representatives (through a local National Osteoporosis Society support group). 26. The National Osteoporosis Society would ideally prefer an outcomes framework which spans public health, the NHS and social care to be put in place. Achieving a reduction in fragility fractures requires intervention from all three, and we do not believe that the NHS can commission in isolation to achieve this outcome. 27. The we hope that the local Health and Wellbeing boards, proposed in the White Paper, facilitate integrated commissioning between public health, the NHS and social care. GP consortia should be bound by law to ensure that they engage with these bodies. 28. The National Osteoporosis Society believes that GP consortia should only include practices which cover a geographically discrete area. We feel that this is necessary to ensure that effective patient care pathways are commissioned and provided across each community. 29. The Royal College of General Practitioners (RCGP) states that consortia will need to be of sufficient size.68 This is to: — pool risk; — create economies of scale; and — communicate on an equal level with large NHS Trusts and external bodies. 68 Royal College of General Practitioners. 2010. Update on Commissioning Activity. Available for download from: http://www.rcgp.org.uk/pdf/Update on Commissioning Activity.pdf. Accessed on 23 September 2010. Health Committee: Evidence Ev w93 30. RCGP anticipates that each consortium should cover a population of at least 500,000, rather than the 100,000 suggested in the White paper. The National Osteoporosis Society agrees with this position. Evidence has shown that local health and social care communities in the UK provide populations of this size with effective care for falls and fracture.69 The Glasgow Fracture Liaison Service expanded to incorporate the larger NHS Greater Glasgow and Clyde board area in 2005. It serves as an example of how the expansion of a primary care organisation can reduce health inequalities among a population for which it has not previously held responsibility. 31. Ideally, we would like GP consortia to demonstrate coterminosity by covering the same geographical areas as local authorities and NHS Trust catchment areas. This will provide the best opportunity for the design and delivery of integrated, high quality care. Public and Patient Involvement 32. GP consortia must take account of patient views through local HealthWatch organisations. In turn, HealthWatches must be involved in commissioning decisions through local Health and wellbeing boards. Elected members of local authorities should represent patients and the public on the proposed health and wellbeing boards. Elected members should also be empowered to hold the work of GP consortia and the health and wellbeing boards account though overview and scrutiny committees. 33. Third sector organisations are often best-placed to act as a conduit between the NHS and patients, their carers and the general public. The sector must be supported and provided with the capacity to encourage these groups become involved in local commissioning decisions. During the Transition 34. PCTs, Care Trusts and shadow GP consortia, in addition to health and social care professionals, must work closely during the transition period. This will be vital in ensuring that successfully commissioned and/ or provided patient care pathways currently in place are not adversely affected by the new arrangements. About Us 35. The National Osteoporosis Society is the only charity dedicated to improving the diagnosis, prevention and treatment of osteoporosis across the UK. The organisation was established in 1986 and is a well respected charity with approximately 25,000 members. October 2010 Written evidence from the Chartered Society of Physiotherapy (COM 38) Introduction The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the 49,000 chartered physiotherapists, physiotherapy assistants and students in the UK. Our members work in the NHS, private practice, the independent sector (charities, private businesses and local government) and universities. The Chartered Society of Physiotherapy is pleased to submit written evidence to this Health Select Committee inquiry into commissioning. We would be willing to provide additional information or clarification of any of the points raised in this submission and would welcome the opportunity to present oral evidence to the Committee. Executive Summary The Chartered Society of Physiotherapy (CSP) believes that the weaknesses identified by the previous Health Select Committee, in its inquiry into commissioning in March 2010, look set to be perpetuated rather than reduced as a result of the proposed reforms outlined in the recent White Paper, in particular the identification of a “lack of skills, notably poor analysis of data, lack of clinical knowledge and the poor quality of much PCT management” and the assessment that the “situation has been made worse by the constant re-organisations and high turnover of staff”. — The CSP is therefore urging the Government to reconsider some of the proposals outlined in the White Paper Equity and excellence: Liberating the NHS. While we welcome the prioritisation of public health, the closer integration of health and social care and an increased focus on patient reported outcomes, we have grave concerns about the scope and speed of the structural changes 69 Skelton A & Neil F, 2009. NHS Greater Glasgow and Clyde Strategy for Osteoporosis and Falls Prevention 2006?2010: an evaluation: 2007?2009. Available for download from: http://library.nhsggc.org.uk/mediaAssets/OFPS/NHSGGC%20Strategy%20for%20Osteoporosis%20and%20Falls%20P revention%202006-2010 An%20Evaluation Skelton%20and%20Neil%202009.pdf. Accessed on: 23 September 2010. Ev w94 Health Committee: Evidence proposed and the resulting impact on patient care. We are also deeply concerned that the proposed shift to GP consortia-led commissioning may fragment patient care, create a postcode “lottery” and increase costs. — The CSP is committed to a National Health Service that is free at the point of delivery; based on need; publicly funded, publicly provided and publicly accountable. The CSP believes that collaboration and communication are the best ways to deliver services within the NHS and that competition between healthcare providers is potentially destructive to patient care. — We believe that these proposals potentially constitute a huge gamble with the NHS—the health of the nation and tax payers’ money. The planned reforms will divert scarce resources away from frontline services, potentially undermining the current efficiency drive. There is a significant risk of patient services becoming fragmented and destabilised, reducing the quality of care and making long-term planning increasingly difficult and the future of the NHS more uncertain. In light of these concerns, the CSP believes that it would be far more productive for the pace of change to be reduced to allow time for pilot studies to be carried out and to ensure that the quality of patient care is not compromised. — The CSP is concerned that because of the short term focus on achieving significant “efficiencies” in the NHS and financial savings in public services, alongside the fragmentation of services and proliferation of providers, commissioners will not be able to address inequalities in health outcomes. — The current pressure on the Health Service to make substantial efficiency savings will inevitably impact on its ability to introduce what could be the biggest organisational change it has experienced since its inception in 1948. — The title of the White Paper is Equity and Excellence, however it is unclear how this equity will be delivered when these proposals could lead to much bigger postcode lotteries than have been experienced before, with patients across the country having access to differing services based on what local GP consortia choose to commission. Commissioning 1. The CSP welcomes the significant improvements already achieved through World Class Commissioning, notably the reductions in waiting times for hospital in-patient services and reductions in death rates from cancer, cardio-vascular disease or stroke. 2. We believe that in order to maintain these standards or improve them, the new NHS Commissioning Board will need input and advice from physiotherapists and other Allied Health Professionals (AHPs) to ensure that it has access to that expertise in its decision making and specialist commissioning. 3. The CSP is concerned that there is little evidence that the proposed GP consortia will have the necessary expertise to commission the right services in the most efficient way. CSP would therefore like to see a commissioning process which has a wider range of clinical expertise (from AHPs for example) at its heart. 4. The CSP strongly supports service redesign and innovation aimed at improving patient care, but also believes that mainstream NHS services are best delivered by NHS-employed staff. 5. We welcome the principle of greater clinical involvement in the planning and commissioning of services outlined in the health White Paper, however at present the proposals do not detail how this will be formally required or ensured. 6. We sincerely hope that the final plans honour the assertion made by the Secretary of State that GPs will involve a range of health professionals, including physiotherapists, in planning and decision-making through the consortia groups. 7. We also welcome the assurance that staff engagement and partnership working will be promoted throughout the NHS and that the recommendations in the Boorman report70 on staff health and well being will be implemented. Physiotherapy has a key role in realising the increased productivity gains outlined in the Boorman Review and the profession is keen to support the roll out of the recommendations. Concerns about Proposed New Commissioning Arrangements 8. CSP has significant concerns that the intention that the commissioning process should improve quality and encourage innovation (and be underpinned by co-operation and collaboration) may be being compromised. The introduction of a competitive model, where the main driver for some local commissioners will be primarily the achievement of financial savings and where the sharing of best practice is limited by commercial sensitivity, will have a detrimental impact on collaboration and cooperation within the NHS. 9. The CSP has concerns over the inevitable increase in postcode lotteries of care as the number of bodies commissioning services increases from 150 PCTs to an undetermined but potentially much larger number of GP consortia. This seems to be in conflict with the assertion in paragraph 1.10 of the White Paper which outlines the desire for the NHS to become less fragmented and insular. 70 Boorman (2009) NHS Health and Well-being, Final Report, November 2009, Department of Health, London. Health Committee: Evidence Ev w95 10. While we recognise the argument that local people will make decisions based on the needs of the local population, this will lead to differences in provision from one area to another. Strong monitoring and accountability processes will be needed to ensure that an unacceptable variation in levels of care across the country is avoided. In addition, planned changes to commissioning arrangements contradict the assertion in the Coalition Programme for Government which states “we will stop the top-down reorganisations of the NHS that have got in the way of patient care”. 11. The CSP is seeking assurances that the new NHS Commissioning Board with its regional arms will be properly resourced to carry out this role on a par with the current provision from SHAs and PCTs. Moreover, the production of the NICE quality standards will not be completed until 2015, by which time the structural changes and new commissioning arrangements will have been in place for at least two years. 12. Consideration must be given to how unacceptable variations in the provision and quality of care are avoided in those areas of healthcare that do not have NICE quality standards by the time the new commissioning arrangements come into being. The CSP, would, therefore, urge the Government to delay the implementation of the structural changes in commissioning to enable NICE to complete its work first. 13. We are sceptical that an increase in the number of commissioning organisations across the country will provide the reductions in management costs that the Government is seeking to realise. We are concerned that administering a large number of GP consortia will prove to increase the NHS management budget in the long-term, diverting resources from patient care. In addition to this, we are concerned about the financial management of the NHS budget once it has been devolved to the local GP consortia. 14. The 26 August edition of the Health Service Journal (HSJ) reported that existing GP consortia had overspent their budgets by 2.5%, which would result in up to £3 billion of overspend if this were repeated by all consortia in the new system, placing huge pressure on the NHS as a whole and individual GP practices. Although these figures have been challenged, this article demonstrates the real probability of future deficits in the NHS budget. 15. The CSP is firmly of the view that collaboration is the best way of providing quality healthcare and that competition, which pits NHS organisations and staff against each other, is destructive to patient care, making pathways of treatment that cross healthcare sectors or providers increasingly disjointed and harder to manage. The CSP is urging the Government to rethink their policy of extending the principle of competition in the NHS. 16. The CSP is concerned about the conflict of interest that may arise from private companies being awarded contracts to undertake local needs mapping and commissioning activities, when they are also competing to provide the commissioned services to the NHS. There must be clear and transparent rules introduced to ensure that no company or individual with an interest in running NHS services can be involved in any way in the process of commissioning or performance management. 17. The CSP also has concerns that an increased plurality of providers will lead to fragmentation of healthcare services, with private companies opting to provide the most profitable services and leaving the NHS to cope with the most complex and resource-intensive work. This happened as a result of GP fund holding, so there is a precedent for this outcome. Safeguards will need to be put in place to ensure that this situation is avoided: a challenge that the CSP believes the Government must be prepared to face. 18. The CSP supports the Government’s commitment to reducing health inequalities, but does not believe that the structural approach to the reforms will deliver this. Instead the plurality of commissioning bodies will lead to increased fragmentation of services and postcode lotteries that could serve only to exacerbate the existing health inequalities the country faces. 19. The CSP is concerned that because of the short term focus on achieving significant “efficiencies” in the NHS and financial savings in public services, alongside the fragmentation of services and proliferation of providers, commissioners will not be able to reduce inequalities in health outcomes. 20. The CSP is particularly concerned about the growing numbers of adults and children who are overweight or obese, and the worrying numbers who take insufficient exercise. Physiotherapists are well placed to encourage and promote healthy lifestyles, including the benefits of regular physical activity. The focus of commissioning has, to date, been primarily on the provision or improvement of acute and community-based health treatment services. 21. The CSP therefore welcomes the Government’s proposal to develop a more strategic focus on improving public health, tackling health inequalities and reforming adult social care. Physiotherapists can make a key contribution as public health responsibilities transfer to local authorities. 22. The CSP is also fearful that the monitoring of key health outcomes and measuring of quality improvement could become more difficult in a more fragmented health system. Ev w96 Health Committee: Evidence Impact on NHS Workforce and Patient Care 23. With regard to the proposals for all NHS Trusts to become Foundation Trusts by 2013–14, we would highlight the risk of there being some rapid financial cutbacks or vacancy freezes in NHS Trusts as they strive to ensure their finances are in order to meet the deadline for becoming Foundation Trusts. This move to Foundation status will be a significant change for a number of Trusts, which will have only a short time to make this transition. 24. The CSP is also concerned about the financial stability of new Foundation Trusts and the risk of these organisations potentially going bankrupt. With the understanding that the Government will not bail out Trusts which end up in this situation, measures will need to be put in place to avoid valuable public assets, such as hospital buildings, being sold to meet debts in the future. 25. The CSP believes that maintaining a stable, quality NHS workforce is crucial to ensuring high quality care for patients. The impact of these proposals on staff, in terms of morale, concerns about job security and future impact of potential changes to their pay and terms and conditions of employment, should not be underestimated, particularly in light of pre-election promises that there would be no top down reorganisation of the NHS, which was understandably interpreted to mean there would be no reorganisation of NHS structures. 26. Significant, rapid change could divert resources and time from patient services if staff feel demoralised and uncertain about their future. To maintain staff moral and help deliver the highest standard of patient care, all potential providers of NHS services should be able to demonstrate to commissioners that they are capable of applying fair, reasonable and legal employment standards, and are committed to achieving best practice. 27. Paragraph 1.21 in the White Paper refers to large cuts in administrative costs, but does not make clear where or how these duties will be covered. The CSP is already aware that vacant posts are not being filled in some areas and hard pressed staff are having to cover the work of absent colleagues. It is important to recognise that an increase in the burden on clinical staff, caused by a reduction in the workforce or administrative support, would further impact on the efficiency and effectiveness of staff resulting in an adverse impact on patient care. The Coalition Programme for Government states that the Government will cut the cost of administration by one third and transfer resources to support doctors and nurses on the front line. 28. The CSP believes that certain administration functions are essential and should not have to be undertaken by already overstretched clinicians. We have concerns as to how this shift in resources will work in practice and are seeking assurances that this will not result in additional administration burden on physiotherapists and other NHS clinical staff. 29. A move to the “any willing provider” approach will have an impact on the career development and employment of staff currently working in the NHS. This approach will surely shift resources away from developing careers, professional development and long term sustainability of services and toward private profit that will not be reinvested in professions. 30. Resources and systems must be put in place to ensure that clear career pathways for physiotherapists and support workers are assured to ensure the future provision and stability of the service. A lack of clear career progression would deter people from training into the profession, resulting in staff shortages and longer waiting lists for patients in the future. 31. The CSP would like to see alternative providers taking student placements, funding CPD and providing rotation posts for newly qualified staff to ensure that, if implemented, the policy of “any willing provider” is truly based on a level playing field. 32. To achieve parity between different providers, commissioners will need to ensure that all providers not only share the costs of providing the health workforce of the future, but operate to the same clinical standards and that there are adequate monitoring arrangements. 33. The “any willing provider” approach will considerably increase competition in the NHS, despite the lack of robust evidence that this will improve productivity or patient care. The CSP believes that professional collaboration and the spreading of best practice normally works best in an environment of co-operation and cohesion of service delivery rather than one of competition and fragmentation. A recent report—“Improving NHS productivity: More with the same not more of the same” published by the Kings Fund, which found evidence for this view, spelt out that the NHS cannot afford to reduce the opportunities for health workers to learn from each other. 34. The strong link between staff engagement and patient outcomes is well researched and will be crucial to the success of planned changes to health services. Although it is primarily the responsibility of providers, commissioners should have a responsibility to ensure early engagement with staff and their trade union representatives when reviewing services and care pathways, developing service specifications and evaluation criteria, and implementing decisions. Health Committee: Evidence Ev w97 Integration of Health and Social Care 35. The CSP welcomes the new and enhanced role for local councils in relation to health improvement and prevention activity. In principle, devolving decision making closer to patients is a good idea. Strengthening local accountability by placing more power in the hands of elected members of local authorities will give patients more influence over health decisions in their area. We agree that giving local councils the power to lead joint strategic needs assessments (JSNA) makes sense, but to be effective these JSNAs must be based on up to date appropriate data and information, and involve all relevant healthcare professionals. 36. The CSP supports the proposal to establish a statutory health and wellbeing board within a local authority, to promote integration and partnership working between the NHS, social care, public health and other local services. At present the proposals do not make clear how this health and wellbeing board would be able to influence commissioning. Given the essential role of Allied Health Professionals in integrating care and the key contribution that physiotherapy can make to improving public health and well being, we consider it vital that Allied Health Professionals are represented on the proposed new health and wellbeing boards. October 2010 Written evidence from the Muscular Dystrophy Campaign (COM 39) Executive Summary — We welcome the proposed National Commissioning Board for specialised services, and believe this to be a necessary step towards a national neuromuscular service for these neglected conditions. However, we also have serious reservations regarding the impact of the proposed move to GP Commissioning for non-specialised primary and secondary care for the 71,000 children and adults with muscular dystrophy and related neuromuscular conditions. — Both the Committee’s report on this subject in March 2010, and the Coalition Government’s response to this report endorsed our concerns regarding the current structure of specialised commissioning for people with rare and very rare conditions. — As our evidence had shown, patients with neuromuscular conditions face a postcode lottery in accessing the specialist multidisciplinary care they require. This has had devastating consequences, with young men with Duchenne muscular dystrophy dying on average 10 years earlier in some parts of the country compared with others, due to a lack of specialist care. — A National Neuromuscular Service, commissioned by the National Commissioning Board through regional specialised commissioning would end the scandal of patients in one part of the country being denied the life-saving care awarded to others, and we would support the creation of the Board. — However, we remain concerned by the lack of clarity regarding specialised commissioning for rare and very rare conditions. We welcome the proposal that specialised services will be commissioned by the new National Commissioning Board; but await further details as to how National Commissioning Board will be funded, and the structure of the regional outposts. — Furthermore, there has been a worrying lack of detail regarding the non-specialised aspects of care for patients with these complex conditions. Neuromuscular conditions are complex multisystem disorders, requiring primary, secondary, tertiary and sometimes quaternary services and clinical evidence is clear that such multidisciplinary care at all of these levels can not only can dramatically extend life-expectancy and transform quality of life for patients with these conditions, but also save vital funds, by preventing unplanned emergency admissions and through reducing the length of hospital stays. — We urgently seek clarification as to how the Commissioning Board will interface with the rest of the system commissioned by GP’s to provide essential factors of this multidisciplinary care such as community nursing, speech and language therapy, continuing care and on-going physiotherapy. — We are worried that the lack of knowledge among GPs could seriously jeopardise standards of multidisciplinary care offered to these patients. The Muscular Dystrophy Campaign 2010 Patients Survey has revealed a serious lack of understanding and experience among GPs of neuromuscular conditions, many of whom only have one or two patients with a neuromuscular condition at their practice. Without this knowledge, it is hard to see how GPs will be able to make appropriate and timely referrals to both specialised and non-specialised services, and coordinate care for these complex and rare conditions. Ev w98 Health Committee: Evidence Introduction 1. The Muscular Dystrophy Campaign represents the 71,000 people in the UK with muscular dystrophy or a related neuromuscular condition. There are more than 60 different types of muscular dystrophy and related neuromuscular conditions, many of which are low-incidence, orphan conditions and indeed some are very rare and are regarded as ultra orphan. Neuromuscular conditions can be genetic or acquired and, with the exception of a couple of acquired conditions, there are no known effective treatments or cures. 2. As these are rare and very rare conditions, they are currently the responsibility of the 10 regional Specialised Commissioning Groups in England, and are listed in the Specialised Services National Definition Set.1 The ultra-rare conditions (affecting less than 400 patients each) are the responsibility of AGNSS (Advisory Group for National Specialised Services).2 3. We submitted evidence to the Committee’s previous Inquiry into Commissioning in September 2009 which highlighted a number of concerns over the working of specialised services as below: — A number of SCGs have told the Muscular Dystrophy Campaign that patients with neuromuscular services are “not a priority”. — We have found that in practice, the Specialised Commissioning Groups have no authority over the Primary Care Trusts in their regions. We have been told time and time again that the SCGs work “on behalf of the PCTs” and that they will only concentrate on those services regarded as important by the PCTs. — There is no clear structure or chain of command for working between Strategic Health Authorities and Specialised Commissioning Groups. This has resulted in completely dysfunctional relationships in some regions—and leaving some SHAs in the impossible position of having the ultimate responsibility for supervising overall healthcare in the region, but having no power to improve health outcomes for people with devastating muscle wasting and weakening conditions— some of which are life-limiting. — Many SCGs do not commission services for the whole region, preferring in some places to stick with outdated commissioning boundaries. — The National Specialised Commissioning Group (NSCG), created on 1 April 2007, is meant to have overall responsibility for the oversight of specialised commissioning. However, we believe their authority over the SCGs is extremely limited and the NSCG is unable to instruct the SCGs to prioritise certain services and conditions. 4. We were pleased to note that these concerns were endorsed in the Committee’s March 2010 report.3 We further welcomed the government’s agreement on these concerns in their response to the Committee’s report (July 2010), and their commitment to resolving the problems with the current specialised commissioning structure through the proposals in the White Paper.4 Need for Specialist Multidisciplinary Care for Neuromuscular Conditions 5. Neuromuscular conditions are complex, progressive multi-system conditions which require multidisciplinary pathways of care. These pathways are recommended by the leading clinicians in this field as drastically improving the quality of life and need for emergency care: “Specialist multi-disciplinary care has been developed by leading clinicians as the best model for delivering effective care for such complex, multi-system diseases. The provision of expert physiotherapy, orthotics, early cardiac monitoring and intervention and corticosteroids has been shown to improve muscle function and maintain independent mobility. The judicious use of spinal surgery and expert respiratory services (including non invasive positive pressure ventilation) helps to improve quality of life, delay the onset of respiratory failure and prolong the life of these patients”.5 6. Multidisciplinary care for Duchenne muscular dystrophy has been recommended in a major international consensus document setting out best practice in care for Duchenne muscular dystrophy which was published in the Lancet Neurology journal in January and February 2010. The Care Standards are the result of an extensive review process by 84 international experts in the diagnosis and care of Duchenne muscular dystrophy.6 7. In addition to improving life expectancy and quality of life for neuromuscular patients, specialist neuromuscular care has been shown by clinical audit data to reduce the likelihood of patients with neuromuscular conditions being admitted to hospital as an emergency. Dr R Quinlivan, Specialist Neuromuscular Consultant at the Centre of Inherited Neuromuscular Disorders at the Robert Jones and Agnes Hunt Orthopaedic and District Hospital, Shropshire has shown that of her 700 patients only eight were admitted to hospital during the 2009–10 financial year. Of these eight admissions, half were unrelated to the patient’s neuromuscular condition. 8. Analysis of unplanned emergency admissions data provided by a number of Specialised Commissioning Groups suggests that £81 million was spent last year on such admissions by people with neuromuscular conditions. We estimate that this figure could be substantially reduced through investment in specialised multidisciplinary care. Health Committee: Evidence Ev w99 Impact of the White Paper on Specialised Neuromuscular Services 9. The Health White Paper: Equality and Excellence: Liberating the NHS was published on 12 July 2010, and proposed the abolishment of Strategic Health Authorities and Primary Care Trusts, with GPs to commission the majority of services. Regional and national specialised services will become the responsibility of a new National Commissioning Board. 10. We welcome the decision to set up the National Commissioning Board for regional and national specialised services. It is imperative that specialised services for patients with neuromuscular conditions are not commissioned by GP consortia, which will not have the patient numbers, knowledge or expertise to commission these complex and costly services. 11. In addition, we welcome the commitment that all services on the Specialised Services National Definition Set will be commissioned by the National Commissioning Board. If this commitment is fully implemented, it would help to end the postcode lottery that patients with neuromuscular conditions are currently experiencing, where each SCG commissions only part of the Definition Set. 12. However, we seek reassurance that sufficient funding will be provided to ensure that the National Commissioning Board is able to commission all 35 definitions. We have repeatedly been told that the current SCGs simply do not have the funding to commission more than just a handful of these services—a substantial and recurring investment would be required for all patients to have access to these vital services, which would be offset by the savings made as unplanned emergency admissions for people with neuromuscular conditions are reduced. We seek further clarification as to how the funding will be delivered for the National Commissioning Board. Currently the funding for specialised services is top-sliced from Primary Care Trust budgets, leading to severe difficulties for the commissioning of these services. We would recommend that funding is delivered at a national level to the National Commissioning Board, and not delivered via GP consortia. 13. We seek clarification as to how the NHS National Commissioning Board will work in practice—and whether regional outposts will be developed. We would be keen to ensure that regional expertise developed in this complex area by individual Specialised Commissioning Groups is not lost in the reorganisation. 14. We urge the government to set a firm timescale for the migration of specialised services to the National Commissioning Board. Already we can report confusion as to the future role of Specialised Commissioning Groups and that this is having a negative and delaying impact on the commissioning of specialised neuromuscular services. It is crucial that patients are not subjected to paralysis in the commissioning and delivery of these services during this period. The urgent and continuing needs of patients with life-limiting conditions cannot be placed on hold due to the NHS reorganisation. Impact of the White Paper on Non-specialised Multidisciplinary Services 15. While we welcome, with reservations, the commitment to keep specialised services apart from GP commissioning, we have serious concerns regarding the provision of essential non-specialised aspects of neuromuscular care in primary care. In addition, we remain concerned that a lack of understanding among GPs of rare conditions will delay referral to the specialised services commissioned by the National Commissioning Board. 16. Already patients and their families can experience severe and substantial difficulties accessing diagnosis and subsequent specialist care through their GP. In 2010 we surveyed 2,000 people living with muscular dystrophy or related neuromuscular conditions to uncover their experiences of accessing the appropriate medical services for their conditions. Our survey revealed that over half of people with muscle disease feel their GP has a poor understanding of their condition and many of those surveyed said they felt they knew more than the GP. Furthermore, many patients who responded told shocking stories of GP ignorance of the condition, which included being labelled a “lazy hypochondriac” and patients having to teach doctors about muscle disease. 17. This lack of understanding can lead to a delay in appropriate referrals and diagnosis which is correlated to life quality and in some circumstances life expectancy. Our survey revealed that 50% of people with neuromuscular conditions did not receive a correct and prompt diagnosis. The dangers of delayed diagnosis are shown in the following experience of two children from the West Midlands: “Two patients with Duchenne muscular dystrophy were misdiagnosed as having learning difficulties. This had catastrophic implications for the young boys and their families especially as Duchenne muscular dystrophy is in fact a life limiting condition. Due to the misdiagnosis and subsequent delay in referral to a specialised centre both boys missed the ‘window of opportunity’ to benefit from steroid therapy and became wheelchair dependent from the age of nine years.”7 18. Our patient survey further reported a severe difficulty in accessing non-specialised services, such as physiotherapy, hydrotherapy and psychological support. Primary Care Trusts have been extremely unwilling to fund these vital services on an ongoing basis—instead only allowing patients access for a six week or six session basis. This fails to recognise both the long-term and progressive nature of neuromuscular conditions. Further, such short-term thinking regarding costs leads to much higher costs in the long-term, through not only unplanned emergency admissions, but greater need of wheelchairs and mobility equipment, community nursing following falls, and social care costs. As GP consortia are expected to be Ev w100 Health Committee: Evidence based on smaller population sizes than PCTs, and thus have smaller budgets respectively, patients are likely to experience even more difficulty in getting these services funded. We recommend a robust structure of engagement between GP consortia and the National Commissioning Board regarding non-specialised services for rare conditions to help ensure that neuromuscular patients have access to all parts of multidisciplinary care. 19. We are extremely concerned about the lack of detail in the White Paper regarding the future of NHS Continuing Care. The only reference to Continuing Care states: “the Department will encourage further pilots to come forward and explore the potential for introducing a right to a personal health budget in discrete areas such as NHS continuing care”.8 We are asking for urgent clarification on who will take on the responsibility from Primary Care Trusts for this costly but essential service. We have already heard from one patient with very high level of care need, who has been told by his PCT that his care package will be halved due to budgetary constraints. This is despite the assessment which has shown that his current care package is necessary for his condition. We are extremely concerned that if the expensive, but necessary costs of Continuing Care for people with severe neuromuscular conditions, and very high levels of care needs is passed to GP consortia. This would place a substantial cost benefit onto GP consortia, which would be against the rationale of specialised commissioning. We would be pleased to work with the National Commissioning Board to ensure that Continuing Care for neuromuscular patients, given the complex nature of these conditions and the costly nature of the care needed, is protected through the NHS reorganisation. October 2010 References 1 National Specialised Commissioning Group Specialised Services National Definition Set http://www.ncg.nhs.uk/info/specialised-services-national-definitions 2 AGNSS: http://www.ncg.nhs.uk/info/agnss 3 Health Select Committee Commissioning (March 2010). 4 HM Government Cm 7877 Government Response to the Health Select Committee on Commissioning (July 2010). 5 Professor Michael G Hanna, Consultant Neurologist, Institute of Neurology, London; et al. Building on the Foundations: The Need for a Specialist Neuromuscular Service Across England (December 2007) 6 The Lancet Neurology The Diagnosis and Management of Duchenne Muscular Dystrophy (January 2010). 7 Muscular Dystrophy Campaign Building on the Foundations: The Need for a Neuromuscular Service Across the West Midlands (April 2009). 8 DH: Equity and Excellence—Liberating the NHS (July 2010). Written evidence from Weight Watchers UK (COM 40) Summary — Previous evidence on weaknesses of NHS commissioning remains valid. — Despite “obesity epidemic”, no mention of commissioning weight management services in Health White Paper. — Little evidence in White Paper that changes will address commissioning shortcomings. — Where will responsibility lie for commissioning weight management services? — Call for level playing field in both evidence base and quality requirements as between in-house NHS and private sector service providers. — Need for list of preferred suppliers of weight management services. — Procurement process requires tailoring to local circumstances. — Payment by results may affect equality of access. 1. Your Committee’s Previous Commissioning Inquiry At a meeting in July 2009 with the then chairman of the Health Select Committee Kevin Barron and Dr Richard Taylor, Weight Watchers was invited to submit written evidence to the Committee inquiry into Commissioning based on its experience of providing weight management services on referral. We agreed with the great majority of conclusions in the Committee’s subsequent report. In our view, not much has changed in the intervening period, and it could be argued that there is little evidence that the current White Paper proposals for commissioning will result in the desired changes. Health Committee: Evidence Ev w101 2. Tackling Obesity should be at the Heart of the New NHS 2.1 Obesity is currently crippling the NHS. Over 60% of adults are overweight or obese (Health Survey for England 2008) and the health and economic consequences are massive (Foresight 2007). For example, it is estimated that 10% of the NHS budget is spent on diabetes, equating to £286 being spent every second (Diabetes UK, 2010). Foresight estimated the annual costs to the NHS of diseases related to overweight and obesity to be £14,416 million. 2.2 As well as prevention strategies (such as healthier school meals, access to green spaces, active transport policies etc) the 26 million adults who are currently overweight or obese need access to effective weight management services. The NHS is the main channel of delivery of such services. However the overweight and obese population is diverse, both in terms of its BMI distribution and weight management needs (DH 2010). Previous clinical research indicates that different weight management approaches are effective with different individuals and therefore a range of service options should be available to NHS patients needing to lose weight. There is no mention or reference to weight management services within the current White Paper proposals and this is a significant omission. 3. How Weight Watchers Works with the NHS 3.1 Just under two thirds of Primary Care Trusts (95) have to date procured weight management services from Weight Watchers. The Weight Watchers Referral Scheme consists of an individual patient pack of vouchers for 12 Weight Watchers meetings. The cost to the NHS is currently £45 for 12 sessions (the cost to the NHS of one 10 minute GP consultation is £20). Most PCTs offer this service free of charge to patients; however patient access varies between PCTs and also between GP practices within those Primary Care Organisations which have procured this package for their patients. The majority of PCTs purchase packs on a pilot basis (less than 250 packs) and therefore only have capacity to offer referral to Weight Watchers to very small numbers of hand selected patients. Each PCT sets its own criteria for eligibility, usually based on BMI and co morbidities, which are currently obviously driven by trust priorities and resources. There are inequalities in access to the Weight Watchers Referral Scheme both within and across PCTs. The most recent independent audit of the scheme (Ahern A et al, 2010) showed that of the 29,326 referrals to Weight Watchers, 26,252 (90%) were female. The median age was 49 years (inter-quartile range [IQR] 38–61 years). The median weight at the start of the referral course was 94.3kg (IQR 83.7–107.7kg), and median BMI 35.1kg/m2 (IQR 31.8–39.5kg/m2). 3.2 Potentially over two thirds of the adult population of the UK need access to some sort of weight management service, and rates of overweight and obesity are rising (Health Survey for England 2008). From the above, it can be seen that the current profile of patients referred to the scheme is not a representative sample of those who need it. Many PCTs are using the scheme solely as a last resort, rather than offering it to all those who may benefit in terms of prevention of overweight, treatment of overweight and treatment of obesity. Instead most are using it purely for treatment of obesity. 4. No Evidence that Proposals will Solve NHS Commissioning Weaknesses 4.1 The Government’s vision set out in the White Paper represents a revolution in how the NHS will be managed and how contracting and commissioning arrangements will work. Whilst Weight Watchers welcomes any initiative which will improve access for NHS patients to weight management services, there is little hard evidence within the White Paper that the proposals will bring the improvements sought. The changes proposed by the government should address the issues highlighted in your Committee’s previous report, not exacerbate the shortcomings. Weight Watchers believes that more work needs to be done to convince the NHS (and its partners) that the proposals set out in the White Paper will improve service delivery, clinical outcomes and patient experience. Commissioning is key to all these. 5. Responsibility for Commissioning Weight Management Services Unclear 5.1 Under the proposals, the current main commissioners of weight management services, Primary Care Trusts (PCTs) will be phased out by April 2013. The vast majority of commissioning responsibilities will be transferred to new GP commissioning consortia. It is not clear within any of the detailed White Paper consultations whether the new GP commissioning consortia will procure weight management services (eg NHS referral to group support programmes such as Weight Watchers) or whether the contracting process will be the responsibility of public health directors, who sit within local authorities and lead on wellbeing services, or of the NHS Commissioning Board. This key question needs to be answered clearly and explicitly. 6. Weight Watchers Supports Transparency in Outcomes 6.1 The White Paper sets out plans to develop a new NHS Outcomes Framework. This Framework, determined by the Secretary of State, will set out annual NHS priorities in terms of outcomes. The NHS Board will then have a responsibility to work with GP consortia and their providers to translate these outcomes into valid indicators for management of the service. Ev w102 Health Committee: Evidence 6.2 Weight Watchers welcomes the whole notion of transparency of outcomes, especially when applied to weight management services for NHS patients. Over the last decade Weight Watchers has made significant investment in research to evaluate the efficacy of its methods (Heshka et al, 2003), and the effectiveness of its NHS Referral Scheme (Ahern et al, 2010; Jebb et al, 2010). Specifically: 6.3 A recently completed randomised controlled trial conducted across three countries (England, Germany and Australia) revealed that patients referred to Weight Watchers lost significantly more weight ("4.02kg) at one year compared to those who received standard care within primary care ("1.59kg). Of those who completed, again patients referred to Weight Watchers lost significantly more weight ("6.87kg) at one year compared to those who received standard care within primary care ("3.17kg). Dropout rates were also higher in the primary care group (50%) compared to the Weight Watchers group (41%) (Jebb et al, 2010). 6.4 Data obtained from the Weight Watchers Referral Scheme database for 29,326 referral courses within 74 PCTs between 2007 and 2010 demonstrated that there was a 58% course completion rate with a median weight loss at three months of 5.2kg (5.5% of baseline weight). 33% of all referrals resulted in a loss of 5% baseline weight and 6.8% in a 10% loss. Of completers, 55% lost 5% of baseline weight, and 12.2% lost 10% of baseline weight (Ahern A et al, 2010). 6.5 As a result of this extensive research and evaluation, Weight Watchers has comprehensively documented the outcomes which can be achieved by referral of patients to Weight Watchers within a primary care setting. We know what the outcomes of our interventions are. In contrast, few NHS providers of weight management services (dieticians, practice nurses, GPs) have accrued parallel outcome data, and as a consequence they know little about the true outcomes of the interventions they facilitate, yet within commissioning circles NHS professionals remain the preferred providers of all weight management services. Weight Watchers sincerely hopes that the move towards a “Transparency in Outcomes Framework” will bring an equal playing field for contracted weight management services delivered to NHS patients. 7. White Paper Ignores Commercial Providers of Weight Management Services 7.1 Through the research, evaluation and audit activity described above, Weight Watchers has fought for acceptance as an effective referral route for overweight and obese NHS patients. The previous Government’s obesity strategy, “Healthy Weight: Healthy Lives”, promoted commercial partnerships as an essential element to solve the “Obesity Epidemic”. Yet this rhetoric seldom became a reality. For example, there was limited recognition of commercial providers such as Weight Watchers within DH, or inclusion within local obesity care pathways drawn up by PCTs. Historically Weight Watchers has encountered commercial prejudices (ie not being perceived as offering as high quality a service as NHS providers) within NHS commissioning circles. It was hoped that the announcement of the Health Secretary’s “Responsibility Deal”, setting out a new era of non bureaucratic partnership with the business community to tackle key challenges in society (such as obesity), would signal a sea change in attitudes within the NHS to commercial providers who have good quality data underpinning the effectiveness of the services they offer to the NHS. However, commercial players have been omitted from the current White Paper and its detailed consultations. 8. Preferred Supplier List of Weight Management Services 8.1 Commercial providers of weight management services to the NHS vary in quality, content, intervention methods and target audiences. They include meal replacements, very low calorie diets, group support, drug treatment, one to one interventions and online services. Whilst NICE (2006) has recommended that NHS practitioners only refer or recommend commercial services which meet best practice guidelines, Weight Watchers’ experience is that this has resulted in a procurement box ticking exercise which is a poor solution to using services with proven effectiveness. It is recommended that as part of the Transparency in Outcomes Framework a specific list of preferred providers of weight management services with proven effectiveness based on high quality research data be issued to NHS commissioners. 9. Simplify and Deregulate NHS Commissioning of Weight Management Services 9.1 Weight Watchers has accrued considerable experience in tendering for NHS weight management contracts. Within our submission to your Committee’s previous inquiry, we detailed the wide ranging frustrations connected to an over regulated, inflexible and insensitive commissioning process often driven by NHS commissioners with little apparent knowledge of the scientific obesity literature and a seemingly poor understanding of the realities of weight management. For example, recently PCTs were adamant that all Weight Watchers meeting leaders should possess Criminal Record Bureau (CRB) clearance, when in reality these facilitators are never alone with children or vulnerable adults. Whilst Weight Watchers was prepared to have its leaders checked, the CRB itself was adamant that leaders did not require clearance. It took months, and considerable resource, for Weight Watchers to liaise between the two parties and argue the case that CRB clearance was inappropriate for its leaders. PCTs were unprepared to listen or conduct a dialogue on the subject, and only finally agreed once they had received notification from the CRB that they were not correct in asking for this requirement. This is a prime example of where standard procurement procedures for health services do not fit the specific style of weight management service offered to the NHS by companies such as Weight Watchers. Health Committee: Evidence Ev w103 9.2 Equally, some PCTs have been requiring us, as part of official tender pre-qualification procedures, to be registered with the Care Quality Commission, when the Commission itself advises us that this is not appropriate. If we cannot tick the right box at the pre-qualification stage, whether it be for CRB checks, CQS registration, offering specialised evaluation services or services for children, our tender is discounted. There is no opportunity for face-to-face dialogue to discuss local needs, query elements or share best practice. 9.3 Weight Watchers welcomes the White Paper proposals to simplify, deregulate and strip away the bureaucracy surrounding procurement. 10. Payment by Results may Affect Equality of Access to Weight Management Services 10.1 Weight Watchers applauds the overall emphasis in the White Paper that it will be outcomes that matter, not targets or activity alone, with government pledging an end to the production line approach to delivering services. As such, providers will be paid according to their performance. However, this principle needs careful application to weight management services. Helping people lose weight is complex, often requiring behavioural intervention, backed up by regular support and review. Obesity is a chronic disease. Losing weight requires great effort and patients often describe the weight loss journey as “an endless battle” (DH 2010). Research suggests that high relapse and dropout rates are common in weight loss treatment studies—ranging from 10–80% (Inelman et al, 2005). For example, in the Counterweight study where weight management interventions are mediated by practice nurses (2004) retention was 22.5% at 12 months. 10.2 It has not been our experience that there exists equality of access to weight management services between PCTs or within PCTs, and there is a danger that if payment by results is insensitively applied to weight management service providers then only patients with lower BMIs (25—30 kg/m̋) and less complex health and socioeconomic needs will be accepted for referral and this will cause further inequalities of patient access to weight management services. Payment by results in the weight management arena will discriminate against larger patients with complex health problems. The solution is to set realistic “performance indicators” specific to different types of services (eg drug treatments, group support, one to one with a practice nurse, very low calorie diets) These very specific “performance indicators” should be grounded in what the credible evidence base indicates is achievable and should form the basis for any “payment by results” scheme. Weight Watchers suggests that these performance indicators include: (a) % of referred patients who complete with their chosen weight management solution. (b) % of referred patients achieving a weight loss of at least 5% of their initial weight. (c) % of patients who complete with their chosen weight management solution who achieve a weight loss of at least 5% of their initial weight. 6 October 2010 List of References Ahern A et al (2010) An audit of the UK Weight Watchers NHS Referral Scheme. Int J Obesity; In press. The Counterweight Project Team (2004). A new evidence-based model for weight management in primary care: the Counterweight Programme. J Hum Nutr Dietet, 17, 191–208. DH (2010) Maximising the appeal of weight management services. A report for the Department of Health and Central Office of Information. ESRO. Foresight (2007) Tackling obesities: Future choices. Project Report, Government Office for Science. Health Survey for England (2008) www.dh.gov.uk/publicationsandstatistics/publishedsurvey/healthsurveyforengland/index.htm Heshka S, et al (2003) Weight loss with self-help compared with a structured commercial programme: a randomized trial, JAMA; 289, 1792–1798. Inelmen, E M et al (2005). Predictors of drop-out in overweight and obese outpatients. Int J Obes, 29, 122–128. Jebb S A et al (2010) Referral to a commercial weight management programme enhances weight loss achieved in primary care. Int J Obesity. In press. Ev w104 Health Committee: Evidence National Institute of Health and Clinical Excellence (2006) Obesity: The prevention, identification, assessment and management of overweight and obesity in adults and children. NICE: London. Written evidence from London Specialised Commissioning Group (COM 41) Introduction 1. This response concentrates on the commissioning of specialised services, where the low number of patients with each condition requires the commissioning to be based on a planning population of more than a million people. 2. The response is made in the light of the White Paper proposals for the commissioning of specialised services (White Paper, Equity and Excellence: Liberating the NHS). These suggest that services within the Specialised Services National Definition Set are to be commissioned by the NHS Commissioning Board in the future. 3. London Specialised Commissioning Group (SCG) effectively commissions a range of 23 services, eight on behalf of PCTs in three SHA areas, from many of the largest Trusts in England. London SCG has won awards for commissioning and performed well in last year’s world class commissioning assurance process. 4. Specialised commissioning has developed considerably since the Carter (2006) review recommendations began to be implemented. In London this has led to the concentration of specialised commissioners from all parts of the capital into a single team. This model might be seen as a forerunner of the changes which will come if the White Paper proposals are agreed. 5. London SCG has a track record of involving clinicians and patient and public representatives in both the commissioning of services and in the monitoring of patient experience. Patient experience in this paper is directly gathered from our regular contacts. Executive Summary 6. The national definition set for specialised services (SSNDS) contains 38 categories of service, some are clearly defined, others merge into secondary care services. Agreeing the funding for specialised services is not straightforward because of inconsistencies in coding. A method is proposed. 7. Specialised commissioning funding could either be retained by the NHS Commissioning Board prior to allocation, or routed through GP commissioning consortia and blocked back. Both methods have positive and negative attributes. London SCG favours retention by the NHS Commissioning Board. 8. While GP commissioning consortia will have the responsibility for commissioning services outside the SSNDS there may be circumstances where it might make sense for this to be done by the NHS Commissioning Board. This might apply where the ideal planning population for a service is larger than GP consortia or there are other factors such as “open access” that require collaborative commissioning across a large population base. 9. Patients with rare or specialised conditions can experience difficulty with co-ordination of services at primary and secondary level. In addition there are conditions which manifest in specialised services where the prevention solution is in primary care, for instance morbid obesity. It is important that GP commissioners are required to collaborate with commissioners of specialised services on patient pathways. 10. There are a particular set of circumstances in London caused by the historical distribution of services. Change is required to respond to modern service standards and treatments. Specialised services can be the catalyst for change. 11. National standards for specialised services will be a great advantage for access to equitable treatment. Specifications for the local application of those standards into contracts with providers require a local knowledge and commissioning relationship. There needs to be a local commissioning approach to most specialised services. 12. The inclusion of maternity services in the scope of the NHS Commissioning Board will allow the whole pathway of care to be commissioned as a single care pathway including Special Care Baby Unit (SCBU) and Neonatal Intensive Care (NIC). There are 244 birthing units in England (source Birthchoice UK), together with all the community maternity services. Since it is a high risk service there needs to be adequate commissioning capacity, nationally and locally. Health Committee: Evidence Ev w105 Evidence to Support Recommendations Issues around the Specialised Services National Definition Set (SSNDS) 13. Like most SCGs across the country the London SCG does not currently commission the whole national definition set. The current governance model for SCGs is as a joint committee of PCTs, and consequently all SCGs vary in their scope of work depending on the policies and priorities of their PCTs. If the NHS Commissioning Board is to commission the whole SSNDS, this will mean that during the shadow year 2011–12 the 10 SCGs need to get as close to commissioning the entire definition set as possible. There are two main reasons for this: — Continuity for patient services—the sort of conditions covered by the SSNDS are uncommon and services and their patients are therefore vulnerable if the expertise commissioning them is lost. — Whichever method of funding specialised services is chosen (see below), the amount required needs to be as accurately assessed as possible. As much of the finance connected with the definition set should be in SCGs as possible, to ease the transition to funding the NHS Commissioning Board. It will be less easy to shift allocations between GP commissioning budgets and the NHS Commissioning Board once budgets have been committed. 14. The funding calculation is of particular importance. Funding the commissioning of the whole definition set will include current spending by SCGs, excluding services outside the definition set currently commissioned by SCGs, for instance HIV outpatient services in London. Where PCTs know they currently fund services in the definition set, this is also easy to identify. Unfortunately the edges of the definition set are unclear, data from providers is often inconsistently coded making the accurate assignment of activity inconsistent. If the NHS Commissioning Board is to commission the entire definition set from 2012–13 it will need more than the known spend in both SCGs and PCTs. Recommendation 1 The allocation of funding to specialised commissioning needs an accurate financial model based on patient level activity information appropriately coded by providers. This must include known SCG and PCT spend on the definition set services and a calculation for the less well defined areas of the definition set where accurate information is unavailable. What is the Best Funding Route for Specialised Commissioning? 15. The allocation of funding could either be routed through GP commissioning groups, and blocked back, or retained prior to allocation. Both methods have positive and negative attributes. 16. One of the successes of the current system in London is the sense of ownership of specialised commissioning by the PCTs and Sectors. There is vigorous debate at the SCG Board and clear oversight by the PCT Chief Executives who sit on it. This means that the boundary between specialised services and the rest of the care pathway for each condition is easy to manage. For some services like HIV or child mental health, the key to managing spend in specialised services is in prevention or early detection in the patients care pathway. 17. Engaging a larger number of GP commissioning groups with this sort of service would be easier if they had a greater knowledge of specialised services, and giving them the allocation and then blocking it back to the NHS Commissioning Board would help connect the whole care pathway. 18. The counter argument to this is that the cost of each patient can be significant, £4–500k per annum is not unusual, and therefore all these services are risk shared. The connection to GP commissioning groups could seem either academic if they are in effect paying an insurance type fee, or risk budget overspend if actual costs were attributed. Added to this, it might seem unimportant to GP consortia to be paying into a risk share fund for a condition the practices have never or rarely seen. Recommendation 2 The funding allocation for specialised commissioning should be retained by the NHS Commissioning Board before the allocation to GP Commissioning Consortia is made. Commissioning Services Outside the Definition Set 19. The major thrust of the White Paper is to devolve commissioning to GP consortia, as close to clinical decision making as possible. The patient care pathways for most common conditions are therefore managed as locally as possible. At the other end of the commissioning scale, specialised services will be commissioned on a whole England basis. There are however a group of services that are in the middle where a collaborative approach may be needed. 20. In London’s case there are services outside the definition set currently commissioned by the London SCG where all the London PCTs have agreed a pan London approach is beneficial. The number of patients with HIV in London is 48% (2008) of the national total and London SCG commissions the entire service. This allows it to have extremely close links with the groups representing patients, as well as commission an equitable, high quality service. Similarly, there has been a recent service review of major trauma services in Ev w106 Health Committee: Evidence London, and the newly commissioned service fast streams the most seriously ill patients to four major trauma centres. This is already showing improvements in services. Both these services are outside the SSNDS. 21. London SCG also commissions specialist pharmacy services across 4 SHAs (Pharmacy in England— Building on Strengths, 2008 White Paper) and plays a major role in pharmaceutical safety and value for money. This is also outside the definition set. 22. The aim is to seek GP consortia arrangements to resolve commissioning arrangements for services where the critical mass of the service requires a very large planning population but are outside the national definition set. There is a danger that the transactional costs may go up if there is too complex a set of differing commissioning arrangements. It would be sensible for there to be a permissive clause in the establishment of the NHS Commissioning Board, which will allow the commissioning of services outside the national definition set where GP Consortia arrangements are found to be complex or unwieldy to put in place. Recommendation 3 The NHS Commissioning Board should have the discretion to be able to commission services outside the definition set where the ideal planning population for a service is larger than GP consortia or there are other factors such as “open access” that require collaborative commissioning across a large population base. The Relationship Between Specialised and General Services 23. Many of the services in the definition set are quite discrete, for instance gender dysphoria or cleft lip and palate surgery, but others have a clear pathway with primary and secondary services. Child and Adolescent Mental Health (CAMHs) tier 4 services are a good example, where the interplay between all parts of the patient pathway is vital to a good outcome. 24. Because of the rare nature of specialised conditions the patient representatives who advise London SCG have commented on a number of occasions, on the lack of understanding of their needs in primary care. The planning for these services therefore requires collaboration and being outside the GP Consortia’s main responsibilities, they may not receive focussed attention. 25. It is also true that in the future it is probable that services will transfer, either into or out of the national definition set. Because most specialised services commissioned in London operate on a risk share, GP Consortia with no experience of the condition may resist having to contribute. 26. All these factors lead to the need for levers in the system to set out the expectation of collaboration. Recommendation 4 GP commissioners should have a requirement to collaborate with specialised services on patient pathways. Service Change and “Designation” 27. A more vibrant provider market with all sorts of new entrants will cause competition in London between providers to become greater, in an already crowded market. For specialised services where markets are small and niche, this represents a potential risk to safe and sustainable services. An example in London is the recent review of Haemophilia services, resulting in two managed networks for adults and children. 28. The distribution of providers in London is a product of the historical growth of services. Change is required to respond to modern service standards and treatments. 29. Specialised services have moved toward “designation” of services which meet nationally agreed clinical standards. Designation may cause substantial service change for providers who do not meet the standards, and once one service is lost it can cause a domino effect since many services are interdependent. Commissioners are also seeking the best value for money through the QIPP agenda. 30. Once a service is designated it may be difficult for new entrants to move into some specialised services markets because of high capital costs, start up costs and the range of interdependent services usually required. This means there is even greater need for the commissioner to hold the designated service to account, for quality and value for money. Health Committee: Evidence Ev w107 31. The point to make is that specialised services can be the key and the catalyst for change. The impact of modern service standards in specialised services will have an effect far beyond the immediate service change and consequences for hospital development in London. This process will need to be managed to avoid unintended consequences. Recommendation 5 Specialised services may need to lead service and consequential provider change in health economies. A National or Local Approach to Specialised Commissioning? 32. A comprehensive set of national specifications for services in the definition set has not yet been developed. Each of the 10 SCGs has a different scope depending on the local circumstances of their constituent PCTs, and the White Paper proposal of a single national commissioning board will promote a consistent approach across the country. This could go hand in hand with a designation process. 33. A series of meetings is currently underway bringing together the QIPP agenda and quality development, held jointly with the Specialised Healthcare Alliance. This has brought together patients, clinicians and commissioners from across the country to propose standards and quality markers in HIV and other specialised services. From this work, together with national bodies like NICE, it will be possible to create nationally consistent specifications and benchmarks for each service. 34. At local commissioning level however there will continue to be a strong need to contract with providers according to local circumstance. The commissioners need to manage their contracts in detail and if commissioners are remote this will not happen. A local approach from the NHS Commissioning Board would solve this potential problem. If the local approach is accepted, each locality could take the lead commissioning role for the providers in their area, and liaison with GP Commissioning Consortia using these providers. 35. The capacity needed to contract with providers will depend, as now, on the level of knowledge of the commissioner and the time devoted to each contract. A detailed knowledge of the provider allows the relationship to tackle difficult issues like the changes needed for QIPP. Commissioning will be carried out on an increasingly higher level if there is insufficient capacity. Recommendation 6 There needs to be a local approach to the commissioning of most specialised services, as well as the national approach for consistency of standards and equity of access. Commissioning Capacity and Maternity Services 36. While maternity services are outside the scope of the SSNDS the proposals will bring their commissioning into the same organisation and presents both opportunities and threats. The principle opportunity is to bring the commissioning of the whole maternity pathway together including SCBU and NIC. 37. Maternity commissioning is however a very different proposition, being integrally networked into each local health economy, at hospital, community and primary care level. It presents a high risk and SHAs have maintained close scrutiny. The commissioning will need local knowledge and enough capacity to manage a comprehensive national service. Recommendation 7 The high risk and widely distributed nature of maternity services will require adequate commissioning capacity, nationally and locally. Recommendations 1. The allocation of funding to specialised commissioning needs an accurate financial model based on patient level activity information appropriately coded by providers. This must include known SCG and PCT spend on the definition set services and a calculation for the less well defined areas of the definition set where accurate information is unavailable. 2. The funding allocation for specialised commissioning should be retained by the NHS Commissioning Board before the allocation to GP Commissioning Consortia is made. 3. The NHS Commissioning Board should have the discretion to be able to commission services outside the definition set where the ideal planning population for a service is larger than GP consortia or there are other factors such as “open access” that require collaborative commissioning across a large population base. 4. GP commissioners should have a requirement to collaborate with specialised services on patient pathways. 5. Specialised services may need to lead service and consequential provider change in health economies. Ev w108 Health Committee: Evidence 6. There needs to be a local approach to the commissioning of most specialised services, as well as the national approach for consistency of standards and equity of access. 7. The high risk and widely distributed nature of maternity services will require adequate commissioning capacity, nationally and locally. October 2010 Written evidence from the Royal College of Psychiatrists (COM 42) Summary — The Royal College of Psychiatrists welcomes increased involvement of clinicians in commissioning but believes that there should be co-commissioning between specialists and GPs and not GPs alone. Psychiatrists have considerable expertise in mental health service delivery and need to be key players in developing innovative and cost effective services. — Mental health services should be commissioned based on care pathways which set out a framework of: (i) assessment standards; (ii) evidence-based interventions; (iii) outcomes to be assessed; (iv) the timeliness of assessment and intervention. Guidance needs to be provided as to the skills and competencies required of the professionals who undertake the assessment and interventions. The Royal College of Psychiatrists and the Royal College of General Practitioners welcome the opportunity to lead the development of such pathways and make them available as templates upon which commissioners could plan local services. — Commissioners have to ensure that they retain a focus on: — hard to reach groups; — patients with complex mental health problems who would not be subject to national commissioning but require often expensive care and may be overlooked in favour of high volume, low cost case. — Commissioning needs to ensure that research and teaching are protected. — The College welcomes the focus on outcomes. Commissioners must ensure that outcomes are for the whole population on GP lists and not just those identified on chronic disease registers. Specialist Services What arrangements are proposed for commissioning of specialist services? 1. The Royal College of Psychiatrists believes that the NHS Commissioning Board will need to work with GP consortia to produce a description of: (i) the nature and extent of population health needs and patient presentations that are currently being made to primary care in their consortia area; (ii) the clinical strategies that are currently being employed to address these at a consortia level; and (iii) the clinical strategies and organisational arrangements that could be employed at a regional and national level. 2. All services should be commissioned based on care pathways which set out a framework of: (a) assessment standards; (b) evidence-based interventions; (c) outcomes to be assessed; (d) the timeliness of assessment and intervention. Guidance needs to be provided as to the skills and competencies required of the professionals who undertake the assessment and interventions. The Royal College of Psychiatrists and the Royal College of General Practitioners welcome the opportunity to lead the development of such pathways and make them available as templates upon which commissioners could plan local services. 3. Two considerations need to be made with regard to mental health. Firstly, many patients with serious mental illnesses have complex health and social care needs. Meeting these needs often requires intervention not only from specialist mental health services but also from local social care agencies, primary care services, voluntary sector organisations, and networks of peers, friends and family. Consequently, a risk may exist for some patients that specialist mental health services (which are often of low volume and high cost) are commissioned at regional and national level, while other services (of higher volume and lower cost) are commissioned at the level of the GP consortia. This could mean: (i) mental health patients with complex needs may ‘fall between’ GP consortia and the NHS Commissioning Board; Health Committee: Evidence Ev w109 (ii) local GP consortia may not fully understand or consider the needs of such patients when commissioning services in their area (including joint commissioning with local authorities); and (iii) patients could receive uncoordinated or fragmented care, or inappropriate “out of area treatments” (with sizeable financial and social inclusion implications). 4. We therefore recommend that attention needs to be given to whether local specialised services need to be commissioned for some groups of patients with complex needs (eg patients with schizophrenia who need key rehabilitation/recovery services). Where properly implemented, such services could introduce costsavings, as individuals with complex needs often engage with multiple services but with minimal coordination between them, leading to inefficiency and ineffectiveness. Offender health and special hospital services should continue to be commissioned at the regional and national level. 5. Importantly, any decision to commission specialised services at a local level will need to be decided by GP consortia and the NHS commissioning Board based on (a) prevalence of the condition in the local population (which could span several GP consortia); (b) the extent to which meeting complex patient needs requires a physical service base (eg therapeutic communities, mother and baby units, eating disorder units or residential adolescent units); and (c) whether the strategic overview and development of such service types across England could be maintained in a localised organisational arrangement. 6. Furthermore (as described in more detail in 11 and 12), the commissioning of low volume specialised services should be based on care pathways which set out a framework of: (a) assessment standards; (b) evidence-based interventions; (c) outcomes to be assessed; and (d) the timeliness of assessment and intervention. Guidance needs to be provided as to the skills and competencies required of the professionals who undertake the assessment and interventions. The Royal College of Psychiatrists and the Royal College of General Practitioners welcome the opportunity to lead the development of such pathways and make them available as templates upon which commissioners could plan local services. 7. Secondly, descriptions of the nature and extent of population health needs should take into account the likelihood that people with serious mental illnesses are often not on a GP practice register. For example, in some areas, we know that over half the people with serious mental illness in a GP registrant population do not appear on the GP register and consequently do not receive physical health care services. This inequality in access to services can contribute to the premature mortality of people with serious mental illnesses (ranging from 10–25 years depending on locality). Commissioning incentives which narrow this gap are therefore required both to improve the information to commission services at a local, regional and national level, as well as bringing people with the most complex needs into primary care. Practical ways in which this could be achieved include the NHS Commissioning Board and GP consortia working to create clinical networks of primary and social care professionals. These networks could link with public health bodies and users and carers, who can draw on existing knowledge (such as that in a Joint Strategic Needs Assessment) to scope and describe the local health and social care requirement. Clinical Engagement in Commissioning How will commissioners access the information and clinical expertise required to make high quality decisions about the shape of clinical services? 8. There are at least four ways: (i) through promoting and sustaining multi-professional involvement; (ii) ensuring that commissioners have the skills and confidence to make decisions about services providing mental health care; (iii) providing information to allow commissioners to implement care pathways; and (iv) developing an overall suite of outcome measures. 9. Firstly, multi-professional involvement in commissioning can be most effectively promoted and sustained through joint-working by the relevant Colleges, national or regional bodies and allied social care professions. Practice staff other than doctors will bring vital insight and expertise to the table—not only in terms of mental health issues but also, importantly, with regard to proper arrangements for the physical healthcare of mentally unwell patients. Foundation Trusts should also consider placing staff within consortia. Although this may present certain conflicts of interest, anecdotal evidence suggests that integrated approaches to commissioning work rather better than combative ones, so agreements at source between commissioners and providers would be an important pursuit. A joint team of mental health specialists and commissioning consortia should evaluate and inform the strategic development of integrated care pathways for psychological therapies. This should be underpinned by patient and carer participation and development. It will also be important for the Boards of GP consortia to consult or, if necessary, include other professionals groups, such as Directors of Nursing and Chief Pharmacists as well as representatives from the Local Authorities, to ensure multi-professional and multi-agency leadership of decision-making. 10. Secondly, there is an opportunity to improve GP skills in mental health. People presenting with mental health conditions constitute 25% of the daily workload of every GP. We believe that (a) at least one member from every GP practice team should have had mental health training; (b) each consortium should have a Ev w110 Health Committee: Evidence Mental Health Lead which could oversee this and other training needs; (c) GP mental health specialist leadership could be strengthened through existing structures (such as the National Leadership Council); (d) post-graduate qualification in mental health should be made available to GPs. 11. Thirdly, information on care pathways needs to be provided to all commissioners. Primary mental healthcare is largely related to persons suffering mild, moderate or (in some cases) severe depression, anxiety and other conditions historically referred to as common mental health problems. GP consortia should ensure that (a) care is being provided in line with commissioned pathways including NICE guidance for the relevant conditions into clinical practice (including NICE guidance on physical health problems where a mental health condition is associated with this); (b) outcomes are evaluated using indices and instruments that have been established (for instance as part of the Improving Access to Psychological Therapies programme); (c) incentives and levers to existing measures of quality improvement such as the Quality Outcomes Framework (QOF) are used to shape pathway implementation, and Commissioning for Quality and Innovation (CQIN) is used to drive upstream interventions, primary prevention and public wellbeing. Consortia must ensure that there are sufficient mental health clinicians including psychiatrists, therapists and support workers to deliver the pathway. The consortia should use aggregated data on, for example, employment, to demonstrate the public health and economic impact of their constituent practices’ activity. 12. To provide the information needed to meet this goal, a “Commissioning Pack” for mental health needs to be produced for GP commissioning consortia. This should: (a) outline and explain all types of services; (b) clarify for GP commissioners the pathways of care; (c) contribute to methodology for clinical quality review by commissioners of providers; (d) capture the effectiveness of alternative solutions and interventions chosen by patients exercising individual budgets; (e) help establish demonstrable improvements in health and wellbeing of mentally unwell and other populations through the use of outcome measures; (f) help undertake clinical and economic analysis on behalf of GP consortia of the operational reconfiguration of inpatient populations and hospital structures required to achieve the objectives of Quality Innovation Productivity and Prevention (QIPP); (g) help design primary prevention strategies for specific conditions (eg postnatal depression); (h) assist the design, in consultation with public health colleagues, of community interventions for health and wellbeing, and (i) assist with evaluation of the impact on communities of primary preventative and wellbeing initiatives. 13. Fourthly, all practices should use care pathway determined outcome measurements. The RCPsych should be consulted to ascertain whether it could play a role in terms of data collection and analysis. For example, an outcomes quality network for mental health could enable consortia to compare their performance with one another in the context of robust and fair outcomes data. The Royal College of Psychiatrists already undertakes benchmarking with mental health services across the country. Data could be used to populate data-packs for individual GP and psychiatrist appraisals. This would align the goals of the local and wider NHS to the aims and objectives of individual practitioners, and also further integrate outcomes data into quality systems in both GP practices and Mental Health Foundation Trusts. How will commissioners address issues of clinical practice variation? 14. Firstly, variability in experience, knowledge, skill and focus is likely to exist both within GP practices and across GP consortia. Since the mechanics of commissioning for mental health are in their infancy, the potential exists for GP commissioners to adopt a path of least resistance—procuring by block contract, for example. This would represent a missed opportunity. We believe the risk of this is can be mitigated by a commissioning framework. This should be set and quality assured by the NHS Board with regional or other local coordination. 15. Secondly, GP Consortia will need guidance to ensure their quality assurance parameters and mechanisms are consistent with those of colleagues (as set out by Care Quality Commission and Monitor). It is likely that systems to enable this in mental health are not as developed as in other areas of clinical commissioning activity. Consequently, the expertise of organisations such as RCPsych and the NMHDU will be essential, as will a commissioning pack in which to make, sustain and extend these connections. 16. Thirdly, in addition, Accountable Officers in each of the GP consortium should be encouraged to identify a Mental Health Lead for that GP consortium (or share one a lead with another consortium). This Mental Health Lead will need to work with consortium or regional commissioning support to ensure the principles of best practice mental health commissioning are embedded into behaviours and processes in consortia. Mental Health Leads should be encouraged to form a network, whether regionally or nationally, to share and develop best practice, and organisations such as the RCPsych and RCGP can assist with their coordination. GP consortia must ensure that they have access to a specialist advice and ensure that primary and secondary care develop a pathway rather than an artificial commissioner/provider split. 17. Fourthly, the use of regularly published and agreed pathways and outcome data would help drive-up clinical quality, consistency, and equity. If sufficiently detailed information were available, this could be used to enable patient choice. It would be advantageous to develop clinical dashboards for clinicians, practices, and mental health teams. If adequately developed and deployed, the use of the Mental Health Clustering Tool (MHCT) can provide a core tool for monitoring and assuring primary (and secondary) care performance. This becomes stronger and more meaningful if aligned to a suite of outcome indicators for different broad areas of mental healthcare. Using Payment by Results Mental Health Clusters commissioners can identify what should happen for whom. Procuring mental healthcare consequently Health Committee: Evidence Ev w111 becomes: (i) much more business-like (and therefore attractive to stewards of public funds); and (ii) a basic minimum standard exists of what a patient can expect from being placed on a certain pathway is achieved (which aids patient empowerment through the passage of reproducible information). Primary care performance may also need aligned incentives, for instance shared audits with secondary care. How will GPs engage with their colleagues within a consortium and how will consortia engage with the wider clinical community? 18. See above. Accountability for Commissioning Decisions How will patients make their voice heard or their choice effective? 19. Commissioning must actively and meaningfully consult and involve representatives from the population it wishes to serve. For urban settings, this must include hard-to-reach groups such as asylum seekers, the homeless, the chronically severely unwell and offenders. Having heard from these groups, commissioning should encourage processes and systems that enable balances of legitimately differing perspectives to be resolved between users, carers and providers in everyday clinical practice. 20. The litmus tests of success in this endeavour is not so much engagement with services (although this is important at the outset). Instead it is the acquisition of recovery and citizenship on the part of patients who become emancipated from being defined solely as “service users”. Commissioning must therefore also ensure that (i) employment, education and/or voluntary activities exist for all; and (ii) that patient expertise and peer mentorship is used where appropriate to provide interventions. 21. The significance of this approach is that it is drives prevention and partnerships. Involving Health Watch and Patient Participation Groups becomes an essential condition to the commissioning process, links with Local Authorities, and forms the bedrock of an approach which is as concerned with the antecedents of mental ill health as treatment itself. 22. Mental health is well-placed to champion multi-professionalism in mental health commissioning. This is because practitioners tend to operate in a culture of multidisciplinary teams in which consultants often have leadership roles. 23. Both Health Watch and Patient Participation Groups must ensure input for individuals with mental health experience, including both those with ongoing illnesses and those who have recovered. What will be the role of the NHS Commissioning Board? 24. See above. How will commissioning interface with the Public Health Service? 25. The setting up of health and well-being boards—underpinned by statutory powers—is an effective structure to achieve joint working across health, social care and public health. These boards should include Directors of Public Health as this would provide a mechanism whereby commissioning will interface with the public health service at the local level. Members of GP consortia will require sufficient training in mental health to ensure they are able to influence debates and discussions about appropriate public health interventions. This will help ensure that public mental health is adequately addressed in the joined up commissioning plans devised by health and well-being boards. How will commissioning interface with Health Watch? 26. GP consortia will be held to account by local HealthWatch groups. HealthWatch should takeover the complaints advocacy services currently run by the NHS, resulting in GP consortia/commissioners being held to some account for the quality of the services they provide, while supporting service users and carers in their healthcare choices. Integration of Health and Social Care How will any new structures promote the integration of health and social care? 27. Firstly, there is also considerable research on joint working and partnership, and it would be very helpful for the Department of Health to summarise this to inform better integrated working. 28. Secondly, GP practices can make stronger links with local authorities by: (i) solutions based on the needs of “citizens” as well as “patients”; (ii) programmatic approaches to commissioning with unified GP and Local Authority leadership; (iii) single commissioning strategies for Brighter Futures; (iv) full engagement with personalisation and self-directed support; (v) Total Place-based models of public sector commissioning; (vi) evaluation against outcomes and decommissioning where there is no evidence of impact; (vii) shared financial and operational risk; (viii) working with social enterprises to build resilience across populations; and (ix) single, lean governance mechanisms. Ev w112 Health Committee: Evidence 29. Thirdly, Joint Strategic Needs Assessment is poorly supported by public health professionals and agencies in some areas. This is because proficiency is lacking in the need to prioritise mental health and specialist learning disability commissioning. Some mental health-specific JSNAs have been developed by a joint Primary Care Trust/Local Authority Health and Wellbeing Teams, and these are examples of good practice. In other areas, local Mental Health and Learning Disability Partnership Boards (established between PCTs and Mental Health Trusts with multiagency representation) have been part of informing and scrutinising the findings of specific population health needs assessments and these partnerships and working models should similarly be preserved. What arrangements are proposed for shared health and social care budgets? 30. No comment. What will be the role of local authorities in public health and commissioning decisions? 31. Local authorities will play a major role in this through the role set out for them in the proposed health and well-being boards. As regards public health, money ring-fenced for local public health budgets (under the Directors of Public Health) should be further ring-fenced for public mental health strategies and interventions. In terms of commissioning, only if members of GP consortia are given both sufficient training in mental health and the requisite training in the needs assessment functions currently carried out by PCTs, will those commissioning mental health care be able to adequately contribute to the joined up commissioning plans across the NHS, social care and public health which the newly-created health and wellbeing boards will be responsible for. Other issues 32. The Commissioning Board must also ensure that universities and NHS training structures will interface with the proposed new system so that teaching and training of undergraduate and post-graduate professionals can be fully supported with minimal disruption during any transitional periods. Thought will also need to be given to how professionals in training can move between jurisdictions in the UK and how revenue flows from consortia to universities and teaching hospitals (in respect of Service Improvement for Training and funding for original research, for instance). Many academic posts are currently supported by NHS Trusts and if they are uncertain of their revenues they will be loathe to continue their investment in these posts, meaning checks and balances may need to be introduced into the system to prevent destabilisation of innovation. October 2010 Written evidence from Baxter Healthcare Ltd (COM 44) 1. Background 1.1 Baxter Healthcare Ltd has been providing products and services to the NHS for over 50 years and we have therefore been engaged alongside the NHS during its evolution over those years. We have a strong track-record of providing healthcare solutions for long-term conditions; be it providing life saving and sustaining products, or understanding the patient pathway that allows a patient to seamlessly travel between hospital and the home to get the right therapy, at the right time. 1.2 We are one of the few companies that support the NHS to deliver a range of specialist services/ therapies. As such, we have drug and service experience in home dialysis, haemophilia, immunoglobulin therapy and provide tailored drug solutions—be it for parental nutrition or chemotherapy, for individual patients throughout hospitals in the UK. We are therefore well placed to view objectively the strengths and weaknesses of the current and proposed specialised commissioning arrangements and welcome the opportunity to be able to respond to this Inquiry. We have grouped our responses around the key headers indicated by the HSC and our responses refer specifically to specialist commissioning: 2. Clinical Engagement in Commissioning 2.1 Because of the nature of rare diseases, clinicians are generally well engaged in defining patient pathways—however at times, these pathways are then reviewed and commissioned in a fragmented manner—which affects continuity of care and leads to a disjointed approach to care pathways. 2.2 Where some specialist therapies have defined patient pathways, it is important that there is a level of commissioning consistency across the country. Commissioning for specialist services, which are often complex, can lead to variability of access to care across the country. An example would be parental nutrition, where the 10 regions in England are proceeding with the implementation of the service revision in different steps and prioritising different parts of the pathway, which can lead to a fragmented service. Clinicians with specialist knowledge need to work together to educate commissioners and implement frameworks that represent a consistent approach across the regions. Health Committee: Evidence Ev w113 3. Accountability for Commissioning 3.1 The NHS Commissioning Board, as defined in the White Paper, will have responsibility for specialist commissioning at national level. We would endorse this proposal as it safeguards specialist therapies in both the short and medium term, particularly during what may become a chaotic period of transition and change within the NHS over the coming year(s). 3.2 We would caution against any immediate review of the current definition set. The set was recently reviewed and again, with so much change planned within the NHS, it is critical that specialist services are maintained and not subjected to huge upheaval, particularly when commissioning of some of these services is already patchy and funding streams often uncertain. 3.3 Consistency of approach in commissioning is critical. Skill sets and understanding of complex patient pathways for specialist therapies is currently variable. It will be important that the National Commissioning Board sets a level of quality and consistency for applying the pathways around the specialist definition set. This may mean that some sort of regional implementing structure is required to ensure this level of consistency. 4. Quality 4.1 NHS Commissioning Board should use NHS levers—such as CQUIN and PROMs to ensure that quality care is delivered. For some specialist areas, such as haemophilia and dialysis, stretching national quality standards could be set to drive up quality—which would reduce regional inequalities to access to care. 5. Funding 5.1 The NHS Commissioning Board will need to be given appropriate funding to support commissioning of high quality specialised services and therefore it is essential that accurate budgets are established for these complex therapies. 6. Procurement 6.1 Procurement of services is a critical element of effective commissioning. Procurement processes must recognise the meaningful differences between the products, technologies and services that support patient choice. In addition they must also protect long-term investment in clinical research, innovation and product development programmes that are required to support future generations of rare disease patients. 7. Patients 7.1 “Specialist commissioning” by its nature presents a complicated model to patients who don’t understand how their therapies are commissioned or funded. One of the central themes in the White Paper is ‘no decision for me, without me’—this must be a key factor when commissioning effective services. Patients should be able to input into decisions about their care, and should have a point of recourse if they have not been included in the decision about their care pathway. 8. Technology Assessment 8.1 Assessing the “value” of products/technologies and services that support rare diseases is clearly difficult. The creation of an ethical framework through AGNSS has been welcomed as a progressive step forward. AGNSS is a new body that needs time to test the effectiveness of the framework over a period of time—we would hope therefore that this body is not restructured or changed and is allowed to continue in its current form. October 2010 Written evidence from the Royal College of Midwives (COM 45) 1. The Royal College of Midwives (RCM) is the trade union and professional organisation that represents the vast majority of practising midwives in the UK. It is the only such organisation run by midwives and for midwives. The RCM is the voice of midwifery, providing excellence in representation, professional leadership, education and influence for and on behalf of midwives. We actively support and campaign for improvements to maternity services and provide professional leadership for one of the most established of all clinical disciplines. 2. We welcome the opportunity to submit evidence to this important inquiry, especially as the granular detail of the policy is still being formed by the Department of Health. Ev w114 Health Committee: Evidence Summary of Key Points — NHS maternity services are set to be commissioned separately from most other NHS services, directly by the NHS Commissioning Board, not by GP consortia. — NHS maternity services should be commissioned by planned maternity networks at the regional level; commissioning via regional outposts of the NHS Commissioning Board would be unnecessary duplication. — Experience has taught us that engagement with the full range of clinical staff by commissioners produces the best results. — Maternity dashboards should be used at a regional level by maternity networks to compare the performances of a range of local providers; maternity networks should be empowered to request and require any relevant information from any provider of NHS services. — New maternity networks should be legal entities, with specific powers set out in statute; experience has taught us that without such powers, some providers will not cooperate with these new networks. — Midwives play a vital role in public health, from breastfeeding, to smoking cessation, to child protection, to combating obesity; the new local directors of public health must ensure that they engage with the work of maternity networks as much as they do with GP consortia. — Quality of care is so important to maternity services; systems must be put in place that compel providers to deliver on high quality care and not just throughput and activity. Introduction 3. In future, NHS maternity services will be commissioned separately from most other NHS services. As set out in the NHS white paper, maternity care will be commissioned not by GP consortia but instead by the new NHS Commissioning Board. 4. Our evidence will therefore necessarily be specific to maternity care and not focus on the planned GP consortia. Given that our submission will address quite a niche aspect of the overall commissioning policy landscape, we will focus solely on what we consider to be the key elements of future commissioning as they affect NHS maternity services. The Committee’s more general questions are perhaps more pertinent to those set to be directly involved in or affected by GP consortia. 5. We welcome the Committee’s view, expressed in its calling notice for evidence, that its inquiry “can contribute to the debate about the implementation of the policies for commissioning outlined in the Government’s White Paper, Equity and Excellence: Liberating the NHS.” We welcome this assertion as we are keen to influence the policy’s implementation, most specifically with regard to giving maternity networks (a white paper innovation) a commissioning role and also establishing such networks in law. Maternity Networks and Commissioning 6. The RCM believes that maternity networks could and should commission maternity services on behalf of the NHS Commissioning Board. While the exact relationship between the Board and maternity networks still needs to be determined in detail, it would seem an unnecessary duplication to have maternity networks and, simultaneously, regional outposts of the Board responsible for commissioning maternity services. We would anticipate that such networks would be accountable to the Board for this function in just the same way that GP consortia will be for their functions. 7. The exact makeup, roles and responsibilities of maternity networks are still very much fluid, but we will in this submission set out ways in which we think maternity networks could contribute to more effective commissioning. Clinical Engagement with Commissioning 8. Currently it is the job of primary care trusts (PCTs) to commission maternity care for women in their area. It is our experience that where PCTs have involved midwives and other clinicians in the commissioning process, a real sea change in the quality of care has occurred. 9. Blackburn is an example where this has happened, with commissioners working very closely with managers, service users, midwives and obstetricians. The resulting reconfiguration of services offered by East Lancashire Hospitals NHS Trust has resulted in obstetric services consolidating in Burnley, with an alongside midwife-led unit delivering 1,500 women annually. Blackburn will have another midwife-led unit, delivering 1,000 women annually, with a small midwife-led unit in Rossendale, handling 300 births per year for a geographically isolated community. 10. Importantly, the commissioners did not read “clinicians” simply to mean “doctors”. They engaged with midwives as well. This is important as too often clinicians are seen as only medical staff, and midwives are the experts in normal birth. 11. The RCM recommends that maternity networks follow a similar approach, with full clinical engagement in all aspects of their work. Health Committee: Evidence Ev w115 12. The Committee asks, “how will commissioners access the information and clinical expertise required to make high quality decisions about the shape of clinical services?” It is clear that the challenge will be less acute for maternity networks than it will for GP consortia as networks will be responsible only for one area of care. As far as maternity networks are considered therefore, securing the direct involvement principally of midwives and obstetricians will ensure that commissioners access proper clinical expertise. The value of this approach in east Lancashire was borne out by the example above. 13. In terms of accessing information, we recommend that maternity networks are given the power to require any and all providers to produce any relevant information. Maternity networks could agree a network-wide maternity dashboard as described by the Royal College of Obstetricians and Gynaecologists. Dashboards are now widely used by providers to collect and review information relating to activity, outcomes, staffing and user satisfaction. If such a dashboard was used across a network, commissioners would have ready access to the performance of various providers and could use the information to discuss variability between providers in the network. Accountability for Commissioning Decisions 14. The Committee asks, “What legal framework will be required to underpin commissioning consortia?” This question is relevant not only to GP consortia, but also to maternity networks. 15. The RCM recommends that the link from the NHS Commissioning Board (which will have responsibility for commissioning maternity care across England) right down to the provider level should be along the following lines: individual care providers will be accountable to a maternity network, which will have powers and duties set out in statute, which will commission care from those providers on behalf of the Board, to which the networks will be directly accountable. 16. The RCM believes that maternity networks must be constituted as legal entities if they are to have sufficient authority to secure the cooperation of all maternity care providers within the network’s catchment area. We are concerned that as NHS trusts attain foundation trust status and as more independent and private-sector providers enter the market, it will become increasingly difficult to foster the degree of collaboration necessary to promote the standards and quality of care that we would want all women to receive. This will be a challenge for maternity networks even if they are established in statute; it will be nigh on impossible if they are not. 17. This is not a theoretical concern, but one backed up by practical experience. An informal maternity network already exists, facilitated by NHS South Central. Whilst this network delivers several benefits— for example, an opportunity to share information, provide mutual support, standardise protocols and pathways, and so on—foundation trusts have often been reluctant to share information and they have restricted the extent to which even senior staff can participate in collaborative enterprise. 18. And it is important to get maternity care right. Whilst this area of care consumes only about 2% of the overall NHS budget, obstetric-related claims for medical negligence account for 46% of all payouts— almost £1.4 billion of the £3 billion paid out under the Clinical Negligence Scheme for Trusts (CNST). Indeed, of the 100 largest payouts made under the CNST, 79 related to obstetrics. Public Health, Commissioning and Maternity Care 19. The white paper states that the public health responsibilities of PCTs will pass to local authorities, which will each employ a Director of Public Health jointly with a new Public Health Service. These directors will be responsible for ring-fenced public health budgets. 20. Local directors will no doubt seek to establish good working links with GP consortia, but the RCM would like to see them also encouraged or required to work closely too with maternity networks. Midwives play a vital role in promoting good public health. 21. This public health role is recognised explicitly in the white paper: “Pregnancy offers a unique opportunity to engage women from all sections of society, with the right support through pregnancy and at the start of life being vital for improving life chances and tackling cycles of disadvantage”. 22. Specific examples of the impact that midwives can have are encouraging pregnant women and family members to quit smoking and promoting breastfeeding. Midwives are also heavily involved in two of the most critical public health issues of today: protecting children and reducing the impact of obesity. Midwives will often be the first health or social services professional to have contact with a family and their role in preventing harm cannot be overestimated. 23. Developing the public health work of midwives may benefit from involving directors of public health in the commissioning of services from maternity care providers. Ev w116 Health Committee: Evidence Promoting Quality Maternity Care 24. The white paper outlines a number of ways in which future payment systems for the delivery of NHS care will reward quality and outcomes in addition simply to activity levels. Examples from the white paper include the development of quality standards by NICE as well as the CQUIN payment framework. 25. Maternity care is not a service that is best assessed simply by throughput, which is what is chiefly rewarded under Payment by Results. 26. Indeed, the final report of the Midwifery 2020 project states this clearly. This project was commissioned jointly by the Chief Nurses of the UK’s four health departments, to set the direction for midwifery and identify the challenges that need to be overcome. 27. In its vision, Midwifery 2020’s final report states: “There will be an increased focus on measuring the quality of healthcare across the whole maternity pathway. The best indicators of quality will reflect: person centredness, safety, effectiveness, efficiency, equity and timeliness.” 28. We therefore welcome the move towards greater reward for quality care and better outcomes. 29. Additionally, there are desired policy outcomes for maternity care contained within the white paper (eg extending choice for pregnant women) that require payment systems to drive their implementation on the ground. Commissioning arrangements will have to incorporate the need to include financial drivers, rewarding trusts that genuinely offer a home birth service and the option of birth in a midwife-led unit. Exactly how these choices are guaranteed by all-important funding streams will need consideration and implementation. Conclusion 30. The commissioning arrangements for NHS maternity services are set to be different from those of most other NHS services. They will be commissioned directly by the NHS Commissioning Board and not by local GP consortia. We welcome this. 31. To make this commissioning arrangement work however the job of commissioning services at the local and regional level should rest not with the Board directly, but with the white paper’s other innovation, maternity networks. 32. Experience has taught us that commissioning, if it is to work, must involve engagement by commissioners with the full clinical team. As maternity networks will have a narrow range of services to commission (unlike GP consortia) this should be easier for them to accomplish. 33. Maternity dashboards offer a template of exactly how maternity networks can monitor performance from across a wide range of providers. To make this work however all providers must be required to provide any and all information and assistance that is required; to this end, maternity networks must be legal entities, with specific powers in law. 34. Public health promotion is an essential component of the workload of an NHS midwife. It is fundamental to what she does. New local directors of public health must engage with maternity networks therefore as well as with GP consortia. 35. Maternity care is about so much more than throughput and activity levels. Quality of care is highly valued by women using the service. To this end, we must see commissioners putting in place systems that encourage and reward providers who provide a high-quality service. October 2010 Written evidence from Ultrasis UK Ltd (COM 46) Summary — Cost-effective and clinically effective treatments such as computerised cognitive behavioural therapy (cCBT) that have been recommended by NICE have been proven to support the increased delivery of services at a much reduced cost. Commissioners must be willing to have a broad knowledge of such new treatments and be challenged where they do not introduce them into routine practice. Health and social care can and should be closely integrated with greater investment in proven health technologies as the global benefit to both systems is closely aligned; this is especially the case for people who are considered most vulnerable such as those with mental health needs. cCBT and other health technologies based on promoting self care enables patients to be treated in non-clinical settings such as social care providers, third sector services, public facilities such as libraries or even from home. — Growth in the use of the internet for health advice is increasing rapidly and it should be the requirement of local authorities and their health care partners to look at solutions that encourage digital inclusion to support the delivery of cost effective services. This in turn will help promote delivery of cost effective solutions to people’s health care needs. Health Committee: Evidence Ev w117 — Technology delivered health care has been proven to support commissioners to end the “post code lottery” of care delivery associated with traditional face to face type services and can be scaled up at massively reduced cost thus increasing access and choice to the patient. It also has the advantage of helping to support access in rural communities and for those who may have difficulties accessing traditional services. — The Coalition Government has stated its support to ensuring greater access to talking therapies to reduce long term costs for the NHS. — The use of web based health care has a significant and growing evidence base and is supported by several key documents that have recently been published: A: NICE Guidance: Depression in Adults—(http://www.nice.org.uk/CG090); B: NICE Guidance: Depression with a Chronic Physical Health Problem—(http://www.nice.org.uk/ CG091); and C: The Business case for Digital Inclusion—(http://www.parliamentandinternet.org.uk/uploads/ Final report.pdf) Introduction 1. Ultrasis is a healthcare company with core expertise in health, psychology, software development and programme management. Amongst our services, we provide a computerised cognitive behavioural therapy (cCBT) programme called “Beating the Blues”: (a) in the Netherlands, commissioned through the majority of health care insurers; (b) in New Zealand, where the Ministry of Health has commissioned “Beating the Blues” to be made available through all GPs; (c) in Northern Ireland, where again the Ministry of Health has commissioned “Beating the Blues” on behalf of all GP Practices; and (d) in England “Beating the Blues” is available in primary care, but is not yet comprehensively distributed at the point of contact with patients—GP surgeries. 2. “Beating the Blues” was developed in the United Kingdom by Ultrasis in conjunction with Dr Judy Proudfoot’s team at the Institute of Psychiatry, King’s College London. 3. “Beating the Blues” was recommended by the NICE Technology Appraisal 97 (TA97) in February 2006 for the management of mild and moderate depression. It consists of a 15-minute introductory video and eight further one-hour sessions, which are normally organised weekly. The programme also includes homework projects to be completed between sessions. Progress reports are made available to the GP or other healthcare professionals, including anxiety, depression ratings and suicidal tendencies. Commissioning 4. Ultrasis supports the Government’s move to GP and clinician led commissioning on the basis of it improving the delivery of evidence based and cost effective care. The current commissioning structures of PCTs are too distant from actual patient care and are overly influenced by professional and systemic norms and vested interests. This has been demonstrated in the case of “Beating the Blues” where following NICE recommendation in 2006, Published Implementation Guidance and Department of Health directives, less than 15% of the suggested treatments have been commissioned. This has led to at least one million people missing out on treatment during this period and the NHS not realising the full cost benefit, indicated by NICE, of £126 million per annum. 5. In November 2006, Prof Louis Appleby, Director of Mental Health, confirmed the NICE recommendation and stated that PCTs were expected to provide the recommended cCBT programmes by 31 March 2007. NICE estimated that 400,000 people per annum should benefit from CCBT. It also estimated that full provision of cCBT would offer cost savings of up to £126 million per annum in England. 6. The White Paper “Equity and Excellence: Liberating the NHS” announced that the Department of Health “will develop payment systems to support the commissioning of talking therapies.” As stated above, talking therapies such as cCBT can offer a huge saving to the taxpayer, so this commissioning support would not only be welcomed by health care providers but will offer a real benefit to patients and commissioners. 7. With many PCTs not currently offering “Beating the Blues” the full cost benefits of using cCBT are not currently being realised. There has been a massive increase in patients requiring access to mental health services. The lack of provision of cCBT, in particular for those with mild and moderate depression and/or anxiety conditions, means that these patients’ needs are not being met. The PCT-led commissioning process has clearly failed the patient and their GPs. The advent of the new proposed commissioning arrangements is an opportunity to rectify this—putting the decision-making at the point of interface between GP and patient. 8. cCBT has been demonstrated to deliver the same outcomes as traditional face to face treatments and can be delivered at 1/10th of the cost. Ev w118 Health Committee: Evidence 9. In a recent report commissioned from the Northeast Observatory on the provision of Improved Access to Psychological Therapies (IAPT) it was identified that a very small percentage of people (1.6%) seen within IAPT actually received a level of service commensurate with NICE recommendations. They stated that it was surprising that services that are simple to commission, such as cCBT, were not routinely available in all services given that they are the easiest program components to establish. 10. NICE also recommend that cCBT should be offered to patients before they are prescribed antidepressant medication, Antidepressant medication is currently estimated to be costing in excess of £350 million per annum and its usage is increasing as many GP’s feel that they have no other option available to them, due to limited access to traditional CBT services where it is not uncommon for a patient to have to wait in excess of nine months for treatment. Integrated Health and Social Care 11. “Beating the Blues” can play a vital role in integrated health and social care. In Northern Ireland, the programme is being made available from all GP practices. In the Netherlands, the programme has been translated into Dutch and is available from providers of psychological therapy and primary care. Most recently, the New Zealand Ministry of Health has commissioned “Beating the Blues” nationally on behalf of its GP’s. The New Zealand system, which is also GP-led, has embraced online therapy, which means that a patient can be prescribed “Beating the Blues” and begin the programme as soon as they get home. 12. The use of cCBT as a means of promoting self-help has huge potential to reduce the burden on often over-stretched services and to free up professionally trained people to see those with more complex needs. It can also be delivered at home or through existing social centres such as third sector partners, libraries and community centres, thus reducing the pressure on busy health clinics. 13. The White Paper also stated: “It is essential for patient outcomes that health and social care services are better integrated at all levels of the system. We will be consulting widely on options to ensure health and social care works seamlessly together to enable this.” New medical technologies will be crucial in helping to bridge the gap between health and social care, allowing for treatment in non-clinical settings. Again, we believe that cCBT is a proven and rigorous example of this, at the cutting edge of e-health technology as recognised in, for example, New Zealand, pioneers in this field. 14. Libraries are increasingly coming under significant pressure to provide a much wider range of services and support to people in their local communities. Provision of cCBT through public libraries has been demonstrated to be of value and could be an exemplar of how the Government could meet its aspirations to “join up” health and social care provision and “unlock efficiencies across the NHS, social care and public health through stronger joint working”. The Department of Health commissioned a review of the potential for this and a draft report is in circulation. 15. Conclusion 16. We strongly support the proposals to move towards GP and clinician-led commissioning as it will have a positive impact on the quality of commissioning decision making and consequently, improving patient care. 17. Informed commissioning led by GP’s and based on clinical need should be used to avoid the current post code lottery of care that is experienced by many patients not being able to access NICE recommended treatments. The PCT commissioning of cCBT has led not only to reduced patient care but significant loss of cost benefit to the NHS. 18. It is our belief that new health care technologies when commissioned as an integral part of clinical decision making can support both local authorities and health agencies to maximise their joint resources. As an example cCBT has been shown to support people back into work and off incapacity benefits as part of pathways to work schemes. 19. Computer delivered health care has been proven to: (a) increase access and choice to patients; (b) reduce cost of delivery; (c) provide GP’s with alternatives to prescribing medication; (d) deliver measurable clinical outcomes; (e) increase self-management of health care conditions and increase patient resilience; (f) realise cost benefits to the treasury as stated by NICE in 2006; and (g) deliver significant cost benefits when commissioned at a national level as part of a joined-up approach to delivering care across health and local authority provision such as in Northern Ireland, New Zealand and the Netherlands. Health Committee: Evidence Ev w119 20. We hope that the reforms outlined in the White Paper will lead to greater provision of these computer based cCBT health care treatments and that the NHS can benefit from significant cost savings, and improved patient care. October 2010 Written evidence from Haringey Better Local Healthcare Campaign (COM 48) Summary of Main Points — The implications of current Department of Health proposals for changes in commissioning do not appear to have been properly assessed. The proposals carry significant risks for patient care and for democratic accountability, and are likely to lead to greater fragmentation of services and increased administrative and management costs. — We are greatly concerned about the ability of GP consortia to address inequities in NHS provision and to plan in a coherent and comprehensive way for the health needs of the population. — The involvement of non-NHS organisations in commissioning will mean public money going to private organisations rather than remaining within the NHS. Robust mechanisms will be vital in order to guard against conflicts of interest: this will add a layer of bureaucracy and involve increased costs. These proposals are likely to lead to a diminution of public accountability and scrutiny. — The proposals to transfer responsibility for commissioning dentistry, community pharmacy and primary ophthalmic services to the NHS Commissioning are illogical, and are likely to result in greater fragmentation to the detriment of patient care. — The lifting of the cap on the ability of hospitals to secure funding from private patients, together with funding constraints, pose a threat of reductions in the amount of treatment and numbers of hospital beds available for NHS patients. — The proposal for all NHS Trusts to become or be part of Foundation Trusts and subject to regulation by Monitor, as well as the Care Quality Commission, will diminish Department of Health and public oversight. — The proposed replacement of Local Involvement Networks (LINKs) with local HealthWatches raises serious concerns about the capacity of the new bodies to carry out their roles. Complaint handling and advocacy arrangements in the NHS need to be examined in a comprehensive way to ensure their effectiveness, and merit more detailed and separate consideration. — The proposal to establish HealthWatch England is potentially welcome but it should be a fully independent body, rather than part of the Care Quality Commission. 1. Introduction 1.1 Haringey Better Local Healthcare Campaign consists of local people in the west of the London Borough of Haringey who are concerned to achieve free, good quality local healthcare close to peoples’ homes that is available on a universal basis, and to ensure that the interests of the most vulnerable members of the community are protected. 1.2 We welcome this Inquiry by the Health Select Committee and this opportunity to comment on the fundamental changes in commissioning that have been proposed in the recent White Paper on Liberating the NHS. We are extremely concerned that the significant risks posed for the care and well-being of health service users have not been properly assessed before the proposals reached this stage. 1.3 Concerns are also raised by the statement in the White Paper that “We are consulting on how best to implement these changes”, which indicates that the Department of Health is not consulting on whether the changes should be introduced in the first place. Our concerns are heightened by reports that certain aspects of the proposals are already being rolled out within the NHS in advance of the results of this consultation on the White Paper’s proposals. This raises fundamental questions about the seriousness of the Government’s consultation process, and it also flies in the face of ensuring proper public engagement in policy changes that are of a very substantial nature. 1.4 This submission to the Committee’s Inquiry focuses on the implications of the proposed changes in commissioning arrangements; inequalities in provision; commissioning of specialist services; increased involvement of new entrants; and accountability for commissioning decisions. 1.5 We would also urge the Committee to examine broader urgent issues relating to healthcare services, notably: — how to ensure there is adequate funding for all frontline health services; — how to expand the community accountability of NHS bodies; Ev w120 Health Committee: Evidence — how to ensure effective and adequately resourced public/patient involvement in and scrutiny of health and social care services at local and national levels; and — how to end the expensive and bureaucratic internal market, and PFI funding schemes. 2. Concerns about Proposed Changes in Commissioning 2.1 A key element of the White Paper is the transfer of power and responsibility for commissioning services to local consortia of GP practices for the great majority of NHS services for their patients, alongside the abolition of Primary Care Trusts (PCTs) from 2013. The implications of these proposals are serious and do not appear to have been properly assessed; in particular, they carry significant risks for patient care and for democratic accountability. There appears to be no conclusive evidence that the Government’s proposals will address the weaknesses in commissioning that were identified in the Health Committee’s report (30 March 2010). 2.2 A crucial function of PCTs and Strategic Health Authorities (SHAs) is to monitor equality of healthcare delivery across the borough and wider regions. Basing budget management on GP consortia, where GPs are themselves small businesses removes the strategic and crucial controlling mechanism from public control. We are also greatly concerned about the implications for patients if a commissioner gets into difficulty. 2.3 Furthermore, with the proposed increase in the numbers of commissioning bodies, the likely results will include greater fragmentation of services and increased administrative and management costs. There must also be serious concerns about the loss of institutional knowledge of local health care services and needs, as well as commissioning skills. The concerns expressed in the recent report by the Parliamentary Select Committee on Health regarding the commissioning capacity of PCTs and the shortage of such commissioning skills are most unlikely to be addressed by these proposals. Despite the existence of some GP commissioning consortia, in general GP practices currently do not have the necessary skills to engage effective commissioning of services. 2.4 The result will be that these consortia will need to recruit additional staff and/or engage other bodies to carry out these functions, leading to increased management costs and decreased public accountability. Moreover, in principle, private bodies, social enterprises or voluntary organisations should not be involved in commissioning NHS health services as is likely to happen. Their involvement will mean public money going to private organisations rather than remaining within the NHS. Disbursement of public funds must be subject to and accompanied by proper public scrutiny and accountability. In addition, mechanisms will be required in order to guard against conflicts of interest in commissioning: this will add a layer of bureaucracy and involve increased costs. We are also greatly concerned that placing these responsibilities on GPs will detract from the vital time and energy that they should devote to their patients and to further professional development. 3. Inequalities in Provision 3.1 The proposals involve the replacement of some 152 commissioning bodies by around 500 commissioning bodies (GP consortia). This is likely to result in the exacerbation of postcode lotteries in health services, with areas that are already disadvantaged losing out even more. PCTs are in a better position than GP consortia to address inequities in provision and to plan in a coherent and comprehensive way for the current and future health needs of the population. For example, Haringey is characterised by inequalities between the east and west of the borough and there are concerns that GP provision east of the borough is not strong. It will be very difficult, if not impossible, to address the already wide inequalities across the borough if these proposals are adopted in Haringey. 4. Commissioning of Specialist Services 4.1 We are concerned that existing PCT responsibilities for commissioning other health services of dentistry, community pharmacy and primary ophthalmic services will be the responsibility of the NHS Commissioning Board. Although the consortia will have some influence and involvement, this has not been defined. We cannot understand the logic of this proposal which will lead to greater fragmentation in the monitoring and commissioning of services. It flies in the face of the aim of achieving integrated services and patient pathway which takes proper account of the full range of people’s needs. 5. Increased Involvement of New Entrants 5.1 The proposed restructuring of commissioning will lead to more outsourcing and reductions in the money available for front-line services. With further fragmentation and new entrants involved in the commissioning process including private companies, more funds will be wasted, and public money will be transferred from the NHS to private corporations and their shareholders. With the lifting of a cap on the ability of hospitals to secure funding from private patients together with funding constraints, we can anticipate a real threat of reductions in the amount of treatment and numbers of hospital beds available for NHS patients. Health Committee: Evidence Ev w121 6. Accountability for Commissioning Decisions 6.1 The proposals include the establishment of new statutory arrangements within local authorities, which will be established as “health and wellbeing boards” or within existing strategic partnerships. These will take on the function of joining up the commissioning of local NHS services, social care and health improvement. However, it will be expensive and take time to equip these Boards with the necessary expertise. It is also not clear whether these Boards will have elected representatives of the community and how and whether the Boards will be accountable to the public. 6.2 We are concerned that these functions would replace the current statutory functions of local authority Health Overview and Scrutiny Committees (OSCs). At present these proposals appear to represent a diminution of public accountability and scrutiny rather than the stated aim of strengthening the local democratic legitimacy of the NHS. 6.3 A further downside of these proposals is the accompanying decrease in democratic accountability and transparency. At present, whilst the system needs further improvement, at least PCT Board meetings are open to the public and their papers are published so that the public can see what decisions are being made and how these are justified. 6.4 We are also greatly concerned about the proposal for all NHS Trusts to become or be part of Foundation Trusts and subject to regulation by Monitor as well as the Care Quality Commission. This is another proposal that will increase the fragmentation of health services. It is inevitable that forcing hospitals to take on foundation trust status will diminish Department of Health and public oversight. Management focus will shift away from meeting local needs to budget management. Moreover, the involvement of two regulatory bodies is a recipe for increased bureaucracy and raises concerns about the quality of care falling between the two organisations with accompanying risks for patients and service users. Monitor’s approach also raises questions about its patient and public engagement in its processes. 6.5 The White Paper proposes the replacement of Local Involvement Networks (LINKs) with the establishment of local HealthWatches with enhanced powers and representation. However, these will continue to be based on volunteer involvement—there are serious doubts about their capacity to carry out their existing duties, let alone take on enhanced roles. The additional roles require professional expertise, including the provision of advocacy for people who wish to make complaints. There are serious issues that need to be addressed concerning the effectiveness and adequacy of complaint-handling within the NHS, including patient advocacy. It is not clear in the least that the proposed HealthWatches will be in a position to play an effective and independent role in this and other respects. 6.6 The existing LINKs network is unproven and has not been properly evaluated. They lack the capacity and resources of their predecessors, such as the PPI organisations and Community Health Councils. In addition, most of the funding that has been allocated to local authorities for the local LINk is disbursed, not on LINks, but on the host organisations, many of which currently provide services under other contracts, but whose services they are meant to be assisting the LINk to monitor. These concerns have not been recognised nor addressed in the White Paper. 6.7 In their present form, there is no evidence that the LINKs have the capacity to take on additional powers and duties, for example for complaints. The question of ensuring effective arrangements for complaint handling and advocacy regarding health services merits much greater consideration than has been afforded in the White Paper. However, the proposal to establish HealthWatch England is potentially welcome but it should be a fully independent body, rather than part of the Care Quality Commission. October 2010 Written evidence from the Pharmaceutical Services Negotiating Committee (COM 49) 1. The Pharmaceutical Services Negotiating Committee (PSNC) welcomes the opportunity to contribute to the Health Select Committee’s inquiry into NHS commissioning. PSNC represents and promotes the interests of almost 11,000 pharmacy contractors in England and Wales. It is PSNC’s responsibility to liaise with the Department of Health and to negotiate the contractual terms for the provision of NHS community pharmacy services. Executive Summary 2. As PSNC’s submission to the Health Committee’s previous inquiry on this subject stressed, PCT commissioning of pharmacy services has been regrettably patchy. This patchiness has prevented many communities from receiving the full benefit of their local pharmacists’ skills, expertise and accessibility. 3. If the new commissioning structures set out in the White Paper Equity and Excellence: Liberating the NHS are to effectively harness the full potential of high quality community pharmacy services, the Department of Health and broader NHS must learn a number of lessons from the shortcomings of the outgoing system. Ev w122 Health Committee: Evidence 4. This submission seeks to address three particular questions raised in the Committee’s Invitation to Submit Written Evidence. These questions are: (i) How will GPs engage with their colleagues within a consortium and how will consortia engage with the wider health community? (ii) What will be the role of the NHS Commissioning Board? (iii) How will commissioning interface with the Public Health Service? This submission reviews the policy challenges and questions that are specific to each of these areas, taking into account community pharmacists’ experience of current commissioning structures. In considering these questions, it makes a number of recommendations the committee may wish to consider in addressing these challenges. These are listed at the end of the submission. How will GP commissioning consortia engage with the wider health community? 5. The White Paper’s proposals to devolve power and responsibility for commissioning services to healthcare professionals are to be welcomed. However, it is of the upmost importance that GP consortia fully engage with all local clinicians and providers in order that locally designed disease pathways and services utilise the skills of all in primary care. There should be a community pharmacy representative on the Board of all GP consortia in order to ensure pharmacy expertise on medicines is used to best effect in the commissioning process. 6. Commissioning of services where GPs are potential providers must be undertaken in a fully transparent manner by a third party unconnected to any potential providers. 7. We welcome the proposals to develop standard commissioning support for GP consortia, such as standard service specifications, tariff pricing and standard contracts. Unnecessary local variability in commissioning of the same service across different PCTs has increased NHS and provider costs. A standardised approach would avoid many of these costs and facilitate more efficient commissioning and delivery of services; this must be a priority in the current financial climate. 8. We believe GP consortia should be required to demonstrate the best use of other primary healthcare professionals and the infrastructure that they have to offer, which is frequently funded by the NHS. One way to demonstrate this commitment would be by commissioning a minimum number of Enhanced services from community pharmacy contractors in all areas. What will be the role of the NHS commissioning board? 9. We welcome the proposal to transfer responsibility for the national community pharmacy contract to the NHS Commissioning Board. The contract, introduced in 2005, has allowed community pharmacy to make a significant contribution to the health of the nation and at the same time save the NHS significant sums of money each year, by effective procurement of medicines. 10. Our experience of PCT commissioning of community pharmacy services over recent years has been varied. Where good commissioning, following the Department of Health guidance,71 has occurred, community pharmacies have been able to act as a full team member within primary care service delivery. Sadly, in many areas this has not been the case and PCTs have failed to make best use of the skills and infrastructure that community pharmacy has to offer, despite the NHS being largely responsible for funding these resources. 11. In learning from this experience, we believe that the pharmacy contract should be developed with more nationally commissioned services and the introduction of directed Enhanced services. These services would utilise standard service specifications to support the efficient delivery of services, yet still allow providers to personalise the service delivery at the level of the patient or person. Over many years, community pharmacies have developed the skills to allow them to personalise services for their customers in order to differentiate themselves from other pharmacies within this very competitive sector. Commissioning at a national level, whilst allowing the personalisation of service offerings at the level of the patient, provides the benefits of efficiency for the NHS and the provider and a locally responsive approach for the patient. 12. Community pharmacy and the other family practitioner services are represented at a local level by Local Representative Committees (LRCs), such as Local Pharmaceutical Committees (LPCs). These bodies provide a range of important functions that support service development for patients and the delivery of effective and cost efficient services by contractors for local commissioners. Currently LRCs have a relationship defined in the NHS Act 2006 with one or more PCTs; a new relationship will need to be established between the LRCs and the NHS, potentially the NHS Commissioning Board’s regional offices, in order that the valuable work of these organisations can be continued. 71 High Quality Care for All: Improving Pharmaceutical Services, Department of Health, April 2009. Health Committee: Evidence Ev w123 How will commissioning interface with the public health service? 13. We welcome the proposals to transfer responsibility to local authorities for public health; this should support a joined up approach to public health challenges by tackling the wider determinants of health in a holistic manner. The Joint Strategic Needs Assessment must be developed in partnership with GP consortia and NHS providers and must be used as the basis for local authority and GP consortia commissioning decisions. 14. Community pharmacies already provide a wide range of public health focussed services such as stop smoking support, NHS Health Checks, emergency hormonal contraception and sexual health screening. The accessibility of the community pharmacy network to patients and members of the public who do not frequently use other healthcare services is a key asset that the NHS and local authorities should leverage to improve public health. We believe that many of these services offer undeniable value to the population and would benefit from being commissioned at a national level. While we recognise the desire to provide personalised services for individuals and communities, we believe it is possible to benefit from the efficiencies of a nationally commissioned service, whilst at the same time providing sufficient flexibility for service providers to personalise their service offering to meet the needs of individuals. 15. The transfer of some commissioning responsibilities from PCTs to local authorities should be informed by the experience of recent years, where we have seen a subtle range of local variations on standard services, such as stop smoking, commissioned by PCTs, without any perceivable benefit being delivered by this varied approach. 16. In order to support cost effective and efficient commissioning of community pharmacy services by local authorities we suggest that the work to develop standard service specifications PSNC has undertaken with the Department of Health and NHS Employers should be augmented by the agreement of standard contracts or service level agreements and potentially tariff prices for some services. 17. We support the establishment of statutory Health and Wellbeing Boards and believe that community pharmacy should have appropriate representation on the Boards, in order that the potential of community pharmacy to improve public health is maximised at a local level. 18. These Boards should help support partnership working and commissioning by local authorities and GP consortia. We recognise the benefits of taking a more holistic approach to public health, but we are concerned that there is the potential in the new system for valuable services to “fall between the gaps” created by local authority and GP consortia commissioning, particularly where a service could be commissioned by either side. This issue could be addressed by the provision of a clear definition of the services that local authorities will take responsibility for in the forthcoming White Paper on public health. 19. It is also likely that without careful collaboration between the two commissioners, there is the possibility of public health commissioning driving conflict with GP consortia, due to public health services, such as screening programmes, driving unplanned healthcare expenditure. 20. We also note the potential for problems where local authorities and GP consortia are not operating across a coterminous area. These risks can all be overcome by commissioning across a coterminous area, with excellent joint strategic planning via the local Health and Wellbeing Board. 21. We are pleased to see the proposal that local authority funds for public health should be ring fenced. In the past such ring fencing has not always been effective in ensuring all funds are spent on the specified area. We therefore suggest that local authorities should be required to publicly account for their spending of the ring fenced public health monies at the end of a financial year. Recommendations 22. A full list of recommendations contained in this submission is set out below: (i) There should be a community pharmacy representative on the Board of all GP consortia in order to ensure pharmacy expertise on medicines is used to best effect in the commissioning process. (ii) Arrangements should be put in place to ensure that commissioning of services where GPs are potential providers must be undertaken in a fully transparent manner by a third party unconnected to any potential providers. (iii) To ensure the most is made of the skills and infrastructure that community pharmacy has to offer the pharmacy contract should be developed with more nationally commissioned services and the introduction of directed Enhanced services. (iv) A new relationship should be established between LRCs and the NHS (most likely in the form of the the NHS Commissioning Board’s regional offices), to replace the valuable relationship between LRCs and PCTs defined in the NHS Act 2006. (v) Pharmacy-provided public health services that are shown to deliver undeniable value to all communities should be commissioned at a national level. (vi) Community pharmacy should have appropriate representation on statutory Health and Wellbeing Boards, to ensure community pharmacy’s potential to improve public health is maximised at a local level. Ev w124 Health Committee: Evidence (vii) To ensure valuable community pharmacy services do not ‘fall between the gaps’ created by local authority and GP consortia commissioning, the forthcoming White Paper on public health should clearly define the services that local authorities will take responsibility for as part of their public health role. (viii) Local authorities should be required to publicly account for their spending of the ring fenced public health monies at the end of a financial year. October 2010 Written evidence from Genzyme Therapeutics (COM 50) Genzyme Therapeutics is one of the world’s major biotechnology companies, committed to researching and producing treatments for serious and life-threatening diseases, and in particular meeting the unmet needs of sufferers of the rarer conditions. Genzyme has a very close interest in specialised commissioning, and wishes to provide evidence and observations relating to that important issue. In Summary — Genzyme fully supports a reforming agenda that empowers many more of the stakeholders in healthcare, and which puts patients first and at the centre of the healthcare process. — The new White Paper proposes GP consortia commissioning of the majority of healthcare, with the new NHS Commissioning Board commissioning current regional and national services. — Without a strong commitment, the differing pace and priority of the GP consortia will lead to increased service inequality—defeating the intention of the reform. — Genzyme’s prime concern is that current functions that have been proven to be effective and costeffective ( such as national specialized commissioning) are neither unwarrantedly discarded or diluted, nor paralysed, by the process. — There is further concern that national commissioning of currently “regional” or “clinical network” services may move them away from the patient (and from many developed local care networks). — It may be better to commission and performance manage at a national level, but continue to deliver locally. Addressing the “themes” of the Committee’s inquiry, and particularly regarding specialized commissioning, Genzyme would wish to comment as follows: 1. (a) Clinical Engagement in Commissioning The Board should retain and develop the expertise that already exists within the national and regional specialized commissioning bodies. The GP consortia should appoint a specialist commissioner who would: — work as an interface; — educate GP consortia about regional and national specialized services and the benefits brought to patients derived from integrated commissioning; and — involve and facilitate GPs having a “special interest”. 2. (b) Accountability for commissioning decisions The Board and the GP consortia must manage both financial and clinical outcome risk. There should be a commissioning outcomes framework that addresses health outcomes and quality of care, and has significant patient input. Decisions should be evidence-based, and follow NICE and NPC guidance. Decisions should only be made within the competency of the commissioner. 3. (c) Patients’ Voices and Choices Commissioners should actively seek the involvement of patient groups. To include the seldom heard (but equally important) voices, involvement and enfranchisement of all could be via the “umbrella” patient organizations rather than through the participation of currently high-profile patient organizations. 4. (d) Role of the NHS Commissioning Board The establishment of an independent Board to provide national leadership on commissioning for quality improvement is welcomed. The Board can develop effective relationships with the GP consortia by agreeing clear, shared, objectives; ensuring timely and full communication; by formulating clear guidelines and procedures for actions; by creating effective and meaningful performance management processes. Further, the Board could support efficient and effective local commissioning by creating effective information Health Committee: Evidence Ev w125 systems; by creating, and requiring compliance with, where appropriate, national disease registries; by conducting research into the clinical and societal values and successes of the new commissioning pathways; by defining and agreeing which services are to be commissioned by which body. 5. (e) Resource Allocation The true treatment and ongoing costs of the services to be commissioned should be established. This should incorporate costs incurred in both primary and secondary care sectors. The costing should also consider the issue of non-healthcare costs that are needed in a patients care package, and growth costs. The costs for services designated to national commissioning should be identified. To avoid the perception of “top-slicing” or “clawback” there should be the simultaneous allocation of funds from the NHS to both the Board and the GP consortia. To manage risk, there should be Board oversight of mandatory risk pooling structures. 6. (f) Specialist Services Many of these are already defined and are commissioned nationally, with very good clinical and costeffectiveness, and no inequality. Some specialist services are provided regionally or through clinical networks. These are more vulnerable to local priorities and so inequalities do exist. It is essential that services currently commissioned nationally are not threatened by any influx of quantity of “ex-regional” services. This could be by reduced attention or even “paralysis” during the redesignation process. October 2010 Written evidence from Dr Jonathan Howell (COM 51) Executive Summary 1. Commissioning in the NHS is a complex activity that requires sophisticated team working and World Class Commissioning has only recently started to make substantial improvements to this key function. Any new alternative commissioning arrangements need to recognise the complexity of the annual commissioning cycle and integrate this with the proposed GP commissioning function as well as ensuring the involvement of secondary care clinicians in the best use of NHS resources. 2. With the proposed demise of PCTs someone, or some organisation, needs to have a statutory oversight of the whole care pathway for patients with a corresponding ability to move resources around the system to obtain improvements in patient care and resource use or to identify gaps in services. 3. Local Authorities, the public health function, health improvement across the population and for specific subgroups, and NHS commissioning all need to be “joined-up” by statutory obligation so as to support the whole care pathway and to be able to assess resource use and to appropriately shift funding in line with this. 4. The prioritisation of new developments can raise complex issues and needs good policy support from the centre to support those decisions that need to made locally. 5. From a public health perspective specialised commissioning cannot be separated from wider commissioning issues and the sorts of linkages referred to above. You cannot commission at the higher levels of care without understanding the pressures affecting other commissioners and ensuring that issues and values are shared. Background Information about Dr Jonathan Howell 6. I am a Consultant in Public Health working for the West Midlands Specialised Commissioning Group (WM SCG). I have a medical background and have worked in specialised services for six years. I worked as a GP for eight years before retraining in public health. My previous post was as Director of Public Health at Cannock Chase PCT. 7. I am a member of the new Advisory Group for National Specialised Services and over the previous five years I have been a member of its predecessors, the National Commissioning Group (NCG) and the National Specialised Commissioning Advisory Group (NSCAG). In 2009 I established the SCG Public Health Network as a formal committee of public health specialists working in SCGs to provide advice and support to the National Specialised Commissioning Group (NSCG), which represents the ten regional SCGs in England. I am also a member of the Faculty of Public Health’s Healthcare Committee and have close links to the UK Public Health Commissioning Network. Ev w126 Health Committee: Evidence Healthcare Commissioning and Current Issues 8. The previous Health Select Committee’s report on commissioning (March 2010) highlighted the underdeveloped state of NHS commissioning although some of the attendant publicity made it sound more as though commissioning had failed rather than it being a relatively late development for PCTs. However, despite its clich„d title, World Class Commissioning (WCC) has started to give a structure and impetus to PCT commissioning that has not been there before. 9. Commissioning has been in variable states of development across PCTs and Specialised Commissioning Groups (SCGs) since the arrival of WCC. This has meant that from the outside WCC still appears weak. This is not helped by the increased freedom of NHS providers as Foundation Trusts. This freedom has meant that commissioning is often on the back foot in a competitive environment where the outcomes for patients are not necessarily the main driving force. 10. The proposal to reorganise the NHS has not helped in strengthening commissioners at the moment as it represents a destabilisation of the current arrangements and relationships. Previous reorganisations have created a major turnover of staff with key skills being lost, other staff being demotivated, and resources consumed in re-establishing teams. Experience shows that if the reorganisation is a large one, then the organisational memory can be lost in forgotten folders in the computer server. The current reorganisation looks to be the biggest on record and is likely to severely disrupt commissioning in the NHS. 11. The functions, illustrated by the diagram of a typical commissioning cycle (see Appendix), reflect the complexity of commissioning if it is to achieve the aim of maximizing the outcomes of the NHS with the optimal uses of resources. It has also been difficult to commission at the right level of detail when, prior to WCC, the Department of Health (DH) had seemingly not recognized this complexity and had not put the right enablers or policies in place to support it. This included things such as an appropriately detailed standard NHS contract and incentives for providers to provide the right information and outcomes. Effective Commissioning 12. The approach to commissioning as illustrated by the commissioning cycle requires close team working between commissioning managers, information specialists, finance personnel and people with clinical insights and expertise in population health, which usually means public health consultants given the positions they occupy in commissioning organisations. This means an appropriate investment in management resources so that the right expertise and team working can deliver effective and evidence based specifications for healthcare services. 13. This investment in commissioning teams is necessary to improve the use of NHS funds in the drive for better outcomes for patients and better value for the nation’s funding of the NHS. Contracts with healthcare providers should reflect good partnership relationships and close working. Providers are obviously closer to the information on the services they deliver and this gives them a stronger position particularly if there is interpretation of the codes for specifying services or even manipulation so that the coding does not always reflect the right use of resources. 14. In this context a major deficit and delay in improving commissioning has been the lack of good data. This has been made more complicated by the introduction of HRG-4 coding, and the confusing overlap of other coding systems, which provide diagnostic and procedural codes (ICD-10 and OPCS-4), and the ability of commissioners to interpret this into usable information. Reliable and valid information is the cornerstone of proactive commissioning and an ongoing review of services so as to maintain good practice and identify unacceptable clinical variation. Clinical Engagement 15. Commissioning will often struggle without good clinical engagement. Clinicians, particularly doctors, make many of the decisions around patients that commit resources and money. Commissioners need to work with clinical leaders to support understanding on both sides. Often clinicians are not directly accountable for the use of resources they commit and will press for the use of new technologies without reasonable evidence. Some will not understand that the inappropriate use of resources for their patients will compromise more effective care elsewhere for other patients. 16. One way of supporting wider clinical engagement is through “managed clinical networks”. These sorts of networks have been widely used in Scotland and are about bringing together clinicians and managers to agree service developments, resource use and to raise service standards in way that a whole systems approach can support. A more local example is the West Midlands Renal Network, which operates on a limited budget but has clear lines of accountability and structured clinical engagement that have helped to facilitate substantial improvements for renal patients. More information on the Renal Network is available at http://www.wmrn.co.uk/index.php?id%3. 17. The White Paper, whilst clearly supporting the role of GPs in commissioning, does not offer a clear role for secondary care clinicians or other professions involved in healthcare both at a primary and secondary care level. It also does not give a sense of the need for the prioritisation of resources. It is widely acknowledged that healthcare resources will not meet all the potential demands for treatment. In this context “patient demand” for a treatment needs to be separated from “patient need”. Patient need can be defined Health Committee: Evidence Ev w127 as the ability to benefit from an intervention and, as such, is a relative term that is partly about differences in the clinical effectiveness of different treatments. When treatments are said to “work” this often disguises the wide variation in effectiveness and value for money that can exist between treatments. Clinicians need to be part of a system that helps to prioritise NHS resources for the optimal delivery of patient services. Prioritisation 18. One of the key aspects of commissioning and, in some ways, the one that requires the most difficult decisions is prioritisation. This is about making measured choices so that NHS funding is used on the treatments that offer both good clinical effectiveness and good cost effectiveness. A health service will always have limited resources and need to make difficult judgments on behalf of the public. These decisions can be uncomfortable for politicians in the public eye where the issues are often simplified and a decision not to fund made to appear irrational. 19. In the past when commissioning has been weak there has often been a failure to manage the introduction of new treatments where the evidence base is weak and the balance of risks and benefits for patients uncertain. This is not only taking long term risks with patients but is a poor way to use NHS resources and may be unbalanced by those clinical fields able to gain the most influence. There are signs that commissioners are developing more robust and coherent policies that are shared widely. However, the proposed reforms may fragment commissioning in the NHS and make rational policy making across the care pathway more difficult. 20. Stronger commissioning makes it more likely that we are able to identify better ways of investing in and managing the care pathway for patients. However, it is often the expensive new technologies for small numbers of patients with serious illnesses at the end of their lives that gain the attention rather than the need to ensure appropriate investment upstream in the pathway to help to stop patients needing these technologies in the first place. An example is with heart failure patients. Heart failure is a relatively common condition often not well managed in the past and yet with expensive device use at the specialized end of the pathway. The two Wanless reports made it clear that without the right balance of investment in preventive measures then the NHS would be treating more ill health at greater cost. 21. The difficult prioritisation decisions can be made across the NHS with the collaborative working of commissioners and the involvement of clinical leaders. This needs work to establish the legitimacy and accountability of the decision makers but this should not be undermined by expedient political decisions or the apparent influence of strong commercial interests. Recent examples are the closer working of the ten SCGs through the NSCG and the involvement of the cardiac professional societies in trying to find a constructive way to introduce new cardiac technologies, such as the ways of implanting cardiac valves. 22. Supporting documents to the White Paper make it clear that decisions should be made within the resources available. However, this common sense approach is undermined by parallel messages about doctors needing to respond to patient demand. This is not only unsafe for patients who may see apparent benefits in treatments without understanding the risks but will have opportunity costs for patients elsewhere. 23. Whilst clinicians need to provide the optimum care for individual patients this must be in the context of broader decisions on where funding will be allocated in terms of population decisions. These must also be evidence based decisions, which means that a range of evidence must be used in the judgment of providing for the NHS interventions. In turn this means an objective interpretation of what the clinical evidence is saying and its likely value to the NHS in the wider scheme of things. This sort of evidence is rarely black and white and is readily influenced by vested interests so that commissioners must have some degree of independence but will also need to have public legitimacy and accountability. Joined up Commissioning, Local Authorities and Public Health 24. The proposed National Commissioning Board and the Public Health Service need to be flexible and adaptable to be able to work across organisational boundaries and to support the appropriate movement of NHS funds. To achieve the rational approach the use of health resources should be as joined up as possible. Although local authorities (LAs)will have a lead in health improvement and use public health expertise it is important that there is linkage between their role and the vast amount of funding that goes into healthcare services. 25. Without a close local authority interest in NHS funding then it will be more difficult to argue for a transfer of funds to support “upstream” interventions and health improvement and to ensure that secondary care services do not grow unduly at the expense of wider population health. It should be part of a commissioner’s task to “work” the care pathway, ie to move resources to earlier parts of the pathway, with the aim of achieving long term health improvements for the wider public. Clinicians at all levels need to be part of this. Public health as a discipline should also be involved in providing the evidence for and in making these linkages. 26. The Health Overview and Scrutiny Committees based in LAs should understand the local expenditure on healthcare and take an active interest in the prioritisation and rationale behind NHS funding decisions. This will be difficult if there is a continuing rationalisation of specialised services from district general hospitals to tertiary centres so as to support better quality care. Ev w128 Health Committee: Evidence 27. There should also be a clear role for LAs to make sure that public health and health services are joined up. Allowing these two aspects to be divided between organisations may lessen the overall impact on the population’s health and not allow the optimal use of health funding. 28. Any public health service or specialist practitioners with an interest in population health should be actively working across whatever organisational boundaries are established. Traditionally this has been a role for trained public health specialists. It is often about the subtleties of change management with a role in supporting innovation and optimising resource use for better health care. There are numerous examples where the NHS is starting to move better care “upstream”, such as managing early renal failure so as to improve patient outcomes and help to keep patients away from needing renal dialysis. 29. One area where the roles of the LAs and the NHS should be not be separated is that of mental health. Mental health services consume a large proportion of NHS funds and have a big impact on social service resources. As many patients with mental ill health will be in the community and often struggling with everyday problems then the NHS and social services, as well as many other supporting LA services, need to be closely aligned, working together and sharing resources. How this will work in the proposed reorganisation is not clear but it needs to be thought through and written into organisational objectives not least to avoid the sort of perverse incentives or “buck passing” that may occur in times of financial difficulty. 30. Somewhere in all this there needs to be a way of taking on board patient views about both individual services and the way organisations deliver services. Commissioners have already started to move in this direction but this requires more research about the models that work. Specialised Services Commissioning 31. Without more detail it is difficult to understand how the proposed GP commissioning consortia will operate and link with other structures in particular the services that need more complex commissioning. 32. Regional specialised services that have been well established have delivered relatively good commissioning models and outcomes although there is still much room for improvement. Although I clearly have a vested interest, the West Midlands SCG has developed a good understanding and relationships with its PCTs. The services we commission are usually complex and technical and merit the specific focus of a commissioning team. 33. The Specialised Services National Definition Set sets out a long list of services that might be considered specialised. In practice many of these were best left with PCTs as little or no additional value would be obtained by moving commissioning to SCGs. However, it is likely that GP commissioning consortia will have a different focus to that of PCTs and may not be oversee the whole patient pathway. As such, some of the services that might be judged to be of an intermediate technical nature, may be better commissioned at a specialised or National Commissioning Board (NCB) level. If the portfolio at this level is larger (and the size of the WM Specialised Commissioning Group budget for 2008–09 was about £840 million, practically equivalent to an extra PCT) then the NCB is likely to need sizeable regional outposts to commission effectively. This is partly about maintaining local intelligence, local relationships with detailed contracts and ensuring that specialised clinicians are appropriately engaged. 34. One aspect of SCGs that has started to improve and has the potential to deliver increased coordination and better policies is the National Specialised Commissioning Group (NSCG) and its subcommittees. This grouping of the 10 regional SCGs has facilitated a move towards a national forum for commissioning issues and a practical point for commissioners to interact with national policy makers such as the Department of Health (DH). It will be important to maintain this sort of structure particularly as the previous National Commissioning Group (NCG) has moved out of the NHS to be part of the DH. The new group (the Advisory Group for National Specialised services—AGNSS) will need to make commissioning decisions that link up with NHS services and allow resources to be appropriately managed and services to link up with the appropriate care pathways. As AGNSS will be using funds that would otherwise be likely to be part of NHS funding then there are good reasons, not least from a patient perspective, to ensure that decisions and resources are “joined-up” in some sort of structured way. October 2010 Health Committee: Evidence Ev w129 APPENDIX THE ANNUAL COMMISSIONING CYCLE ILLUSTRATING THE KEY PARTS WHICH GO INTO COMMISSIONING A PATIENT SERVICE Assess needs Review current service provision Decide priorities Strategic planning Design service Specify outcomes & procure services Managing demand and performance Managing performance (quality, performance, outcomes) Shape structure of supply Clinical decision making Manage demand and ensure appropriate access to care Written evidence from British Pregnancy Advisory Service (COM 52) This submission states that: — bpas is generally supportive of the aims of the NHS White Paper’s proposals on commissioning, which aim to improve value for money for the NHS and quality for patients, but has concerns about how this will be delivered; — bpas seeks assurances that GP commissioning consortia will be obliged to commission to the National Standard Service Specification for Termination of Pregnancy. There has been progression in the quality of commissioning of abortion services in recent years and bpas is concerned that the change to GP commissioning consortia will disrupt this progress; — bpas recommends that responsibility for the commissioning of abortion services, and in particular later abortion services, is given to the National Commissioning Board, in order to protect specialised services, which a small number of vulnerable women require annually. Clinical Engagement in Commissioning How will commissioners access the information and clinical expertise required to make high quality decisions about the shape of clinical services? Commissioning for sexual health services, and abortion services in particular, can be challenging. A high quality service requires a holistic approach to treatment, which should include contraceptive advice and services, STI testing, as well as pregnancy advice and access to abortion. There have been significant problems in the past regarding inequality in provision of abortion services nationally and there has been progress recently in this area.72 The development of the National Service Specification, as a mandatory requirement for the new NHS contract, was designed to enable commissioners to establish a quality abortion 72 Stenson, D, 2010, Commissioning abortion and sexual health services, Best Practice and Research Clinical Obstetrics and Gynaecology. Ev w130 Health Committee: Evidence service for their region and bpas hopes that GP commissioning consortia will work to these standards.73 In 2009 189,100 women resident in England and Wales had an abortion and abortion services are significant in the lives of many women at some time.74 It is essential for the health and wellbeing of women that high quality abortion services are available across the country. bpas is concerned that the move from PCT commissioning to GP commissioning increases the possibility that, in a time of financial pressure, decisions will be made that will prioritise saving money over providing the services that women need. New GP commissioning consortia must avoid commissioning abortion services which, for example, force women to travel out of their local area for routine care, or to have a limited choice of treatment. How Open will the System be to New Entrants? Will care providers be free to offer new solutions which offer higher clinical quality, better patient experience or better value? bpas’ extensive experience in dealing with a range of PCTs and various NHS commissioning approaches has demonstrated that, in some instances, commissioners will opt to commission services from providers within the NHS regardless of the relative value that can be obtained by commissioning a third sector provider from outside the NHS. This indicates that the problems with current commissioning arrangements are not simply systemic but also cultural. This can sometimes lead to decisions that do not provide the best value for the NHS or the best quality service for patients. There is a significant challenge to the success of these reforms posed by culture barriers in commissioning and the Government must find ways to address this to make sure that GP commissioning consortia fully engage with Third Sector providers in order to offer the best available service to patients, as well as saving the NHS money. What arrangements will be made to encourage the Third Sector both as commissioners and providers? As outlined above, Third Sector providers are often disadvantaged when it comes to the commissioning of their services because some NHS commissioners tend to opt for services provided by directly by NHS hospitals on principle, or because this is the model they are familiar with. This can undermine progress in the development of services, and impair the tender-process. Contracts that allow women to self-refer into pregnancy advisory services have increased the efficiency in this aspect of sexual health and GP commissioning consortia should be encouraged to develop contracts that offer this. Self-referral streamlines the pathway and enables women to access earlier treatment, which is safer and more cost-effective for the NHS. Contracts should provide women with the services and support they need when faced with an unintended pregnancy and often this will not mean an appointment with a GP. GP commissioning consortia must be encouraged to draw on the expert knowledge that specialist providers such as bpas offer and ensure that they commission services that best fit the needs of their patients. Accountability for Commissioning Decisions How will commissioning interface with the Public Health Service? The publication of the NHS White Paper prior to the publication of the Public Health White Paper has created a difficulty for healthcare providers working in sexual and reproductive health. The proposals outlined thus far do not explain in any detail how the new Public Health Service will operate and how, in practice, the local authority will take responsibility for public health in their local area. bpas’ response to the NHS White Paper therefore cannot reflect in full changes which will affect our operations and, potentially, how we deliver our service. It is essential that further information on the proposed Public Health Service is made available as soon as possible in order than providers can begin to understand how existing structures and responsibilities will change. Specialist Services What arrangements are proposed for commissioning of specialist services? bpas notes the provision in the consultation for the commissioning of maternity services to be led by the NHS Commissioning Board. Our experience suggests that services for pregnant women who do not choose to continue with the pregnancy would also benefit from specialised commissioning. Over recent years, much progress has been achieved in standardising the way in which abortion services are provided. Before the introduction of national targets, performance indicators and commissioning guidelines specific to these services, services varied enormously between PCTs. For example, qualification for NHS funding might be different between women from different PCTs attending the same clinic for the same treatment. Similarly, differing clinical routines or reporting requirements might be imposed. This resulted in a service that was inequitable and inefficient. bpas is concerned that any changes in commissioning arrangements should not undermine the progress that has been made towards the development of a more equitable and accessible abortion service. 73 74 DH 2009 National Service Specific Specification for the Termination of Pregnancy Services http://www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyandGuidance/DH 111203 DH Abortion Statistics 2009 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Statistics/DH 11603 Health Committee: Evidence Ev w131 The Department of Health has for many years been considering establishing a booking service for later abortion, as recommended by the Chief Medical Officer in 2005.75 Less than 2% of the abortions performed per year are over 20 weeks gestation across England and Wales so GPs encounter women seeking abortion at this stage infrequently, if ever.76 As GPs will be responsible for identifying local health needs it is possible that there will be a lack of focus on this area and it will be the most vulnerable of women who suffer because of the lack of access of services. Removing abortion services, and specifically the commissioning of later abortion, from the responsibility of GP commissioning consortia, and giving that responsibility to the National Commissioning Board would remove the risk of these highly specialised and time-sensitive services being negatively affected by the move to GP commissioning. About bpas: Approximately 60,000 women each year have treatment for termination of pregnancy at bpas after attending for non-directive pregnancy counselling and information, which is monitored by and registered with the Department of Health. More than 90% of bpas work is carried out on behalf of the NHS. bpas is also a specialist provider for women presenting late in pregnancy for abortion, which involves relatively small numbers of patients, but which tend to be women in especially complex and sensitive circumstances. bpas undertakes 80% of the abortions taking place between 20 weeks’ gestation and 24 weeks gestation in the England and Wales each year, under contract to the NHS. Beyond 24 weeks’ gestation, all terminations in the UK take place in NHS premises. bpas is regulated by the Care Quality Commission, Healthcare Inspectorate Wales, NHS Quality Improvement Scotland and the Department of Health. bpas works closely on policy and training issues with the Royal College of Nursing, Royal College of Obstetricians and Gynaecologists, and the Faculty of Family Planning and Reproductive Health Care. bpas is a research-led organisation and facilitates academic and Department of Health research projects under the scrutiny of its independently-constituted Research Ethics Committee. The British Pregnancy Advisory Service (registered charity number 289145) was set up in 1968 after the implementation of the 1967 Abortion Act in order to provide services, train doctors and provide premises for safe legal abortion, at a time when the NHS not always able or prepared to provide abortion services. bpas’ abortion treatments, comprehensive counselling services, male and female contraceptive and sterilisation services and sexually transmitted infection testing and treatment are all not-for-profit. All of the charity’s services are conducted according to the relevant professional guidance under the scrutiny of bpas’ Clinical Governance Committee, which involves independent experts in its membership. For further information about the charity or its services, please see www.bpas.org. October 2010 Written evidence from LighterLife (COM 53) Executive Summary LighterLife programmes provide a multi-component, effective and cost efficient solution for people who are heavily obese and have large amounts of weight to lose. Problems with the current system of commissioning have meant that such programmes have not been used to their full potential in the service provision for obese and overweight people. The commissioning reforms proposed by the Coalition Government present a number of potential improvements to the system. However, questions remain about a number of areas. LighterLife would make the following recommendations: — Greater clarity is needed on NICE’s role under the proposed new commissioning arrangements, as well as the role of guidance from the NHS Commissioning Board. — The Quality and Outcomes Framework should create real incentives for GPs to help obese individuals achieve a healthy weight. — Clarity is needed on whether obesity will be included within the proposed Outcomes Framework, and whether or not the Commissioning Board will then provide guidance on how improved outcomes should be achieved. — Clarity should also be provided on the information systems and tools which will be established and used to ensure the promotion and extension of information to support patient choice. 75 76 DH 2005 An investigation into the British Pregnancy Advisory Service (BPAS) response to requests for late abortions: A report by the Chief Medical Officer. DH Abortion Statistics 2009 http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Statistics/DH 116039 Ev w132 Health Committee: Evidence — New Commissioning arrangements should encourage the entrance of new providers to the marketplace, particularly where they are able to offer a service which meets the needs of patients in the way current NHS services do not. — The role of the Public Health Service and local authorities needs clarifying, including exactly how much influence local authorities are likely to have over commissioning decisions. What distinctions will be drawn between general health improvement activities, and the commissioning of specific services such as weight management services. Introduction 1. LighterLife is a UK company offering weight loss and weight-management programmes for people who are clinically obese or overweight. Our programmes are based on the recognition that lasting weightmanagement success can only come by addressing the underlying reasons behind weight gain. Without this understanding, weight re-gain is highly likely. 2. The LighterLife programme was researched and developed over many years before finally being launched in 1996. In 2007 LighterLife for Men was established—the only national weight-management and coaching programme developed specifically for men. In November 2008 LighterLife Lite was launched—a weight-loss programme for overweight people, with one to three stone to lose (BMI 25–29.9). 3. LighterLife is supported by expert teams, including nursing and nutrition advisors, a medical director, psychotherapist support and a medical advisory board, comprising international experts in obesity, metabolism, endocrinology, clinical nutrition and psychology. The board’s role is to review all clinical aspects of LighterLife, and provide advice and direction to ensure compliance with best practice applicable to the use of very-low-calorie diets (VLCDs) and low-calorie diets (LCDs), current evidence-based research and health guidelines, including NICE guideline 43 on obesity. This ensures the best possible programmes are delivered, thus facilitating safe and effective weight loss. 4. We would like to thank the Health Select Committee for the opportunity to comment on the Coalition Government proposals for NHS Commissioning. While our comments will focus on the commissioning of services for obesity, we hope that these examples illustrate wider issues with both the current system of commissioning and the new proposals. LighterLife Programmes 5. LighterLife offers multi-component programmes, with increased physical activity, behavioural change and healthy eating being key features. The emphasis is on identifying personal psychological drivers of obesity and overweight. This enables individuals to achieve a healthier and manageable BMI by making sustainable changes to the way they eat, think and live. 6. Weight loss is initiated via either: — LighterLife Total—a VLCD for the obese (BMI ?30kg/m2) or for women/men with BMI ?28–29.9kg/m2 and a waist circumference 88cm/102cm, using four nutritionally complete Foodpacks per day; or — LighterLife Lite—an LCD for the overweight (BMI 25–29.9kg/m2), combining three nutritionally balanced Foodpacks (including soups, shakes, bars and porridge) per day with a meal from a selection of specified foods to provide key nutrients and energy during weight loss. 7. In conjunction, LighterLife Weight-Management Counsellors work with participants in single-sex, weekly groups (maximum 12) to facilitate techniques from transactional analysis and cognitive behavioural therapy. Developed for behavioural modification in weight management, these techniques aim to help participants understand their relationship with food and develop new skills to support healthier eating and lifestyle behaviours, including being more active. 8. Following weight loss, LighterLife’s Management Programme focuses on establishing a healthier lifestyle through the continued development of a healthier psychology. It empowers people with coping mechanisms developed in the weekly group meetings to support ongoing change, both physical and emotional. This enables sustainable weight management and a reduction in the risk of weight-associated co-morbidities. The Management Programme progresses individuals to a healthy, balanced and varied diet, consistent with current advice on healthy eating, and support meetings and weight checks are free for life. Why is Obesity an Issue? 9. There is a very pressing need to find an effective way to tackle obesity. In England, obesity is linked directly to around 9,000 premature adult deaths a year and obesity-related deaths are second only to smoking. In 2008, 66% of men and 57% of women were either overweight or obese, with 24% of all adults obese.77 Over 40 serious health conditions are linked to obesity, including type 2 diabetes, heart disease and certain cancers. 77 Statistics on obesity, physical activity and diet: England, 2010, The Health and Social Care Information Centre, p 13, downloadable from: http://www.ic.nhs.uk/webfiles/publications/opad10/Statistics on Obesity Physical Activity and Diet England 2010.pdf Health Committee: Evidence Ev w133 10. Since the Health Select Committee’s 2004 Obesity report, a number of initiatives have been launched at the national level in attempt to halt the UK’s growing obesity problem, but obesity levels continue to rise. The projections for obesity among UK adults remain broadly similar to those identified in the 2007 Foresight report: by 2050 obesity will affect 60% of men, 50% of women and 25% of children. 11. The Coalition Government has identified obesity as one of the biggest public health problems facing the UK. The Conservative party pledged prior to the General Election that they would put much more effort into prevention in an effort to avoid the rise of lifestyle-related diseases which cost the NHS large sums of money. Current Commissioning Problems, and Opportunities and Challenges Presented by the Coalition Proposals 12. Despite the attention and resources given to the issue of obesity, the current commissioning system has failed to provide most obese individuals with access to effective and sustainable solutions for their weight problems. There are a number of issues which need to be addressed: 13. Currently, weight management commissioning is based on a one-size-fits-all model, which lacks the flexibility necessary to make provisions for the most severely obese—those with a BMI of 40!. Most tenders for weight management services set maximum weight loss targets of 0.5-1kg a week, or a total weight loss of 5% of body weight. This reflects the NICE guidance on obesity,78 but ignores the fact that not only is it possible for severely obese patients to lose more weight than this safely, but that this is in fact often desirable to help such individuals achieve a healthy weight. Such people could benefit from having access to VLCDs, which are highly effective for patients with a large amount of weight to lose. Additionally, individuals on the LighterLife programme are able to benefit from the out-of-hours support which our Weight-Management Counsellors are able to provide, but which is often not available within NHS structures. 14. There is a lack of real knowledge among commissioners of the options available to their patients for effective and sustainable long term weight management. One of the key questions here is the role of NICE in providing advice to GPs to inform their commissioning decisions. David Willets, the Minister for Science and Innovation, has hinted that the role of NICE could be watered down, saying that, “NICE will, of course, continue to offer advice but ultimately GPs will have scope for responding to what their patients are demanding”.79 15. Recommendation: Greater clarity is needed on the exact role of NICE under the proposed new commissioning arrangements. While we welcome GPs having the flexibility to decide what is best for their patients, GPs need to have an accurate source of advice and guidance on which treatments are cost and clinically effective. Additionally, it would be useful to know the relative roles of NICE guidance, as opposed to their quality standards, and guidance from the NHS Commissioning Board. 16. There is also a need for appropriate information to be made available to support patient choice. To ensure that individuals are aware of the options to manage their weight, and to give them the tools to make healthy lifestyle choices, information should be available on different options for weight loss, including on the role that safe and effective LCD and VLCD programmes can play in helping people achieve and maintain a healthy weight. As an example, NHS Choices, the Government website that is designed to inform NHS users about the causes of and treatments for ill health, has previously contained out-of-date or inconsistent information about VLCD products. The availability of such information will also be necessary to support the use of personal health budgets. This links in with the question identified in the terms of reference on how will commissioners access the information and clinical expertise required to make high quality decisions about the shape of clinical services? 17. Recommendation: Clarity should also be provided on the information systems and tools which will be established and used to ensure the promotion and extension of information to support patient choice. 18. The quality and outcomes framework (QOF) does not, in its current form, provide GPs with a real incentive to help patients effectively manage their weight. Points are available under the QOF for GPs who keep a register of all patients in their practice who are considered obese, but there are no additional benefits for actually helping these patients to achieve and maintain a healthy weight. This weakens GPs incentives to take action and improve their knowledge and skills in this area. 19. Recommendation: The current review of the QOF should take this into account and create real incentives for GPs to help obese individuals achieve a healthy weight. 20. As part of the new proposals, an Outcomes Framework will be developed with the aim of the improving the overall performance of the NHS. The Commissioning Board will develop guidance on how best to meet the outcome goals. 78 79 NICE CG43: Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. http://www.guardian.co.uk/science/blog/2010/sep/17/willetts-science-funding-homeopathy Ev w134 Health Committee: Evidence 21. Recommendation: Clarity is needed on whether obesity will be included within the Outcomes Framework, and whether or not the Commissioning Board will then provide guidance on how improved outcomes should be achieved. To what extent will existing NICE guidance be taken into account when such guidance is developed? There is also a need to consider how far the development of quality standards will impact on this. 22. In general, the health service has not always been welcoming to private providers of weight management services and has not always recognised the useful role which they can play in reducing obesity. The Government has promised to make it easier for private providers to enter the market place, and we will be very interested to see how this works in practice. Answers to Specific Questions in the Terms of Reference 23. Will care providers be free to offer new solutions, which offer higher clinical quality, better patient experience or better value? 24. Private providers are able to make an important contribution to tackling obesity, by providing services which are able to effectively help the obese and overweight. However, commissioners have not always recognised the value that such services can provide. 25. Costing around £70 per week for LighterLife Total, our programmes are an extremely effective and cost efficient, as well as less intrusive, alternative to drugs or surgery for the obese. It is not financially feasible to provide bariatric surgery for everyone who meets the eligibility criteria, hence there is a need to find alternative solutions. Recent research has shown that nutritional interventions accompanied by appropriate support are able to provide equally effective weight loss as that achieved by gastric banding.80 26. LighterLife programmes also provide added value in that they offer out-of-hours support to those individuals on the programme; this support is ongoing both during and after the period of initial weight loss and assists the individuals in maintaining their weight loss in the long term. 27. Recommendation: Government should ensure that the new Commissioning arrangements allow room for new providers to enter the marketplace, particularly where they are able to offer a service which meets the needs of patients in the way current NHS services do not (for example, by providing ongoing support to achieve lasting outcomes and by providing an out-of-hours service). 28. How will commissioning interface with the Public Health Service? 29. The role of the new Public Health Service needs further clarification. Will the Public Health Service have a role to play in the commissioning of services that impact on public health, such as obesity? If so, how far will this overlap with the new GP commissioning consortia? Additionally, how will the Public Health Service interact with the Outcomes Framework? The Public Health Service will have a role in setting outcomes for public health issues, but it is not yet clear where exactly obesity will fit in. 30. Will the Public Health Service also have a role to play in providing commissioners with information on different available options for treatment for conditions such as obesity, which would help ensure that GPs are fully informed of all the options available to them and thus help improve the quality of care available? 31. What will be the role of local authorities in public health and commissioning decisions? 32. Equity and Excellence states that PCT health improvement functions will be transferred to local authorities, that Local Directors of Public Health will be jointly appointed by local authorities and the new Public Health Service, and that new “health and wellbeing boards” will work to join up the commissioning of local NHS services, social care and health improvement. However, they will not have any direct involvement in commissioning. 33. Clarification is needed on exactly how much influence local authorities are likely to have over commissioning decisions. We would also be interested to see what distinctions will be drawn between general health improvement activities, and the commissioning of specific services such as weight management services. This ties into the above question of the interface between commissioning and the public health service. 34. How will vulnerable groups of patients be provided for? 35. One of the biggest problems with commissioning to date has been the way in which services have failed to meet the needs of individuals with exceptional problems, such as individuals who are severely obese. We would be very keen to have clarification on how the new arrangements will ensure that there is sufficient provision for such patients. 36. LighterLife programmes are very useful in this regard due to the levels of support they are able to offer to individuals who have traditionally struggled to lose weight. The small, single-sex groups, the use of transactional analysis and cognitive behavioural therapy and the out-of-hours support are all extremely 80 Rolland, C, Hession, M, Murray, S, Wise, A and Broom, I. (2009), Randomized clinical trial of standard dietary treatment versus a low-carbohydrate/high-protein diet or the LighterLife Programme in the management of obesity. Journal of Diabetes, 1: 207–217. doi: 10.1111/j.1753-0407.2009.00033.x. Health Committee: Evidence Ev w135 helpful for those with severe weight problems; this level of support is generally not available from NHS providers. There is therefore a need for Commissioners to recognise the contribution that such providers can offer in helping vulnerable individuals with complex needs. Further Comments on the Coalition Plans for the Commissioning of Health Services 37. Proposals for reforming the health service contained within Equity and excellence have the potential to positively impact on the commissioning of health services for weight management. 38. The outcomes framework is intended to replace process targets with a set of focused outcomes against which the new NHS Commissioning Board will be held to account. There will be five outcome domains, which include preventing people from dying prematurely. Although obesity is not explicitly mentioned in this section, it does mention cardiovascular disease, the tackling of which will inevitably involve preventing obesity. 39. Such a focus on outcomes has the potential to improve the commissioning of weight management services by encouraging health professionals to focus on the interventions which will be most effective at helping obese people achieve and maintain a healthy weight. However, as the outcomes framework is not supposed to be top-down, it is not yet clear how exactly it will work and how effective it will be at improving outcomes. There are a number of questions which need to be answered in this area: — How will public health outcomes such as obesity, tobacco and smoking be included within the overall framework? — Will the focus on specific areas such as obesity be lost in such a broad general framework? — How can consistency in the quality of the commissioning be ensured across the board? — How will health professionals be rewarded for improving outcomes and held to account for failing to improve outcomes? — Outcomes in areas such as cardiovascular disease are affected by a number of factors, many of which (including obesity) are long term in nature. Therefore, it could take a number of years to see significant improvement, and the outcomes will only be clear in the longer term. How will quality be measured in the shorter term? 40. The move towards GP commissioning also has the potential to improve the commissioning of weight management services. The rationale behind this radical change in commissioning arrangements is that GPs are best placed to know the needs of their patients and therefore to understand which health services they need. One of the issues with commissioning arrangements at the moment is that they are done to a one-sizesfits-all model which does not adequately provide for patients with exceptional needs, such as the very obese. In theory, GP commissioning ought to alleviate this problem as the commissioners should be more aware of their patients and their needs. 41. Again, however, it is not clear how this will actually work in practice. It is not yet known exactly how big the GP consortiums which will replace primary care trusts will be, but if they end up being of a similar size and geographical reach to the PCTs, how will this allow GPs to focus more on the needs of individual patients. The Department of Health has itself stated that not all GPs will be expected to be involved in all areas of commissioning;81 the likelihood is that GPs will focus on particular areas of interest and expertise and that a small number of GPs will actually be involved in the commissioning of weight management services. Therefore, this reform will not necessarily mean that the people making decisions about commissioning are closer to the patients who will be affected by such decisions. Conclusion 42. This paper has attempted to highlight some of the main issues problems with the system of NHS commissioning at it stands at the moment, using the issue of obesity to highlight wider points. While the proposals outlined in the NHS White Paper, Equity and Excellence, present opportunities to potentially improve the system of commissioning, there are also some pitfalls and a number of areas in need of further clarification. October 2010 Written evidence from the National Association for Voluntary and Community Action (COM 54) NAVCA is the national voice of local support and development organisations in England. We champion voluntary and community action by supporting our members in their work with over 160,000 local charities and community groups. NAVCA believes that voluntary and community action is vital for vibrant and caring communities. 81 http://www.dh.gov.uk/prod consum dh/groups/dh digitalassets/documents/digitalasset/dh 119327.pdf Ev w136 Health Committee: Evidence We provide our members with networking opportunities, specialist advice, support, policy information and training. NAVCA is a vital bridge between local groups and national government. Our specialist teams take a lead on the issues that matter most to local support and development organisations. We influence national and local government policy to strengthen local voluntary and community action. NAVCA’s work is guided by the values of equality of opportunity, participation, co-operation and democratic involvement. In supporting the local voluntary and community sector we help to combat poverty, disadvantage and discrimination, and improve the quality of life for communities, groups and individuals. Introduction 1. NAVCA welcomes the opportunity to submit written evidence to the Health Committee inquiry into Commissioning. In our response we focus on the issues that are most relevant for our members, for local voluntary organisations and community groups and for excluded communities and individuals. These include: — wider outcomes and social value; — health inequalities; — the voluntary and community sectors role in commissioning; — grant funding; — commissioners’ skills and understanding of the sector; and — integration of health and social care. 2. We welcome ambitions that seek to make services more accountable to patients and the public, to provide meaningful choice, and to reduce bureaucracy and top-down control. What is less clear is how the reforms proposed in the White Paper ‘Equity and Excellence: Liberating the NHS’ will make these ambitions a reality. Wider Outcomes and Health Inequalities 3. We agree that health commissioning is too remote from patients and the public. We welcome an increased role for those with clinical expertise in the commissioning process, particularly where this will improve clinical pathways and the commissioning of acute services. However, we believe there is a risk that moving from PCT commissioning to GP consortia could swing too far in favour of a clinical model. 4. It is essential that health commissioning incorporates wider social outcomes and reduces health inequalities: it should not just focus on clinical interventions. Commissioning needs to focus both on geographical communities and communities of interest, as well as on individual patients. It is critical that there is continued investment in prevention and early intervention. 5. In a challenging financial climate, radical approaches are needed to support more innovative, cost effective interventions across agencies. Commissioning for improved health and well-being needs to be based on a total place approach, creating incentives and opportunities for local authorities and their partners to break down service silos, join up budgets, reduce costs and deliver better outcomes for local people. A joint approach is needed, looking across services, such as education, employment and housing, to commission for the improved health and well-being of local populations. However, the challenges of implementing this approach should not be underestimated, particularly where resources are already overstretched. 6. In order for Health and Wellbeing Boards to be effective in joining up the commissioning of local NHS services, social care, health improvement and the wider local authority agenda, they will need to have statutory powers to hold GP Consortia to account in this area. 7. The full value of what is being delivered in a contract needs to be evaluated and needs to be considered at the early stages of the commissioning cycle. NAVCA believes this demands a better understanding of social value in commissioning and procurement. Social value is the additional benefit to a wide community over and above the direct purchasing of services. We would welcome government support for the Private Member’s “Public Services (Social Enterprise and Social Value) Bill” introduced to parliament by Chris White MP. 8. Wider outcomes and community benefits should not be seen as the responsibility of the proposed Public Health Service alone but must be integrated into commissioning practice across the public sector. We are concerned that in seeking to increase clinical expertise in the commissioning of health services, a lack of commissioning skills and the need to achieve extreme productivity savings could lead to a focus on clinical interventions, acute care and short term savings at the expense of preventative services and cross community benefits. Health Committee: Evidence Ev w137 What voluntary organisations and community groups can contribute to commissioning and engagement with the sector? 9. Voluntary organisations, charities and community groups have a much wider role in the commissioning of public services than just being contracted to deliver those services. They also have a key role in helping to identify needs, particularly for marginalised groups, and in shaping service design. Intelligent commissioning needs to involve both patients and the wider community at the early stages of the commissioning cycle and ensure the needs of the most excluded are taken into account. Recently developed National Occupational Standards for Commissioners cover a range of skills including engaging with community partners. Our concern is that GPs have limited experience of working in a culture of public participation. In some areas our members have reported great difficulty in trying to engage with practice based commissioning. We have particular concerns that GPs are not involved in and often unaware of the neighbourhood level preventative work which is carried out by many small local voluntary sector organisations. 10. The voluntary and community sector has a long history of successfully engaging with the most excluded groups, communities and marginalised individuals. Success in this area is a result of being rooted in the local community, as well as having particular skills around engagement, involvement, partnerships and representation. Many of the most vulnerable citizens are not registered with a GP: it is the voluntary and community sector which often works with these people. 11. NAVCA’s members support and champion local voluntary organisations and community groups. We call them support and development organisations, locally they are often known as CVS or Voluntary Action. These organisations are well placed to take a greater role in engaging with local communities and identifying their needs. They already have many of the skills required to identify gaps in the provision of community services, to develop service specifications or to contribute to training GP Consortia in public participation and working in partnership with the voluntary and community sector. 12. Local support and development organisations also have skills and experience in bringing together commissioners and local groups. This is evidenced in the directories research project which looked at the use and development of supplier directories in the voluntary and community sector, see Third Sector Directories Research (North West Region-wide) July 20101 13. Bringing commissioning closer to local communities should result in increased opportunities for the voluntary and community sector to engage in sharing their expertise on local health priorities, setting outcomes and designing services to meet need. If meaningful engagement is to continue, local support and development organisations will have an essential role to play, developing links and building bridges between local groups, communities and GP Consortia. At present, our members often receive funding for this work from PCTs. This may be through grant aid, enabling a specialist health partnership officer to be employed, grants for specific projects or contracts to deliver services around partnership working, engagement and representation. With commissioning structures changing, it is essential that this wide-ranging engagement work continues to ensure that the benefits of working with the voluntary sector are realised and that commissioning is effective in reducing health inequalities. 14. Health and Wellbeing Boards are seen as the vehicle for aligning health commissioning with wider outcomes, therefore it is essential that they have appropriate voluntary and community sector representation. GP Consortia will need to fully engage with and integrate into these boards and other local strategic partnerships. 15. One of the proposed functions of the Health and Wellbeing Boards is to undertake a scrutiny role for major service re-design. However, scrutiny functions need to be separate from the original decision making bodies and appropriate checks and balances are needed across the system to ensure accountability for decisions, to ensure that local politics do not inappropriately influence decision-making and that decisions are taken at the right level. 16. We value the intention to strengthen the patient and public voice through local HealthWatch and to increase accountability to patients and local communities. We believe that in order for this to be successful HealthWatch should be commissioned and delivered at a local level by organisations that are based within and understand local communities. Independent research undertaken by Warwick Business School, published in January 2010,82 indicates that where the contracts for LINks host organisations are held by local organisations, the LINk has been better able to represent the core values of the local community and engage with disadvantaged people. HealthWatch should focus not only on strengthening the involvement of individual patients, but provide an increased role for the engagement of communities in both operational and strategic commissioning. 17. We are concerned that reorganising commissioning structures, as proposed in the White Paper, will incur significant additional costs and risk at a time when public finances are under great pressure and resources are desperately needed for service delivery. 82 Local Involvement Networks (LINks) Local Authorities Research Consortium Research Project Report Jan 2010. Ev w138 Health Committee: Evidence 18. We are concerned that the process of transferring commissioning from PCTs to GP consortia could in effect become a very expensive rebranding exercise. It is difficult to see how this reconfiguration will reduce overhead costs. In addition to the financial cost of buying in commissioning support services, there is a risk that commissioning could take a step backwards and revert to overly bureaucratic and disproportionate practices, particularly in regards to procurement. 19. The previous Health Committee report on commissioning suggested that commissioning weaknesses remained 20 years after the introduction of the purchaser/provider split. However, improvements in commissioning have been made. GP commissioning consortia will have fewer skills and less experience in commissioning than PCTs. It is likely that they will need to buy these skills in. In addition to needing access to wide ranging commissioning skills, GP consortia will be bound by other public duties such as equalities duties. We expect that this is another area where they will need to buy in outside specialist support. 20. Inexperienced Commissioners result in bureaucratic and risk adverse procurement processes being followed when they do not need to be. For example full Part A processes are often followed for Part B or below threshold contracts. This increases procurement costs and therefore reduces the funding available to frontline services. With PCTs, NAVCA members have started to see some improvements in this practice. We believe improvements are due to the increasing skill and confidence of commissioners, who are seeking more innovative and cost effective ways to secure services and who are not letting themselves be overly-controlled by procurement departments. We need to ensure that the move to GP commissioning consortia does not create a return to overly bureaucratic, inefficient procurement practice, owing to a lack of commissioning skills within the consortia. Where these skills are bought in there is a risk that expensive, risk adverse practices could once again dominate. 21. We are also concerned that risk adverse practice and a lack of understanding around procurement regulations could result in reduced use of grant funding. A number of recent guidance documents published by both the Department of Health and other government departments have made it clear that contracting should not inappropriately replace grant funding. There continues to be a place for grants in a mixed economy of funding. Competitive tendering and outcomes based, payment by results contracting is not the most appropriate or efficient delivery mechanism for all services. Local community based organisations, relying on volunteer effort, can deliver very cost effective preventative support, which can reduce the need for costly health and social care interventions, such as emergency hospital admissions. If we are to see a growth in innovation and increased choice for patients, grants are also an important mechanism in stimulating the market. 22. We are also concerned that some GP Commissioning Consortia may seek to simplify their commissioning role by awarding larger contracts to a reduced number of suppliers. We would argue that a number of services, especially community based provision, are more effectively delivered by local organisations. If only larger contracts are tendered, many valuable and cost effective voluntary and community sector services would be lost, thus reducing patient choice. GP Consortia will need to have the skills to recognise where outcomes can be better achieved by procuring services in smaller scale contracts or lots. 23. If large contracts are to be awarded to prime-contractors, then we would expect some form of protection to be developed for smaller sub-contractors, including recognition that it is often more time consuming and expensive to work with marginalised communities or with those with multiple or complex needs. Protection of sub-contractors needs to be incorporated into contracts as well as a framework to guide good practice, like the DWP’s Merlin Standard. If these safeguards are not put in place, an unfair proportion of risk could be borne by those further down the supply chain, and the most vulnerable patients could be excluded from services. Difficulties of working with GP consortia that are not aligned to local authority boundaries 24. It will be difficult to align health and social care commissioning where GP Consortia cover different boundaries to those covered by local authorities. Whilst in some areas this has continued to be an issue for PCT and Local Authority joint commissioning, many areas currently enjoy coterminous boundaries. We are concerned that joint commissioning will be made more difficult and inefficient if GP consortia have no prescribed geographical coverage. This will also present problems and inefficiencies for the voluntary and community sector in engaging in partnership working. The reasons why PCTs were reduced in number and aligned more closely to local authority boundaries should not be ignored. Where will challenges be directed? 25. From what we understand under the proposed changes Monitor and the NHS Commissioning Board would be responsible for ensuring transparency and fairness in commissioning decisions. We are concerned that, if these bodies are insufficiently resourced to operate effectively at a regional or local level, poor practice could go unchecked and providers could have difficulty in challenging bad practice at a local level. Dispute resolution procedures in the form of Co-operation and Competition panels currently exist at PCT and SHA level, as well as at national level, ensuring accessibility for local providers. Health Committee: Evidence Ev w139 Conclusion 26. Whilst we support the stated aims of the White Paper, of putting patients and the public first, improving accountability and healthcare outcomes and increasing efficiency, we have many concerns about the practical implications of the proposals. Not least, we are concerned that over recent years the NHS has suffered from too many reorganisations, that the proposed rate of change may be too rapid and that the increased risks and costs involved in implementing these fundamental reforms, are too high. We are particularly concerned to ensure that there are no unintended negative consequences from the reforms, that the progress which has been made with respect to the role of the voluntary and community sector is built on, and that the health inequalities for most disadvantaged groups in our communities do not increase. October 2010 Written evidence from the County Councils Network (COM 55) 1. The County Councils Network (CCN) is a cross-party special interest group of the Local Government Association which speaks, develops policy and shares best practice for the County family of local authorities, whether unitary or upper tier. CCN’s 38 member councils, with over 2,500 Councillors, serve 24 million people over 45 thousand square miles or 87% of England. 2. Health and Social Care are important issues for our member authorities and the communities they serve. CCN therefore welcomes the opportunity to engage with the CLG Select Committee’s inquiry and contribute to the debate about the implementation of the policies for commissioning outlined in government’s White Paper Equity and Excellence: Liberating the NHS. This submission has been developed following dialogue with CCN member councils including Leaders, Cabinet Members for Health and Adult Social Care and engagement with the wider local government sector, including the LGA Group whose submission we also strongly endorse. 3. The restructuring outlined in the White Paper raises a number of issues for CCN member authorities. The following response outlines these issues in relation to commissioning and the wider implications of the White Paper proposals. 4. CCN supports the further integration of health and social care services through joint commissioning. It is essential that this builds on existing good practice where GPs, community health and social care work together to plan and commission support that delivers improved health and wellbeing outcomes. 5. However CCN does have some concerns particularly regarding the proposals for the role of GPs in the commissioning process. 6. Not only have GPs expressed limited enthusiasm to take on a strategic commissioning role but, at least in the short term it is open to question whether GP consortia will have the capacity or capability to undertake this role effectively 7. It is essential that local authorities are genuine partners in the commissioning process to ensure that the potential for joining up at the local level is realised, especially where there is little historical engagement with GPs or where the development of practice-based commissioning is limited. 8. Local authorities have the knowledge and experience to take on the strategic commissioning responsibilities for all GP consortia in the locality. This would maximise the potential for joining up commissioning across health, social care and children’s services, would enable a proper strategic overview for an area and link to a place based approach to service delivery. 9. Local authorities can also support GP consortia in the commissioning of specific services where GPs have limited experience or knowledge, including people with mental health problems, drug and alcohol dependency, learning disabilities as well as homeless people and carers. 10. Local authorities can also offer support to GP consortia through the provision of back office functions such as HR, pay roll, IT support and expertise on aspects of quality assurance, data collection and performance monitoring. 11. There is also no requirement for GPs to form consortia that are coterminous with local authorities. Indeed the letter from the Secretary of State for Health to all General Practitioners in England (24 September) makes clear that this is not a requirement “Depending on your circumstances it may be appropriate to structure consortia across local authority boundaries, opt for a small consortium which commissions some care through a pan-consortia arrangement, or combine with a large number other GP practices to create a single, large consortium”. However, if consortia do not relate to upper tier local authority areas it would undoubtedly make joint commissioning, pooling of resources and service effectiveness more challenging to deliver. It is also difficult to see how place based budgeting for a local area would work in these circumstances. 12. Whilst not specifically issues relating directly to commissioning there are also a number of other issues which will impact on commissioning and the effective delivery of improved outcomes. Ev w140 Health Committee: Evidence Democratic Accountability and Effective Scrutiny 13. CCN supports the creation of Health and Wellbeing Boards (HWBs) to enable local authorities, with partners, to take a more strategic approach to promoting integration across health and adult social care, children’s services and the wider place agenda however. We also support the proposal that HWBs should be a statutory requirement and that they should be positioned at the unitary and upper-tier level. 14. However, whilst local authorities are set to receive additional responsibilities to ensure effective local integration these proposals do not necessarily deliver the powers commensurate with such responsibility. 15. CCN believes that to ensure more local democratic accountability and better local integration HWBs require further powers and responsibilities and support the LGA’s proposals outlined in their response. 16. The White paper proposes that Health and Well-being Boards (HWBs) will have a scrutiny function, and therefore Health Overview and Scrutiny Committees (HOSCs) will cease to exist. CCN members are concerned that the current proposals reflect a fundamental misunderstanding of the distinction between executive and scrutiny roles in local government. 17. Health and Well-being Boards are expected to include all the key commissioners in a local area and will be expected to deal with commissioning strategies and performance. This is clearly an executive function which is in conflict with the role of scrutiny currently provided by HOSCs and the separation of executive and scrutiny functions. 18. It is not appropriate for Health and Well-being Boards to have both the executive and scrutiny functions as they cannot effectively scrutinise their own decisions. The introduction of HOSCs has made a real difference in championing the public interest and challenging health commissioners and providers to deliver better health services. CCN believes that is a real need for an independent scrutiny function to be retained. This will ensure that the scrutiny of health services is transparent and has a strong element of democratically accountable oversight, independent of the health service, in order to ensure that it is responsive to the local public’s needs. This must build on local authorities’ experience of HOSCs, working with strategic partnerships, Joint Strategic Needs Assessments, close work with PCTs’ public health teams and place based approaches to service delivery. 19. There are also other issues of democratic accountability with GPs, who have the status of independent contractors to the NHS, being given significant freedoms but directly accountable only to the new NHS Commissioning Board and not locally. This is clearly at odds with the imperative for local accountability and the flexibility required to meet local needs within a democratic structure. 20. CCN agrees that Health and Well-being Boards must be position at the upper-tier level (reflecting responsibility for Adult Social Care). However it will be important to reflect the context in two-tier areas where some functions that impact of health improvement (such as Leisure, Housing and Environmental Health) are District level responsibilities.. Resources 21. There are also a number of issues relating to resourcing of these proposals which will also affect the commissioning and delivery of improved outcomes. 22. Whilst the government recognises that councils will require additional resources to undertake this enhanced public health role the imposition of a ring-fence runs counter to the place-based approach advocated by CCN in our manifesto and by the LG Group. Mainstream services such as housing, early years support, transport, leisure and recreation and social care make a far more significant contribution to public health and health improvement than the marginal resource in the ring-fenced budget. 23. To the extent that a fundamental aim of the reforms is to save 45% of NHS management costs, there has to be a risk of significant cost shunting towards the GP consortia and local authorities. Councils will need to be cautious with regard to the loss of PCT and SHA capacity, a proposed cap on GP consortia spend on analysis, engagement and commissioning, and the promise of “no bailouts to organisations which overspend public budgets”. Whilst local authorities have always worked with this system, this will be a new position for health colleagues who have been able to operate with deficits in the past. 24. In CCN member councils many Directors of Public Health are already joint appointments. With this now becoming a statutory duty further clarity will be needed around the arrangements for the employment of public health teams and the accountability of the Local Director of Public Health. Outcomes Framework 25. A focus on outcomes rather than targets, particularly with the commitment to integrate health and social care outcomes into the quality standards, must be welcome. However, it is essential that local areas are able to develop their own outcome measures based on the needs and expectations of local people. It is also not clear how this will fit with the development of the national outcome framework and link to a place based approach to priority and budget setting. Health Committee: Evidence Ev w141 26. It is also important that any framework incentivises cross agency working and has a clear patient focus in order to deliver outcomes which require integrated care across the NHS, public health and social care services. The potential opportunity for delivering better outcomes in a more efficient and effective way requires a fundamental shift in mindset towards a greater focus on prevention outcomes and the necessary incentives and aligning of budgets across organisations to achieve this. HealthWatch 27. We welcome the White Paper proposals on enhancing the voice of local people, building on existing mechanisms for engagement, through the commissioning of a complaints and advocacy service. However CCN believes that this should not be prescriptive and that local authorities should be free to commission these services from the most appropriate provider (such as CAB) rather than being limited to commissioning them from either their local Health Watch or National Health Watch. 28. Furthermore, the current proposals for existing LINks to become Local Health Watch with enhanced responsibilities poses a number of concerns, including: — funding for existing LINks runs out at the end of March 2011—there is currently no commitment from the Department of Health to provide funding after this time—leaving local authorities with a potentially open ended commitment; and — responsibilities are still very health focused and need to be broadened to include social care issues if HealthWatch are to act as an advocate for local people. Conclusion 29. CCN is committed to working with our member councils to ensure the delivery of improved health and well-being outcomes. We have submitted a response to the Department of Health White Paper consultation outlining the same issues and will also be responding to the further consultations in due course. 30. CCN strongly believes that by addressing the points raised in our response the effectiveness of the proposals set out in the Health White Paper would be significantly enhanced and will deliver better outcomes for individuals and communities. October 2010 Written evidence from Genetic Alliance UK (COM 56) Summary — The provision of high quality specialised services is vital to the members of Genetic Alliance UK. — Services currently commissioned at regional level and at national level should be commissioned centrally by the new NHS Commissioning Board. — The budget for specialised commissioning should be flexible and should allow for the expansion of the portfolio of specialised services to ensure that services are commissioned at the most appropriate level in the NHS. — Membership of the NHS Commissioning Board should include a designated expert on specialised commissioning and expert patient representation. Introduction 1. Genetic Alliance UK (formerly Genetic Interest Group) is the national charity supporting all those affected by genetic conditions. Genetic Alliance UK aims to improve the lives of people affected by genetic conditions by ensuring that high quality services and information are available to all who need them. Our membership represents more than 130 voluntary organisations working for a wide range of conditions, many of which pose complex health and social care needs. 2. A baby with a genetic condition is born every half an hour in the UK; of these only four in 10 will have their condition cured or ameliorated, the rest will die or live with a lifelong chronic condition. Most of the patients and families supported by our members are frequent users of the NHS and require good quality coordinated care from a wide variety of local, regional and national centres in many areas of specialisation. Specialised Commissioning 3. Specialised services, commissioned currently either at a national or regional level are vital to our members. Of the 45 services commissioned nationally, six are services specific to genetic conditions, and 27 of the remainder frequently treat those affected by genetic disorders; and of the 34 defined services in the Specialised Services National Definition Set (SSNDS), regionally commissioned specialised services, four are services specific to genetic conditions, and 28 of the remainder frequently treat those affected by genetic conditions. Many patients with a genetic condition will need to use more than one of these services. Ev w142 Health Committee: Evidence 4. As the Health Select Committee has recognised in its Fourth Report of Session 2009–10, entitled “Commissioning”, the recommendations of Sir David Carter’s 2007 review of specialised commissioning have not been fully implemented. Specialised services commissioned regionally, those in the SSNDS, are delivered to varying degrees across the country (from a total absence of a particular service, to proper provision of the service) according to how and whether the relevant Specialist Commissioning Group (SCG) has commissioned the relevant service. Structure of Specialised Commissioning 5. Genetic Alliance UK welcomes proposals in the White Paper Equity and excellence: Liberating the NHS, to give responsibility for commissioning of specialised services to the NHS Commissioning Board, separating this task from the GP consortia. There is little further detail in the White Paper and auxiliary consultation document Liberating the NHS: commissioning for patients as to how specialised commissioning will be organised in the future though. 6. The National Specialised Commissioning Group (NSCG), NHS Specialised Services (NSS) and the Advisory Group on National Specialised Services (AGNSS), have amassed a considerable amount of experience and expertise in this area. Genetic Alliance UK would like to see this expertise preserved, and housed within the new body overseeing specialised commissioning to ensure continuity and consistency. 7. The proposed new commissioning structure for England contains no analogous bodies to the Strategic Healthcare Authorities, SCGs, and Primary Care Trusts. In our view, there is therefore no logical reason for retaining a separate regional layer for commissioning specialist services. All services in the SSNDS, currently commissioned on a regional basis should be commissioned on a national basis. Demand and need are constant across the population, and the critical mass necessary for effective patient care and efficient use of resources is best achieved with a common framework across the country. 8. A centralised system for the commissioning and planning of services in the SSNDS will allow choice of geographic distribution of centres appropriate for their catchment population; will reduce inequality in the current system caused differing SCG attitudes; and will allow contracts with care providers to be negotiated with one body. Budget for Specialised Services and Designation of Specialised Services 9. The current budget for specialised commissioning, ie the budget for services commissioned by SCGs and the budget for services commissioned by NSS should be preserved and protected, with an additional provision to reflect the fact that SCGs do not currently commission the full portfolio of services in the SSNDS. This fund should be allocated directly to the NHS Commissioning Board. Any other service or group of services that will also be commissioned by the NHS Commissioning Board should have a separate budget. 10. The budget assigned for specialised commissioning should be flexible and allow expansion when new candidate services for SSNDS designation or national commissioning appear. Those services in the SSNDS which care for those affected by conditions grouped according to their pathologies, such as the specialised neurosciences services, renal services, endocrinology services and services for metabolic disorders, should be funded in such a way that they are able to provide new services to those affected by particular conditions, as an alternative to an addition to the SSNDS or a new nationally commissioned service. This, more flexible funding strategy would go some way towards solving one of the problems with the current system; that of a long queue of services applying for nationally commissioned status. 11. Just as there should be measures in place to decommission services that are not working; there should be measures in place which ensure that services are being commissioned at the level most appropriate to the population requiring the service. As populations and health service provision evolve, this level is likely to change for certain services. Very specialised services may become more widely used in the future, and commonly used services may become unnecessary for the majority of the population. NHS Commissioning Board 12. To carry out its role, the NHS Commissioning Board must have a good understanding of the users of the systems it presides over. Genetic Alliance UK would like to see a position for a designated expert on specialised commissioning. Specialised commissioning is important, but it is often poorly understood by providers of local, high volume healthcare. It is important that the specialised commissioning structures, which have improved so much over the past few years, have an advocate on the NHS Commissioning Board. This member should work closely with the National Clinical Director for rare diseases, as proposed in the Chief Medical Officer’s report of 2009. 13. GP consortia should have representation on committees responsible for the commissioning of specialised services. There should be means by which GP consortia can propose to this body services that might be more appropriately commissioned by the NHS Commissioning Board for adoption as a specialised service. Health Committee: Evidence Ev w143 14. In many cases, the argument for the arrangements for commissioning a specialised service on a national level are irrefutable, and an enormous benefit in terms of quality of service and economies of scale. In these cases the GP consortia representatives on the NHS Commissioning Board should ensure that they communicate these benefits back to consortia. 15. Patients and carers have a great deal of expertise to contribute to designing and improving healthcare delivery. Genetic Alliance UK believes there should be expert patient involvement at NHS Commissioning Board membership level, and that there should be consultation of appropriate patient organisations according to specific commissioning decisions. 16. Members of smaller patient organisations are busy, and tend to be staffed by volunteers with many other commitments. Commissioners should ensure that there is sufficient flexibility in meeting and consultation arrangements to allow groups such as these to contribute. 17. Consideration should be given to how volunteers will be recompensed for their time spent contributing to commissioning decisions. A stipend will facilitate participation from members of voluntary organisations, and place patients and carers on a level playing field with their fellow contributors. Conclusion 18. It is the view of Genetic Alliance UK that the planned reorganisation of commissioning in England is an opportunity to strengthen the commissioning of specialised services. We hope this opportunity will be taken. October 2010 Written evidence from Cambridge Weight Plan (COM 57) Summary Cambridge Weight Plan offers a number of flexible weight management programmes, which provide the overweight and obese with an effective and sustainable way to achieve a healthy weight. Obesity is one of the key public health problems today. However, commissioning in this area has not proved adequate to effectively tackle this problem. While the Coalition proposals to overhaul the commissioning system and replace it with a GP-led system could help improve the commissioning of services, there are a number of areas needing clarification. We would recommend the following: — The tendering process needs to be sufficiently flexible to allow for innovative solutions. Also, when tendering for weight management services; flexible multi-component programmes should be considered the highest standard. Sufficient use should be made of the opportunities offered by Personal Health Budgets (PHB), which will now become more widely available. — The Government should provide further clarification on the role of the Public Health services and local authorities in the new commissioning arrangements. — The new commissioning arrangements need to provide room for new providers to enter the market place, particularly where they are able to offer something that is lacking from the current service provisions. — The Department of Health should provide clarity on the expected role of NICE once the new commissioning arrangements are in place, in order to ensure that GPs have somewhere they can go to for clear advice. The Department of Health should also take steps to ensure that GPs have access to information on how to manage patients during effective weight loss. — Obesity should be specifically included within the Outcomes Framework, in order to ensure that there is sufficient focus on a condition which has knock-on effects on many other conditions. Introduction 1. Cambridge Weight Plan (CWP) offers a variety of weight management options, including Low Calorie Diet (LCD) and Very Low Calorie Diet (VLCD) programmes, for those who are overweight and clinically obese. They are primarily aimed at those with severe weight problems, typically with a Body Mass Index (BMI) greater than 30. 2. We offer flexible programme options between 415 and 1500 kcal/day, all using a nutritionally balanced formula food as their foundation. The products contain carefully formulated amounts of energy, protein, carbohydrate, fat, fibre and all essential micro-nutrients, and at least 100% of the RDA of essential vitamins and minerals when used as a VLCD. 3. CWP would like to thank the Health Select Committee for this opportunity to comment on the proposals contained within the NHS White Paper, Equity and Excellence: Liberating the NHS. Ev w144 Health Committee: Evidence How Cambridge Weight Plan programmes work 4. Cambridge Weight Plan products and programmes are only available through specially trained and accredited Cambridge Consultants, who provide initial screening and advice to clients. The Consultants provide individual and/or group support throughout the client’s diet 24 hours a day, seven days a week, which is a major factor in maintaining motivation and achieving long-term maintenance of weight loss. 5. Protocols are in place to ensure that clients only participate in appropriate programmes, to ensure that they do not have any listed contraindications, and to refer the client to their GP if necessary. All clients are also strongly encouraged to see their GP before commencing a programme. 6. The CWP programmes use a four-stage process: preparation, losing weight, stabilising weight, and weight maintenance. 7. During the weight loss stage, clients with one stone or more weight to lose can use a very low-calorie diet programme, completely avoiding conventional foods for an appropriate period of time. These are replaced with three or four specially formulated, nutritionally balanced soups, shakes, porridges or meal bars a day. This approach allows participants to take a complete break from traditional food, with which they have a difficult relationship. 8. A slightly higher energy very low-calorie diet (615 kcal/day) allows one conventional meal a day. In accordance with the NICE Obesity Guidance, very low-calorie diets can be used for up to 12 weeks at a time. 9. There is a further range of Low Calorie Diet programmes, in the range of 810–1,200 kcal/day, for people needing to lose less weight or choosing to lose weight more gradually. These programmes use a mixture of CWP products and conventional meals. They are organised into different steps with the number of calories increasing at each step. 10. Additionally, clients follow Fitness with Cambridge, a stepped programme of physical activity which encourages them to develop appropriate activity and increase fitness levels. This can range from easy to do stretches to full aerobic movements and pool exercises. Obesity and Commissioning 11. Obesity remains a major and growing problem in the UK. According to data released by the Health and Social Care Information Centre in February 2010, over two thirds of men and half of women in England are overweight or obese. The 2007 Foresight Report on obesity predicted that by 2050 obesity could affect 60% of adult men, 50% of adult women and 25% of children. The resulting costs to the NHS could be in the region of £10 billion a year, with wider costs to society reaching nearly £50 billion a year. This is due to the large number of serious health conditions associated with obesity such as heart disease, type 2 diabetes, stroke, cardiovascular disease, osteoarthritis, gallstones, sleep apnoea and increased risk of cancer. These projections are backed up by a more recent report from the National Heart Forum, published in February 2010. 12. For obesity to be efficiently tackled, effective commissioning arrangements for weight management services need to be in place. At present, this is not the case. This section outlines some of the current problems which we have identified through our experiences, and identifies the challenges and opportunities presented by the proposed new arrangements. 13. How will GPs engage with their colleagues within a consortium and how will consortia engage with the wider clinical community? 14. Switching from the current commissioning system to one which is led by GPs has the potential to improve the overall quality of commissioning but only if the current fundamental problems, as identified in the Health Select Committee’s previous report on this topic, are addressed. 15. The switch to GP-led commissioning will hopefully lead to greater clinical involvement in commissioning, and mean that decisions about health services are made by those who have greater knowledge about patients’ individual needs. While this is a sound idea in theory, it is still unclear how commissioning decisions will actually be made in practice. The Department of Health has said that not all GPs will be expected to be involved in all areas of commissioning;83 the probability is that GPs will focus on particular areas and that a small number of GPs will actually be involved in the commissioning of weight management services. This will not necessarily lead to better decision making than when decisions are made by a small number of officials. 16. The mere action of commissioning particular services will inevitably lead to a restriction of choice as one particular service may not be meeting the individual needs of all patients. 17. To counter this effect, a number of points should be taken into account. Firstly, the tendering process needs to be sufficiently flexible to allow for innovative solutions. Secondly, when tendering for weight management services, flexible multi-component programmes should be considered the highest standard. Thirdly, sufficient use should be made of the opportunities offered by Personal Health Budgets (PHB), which will now become more widely available. 83 http://www.dh.gov.uk/prod consum dh/groups/dh digitalassets/documents/digitalasset/dh 119327.pdf Health Committee: Evidence Ev w145 18. How will commissioners access the information and clinical expertise required to make high quality decisions about the shape of clinical services? 19. At present, neither GPs nor other commissioners have sufficient current knowledge of the options available for individuals looking to achieve a healthy weight, particularly interventions which do not involve drugs and surgery. 20. There is a gap in the spectrum of therapeutic options for treating obesity between smaller weight losses following use of obesity drugs (8–10kg) and larger weight losses following bariatric surgery (25–40kg). That gap can be filled in a therapeutically effective, economic manner by LCD and VLCD programmes. 21. Dietary interventions, such as VLCDs, can indeed provide an effective and economic option for those looking to lose large amounts of weight, but at present tools are not sufficiently available for commissioners to evaluate the effectiveness of particular options to fulfil the individual needs of their patients. 22. NICE obviously has a role to play here in providing guidance, and indeed they have produced several pieces of guidance on obesity. However, these are general in nature and do not provide GPs or commissioners with the knowledge to evaluate individual interventions. There has also been some question about what the role of NICE will be in the future. While the Government has signified its commitment to NICE by pledging to place it on a firmer statutory footing, Ministers have also called into question the extent to which health professionals will be expected to follow the guidance handed down by NICE. In addition, NICE guidance currently does not get updated frequently enough to ensure that it provides up to date and accurate advice. 23. This lack of knowledge also extends to how patients should be managed once they are in the process of losing weight, including how to manage individuals with conditions affected by their weight such as type 2 diabetes (eg adjusting medication). There has been a lack of focus on structured management of overweight and obese individuals in primary care, and there is a need for clear guidelines on this. In order to help address this, CWP collaborated with the National Obesity Forum to produce Medical Management during Effective Weight Loss, a booklet which provides GPs with a resource that helps them to give the best advice to the growing number of patients requiring medical management during effective weight loss. 24. Accurate and comprehensive guidance is also important to patients, especially if the new arrangements are to achieve their aim of empowering patients and allowing them to be more involved in decisions about their health for example by promoting the use of PHBs. NHS Choices provides an excellent resource for individuals seeking advice and information on a wide range of health issues. However, there is a need to ensure that, for issues such as obesity, the information provided is fully comprehensive, up-to-date, and makes use of the latest research. 25. The Department of Health should provide clarity on the expected role of NICE once the new commissioning arrangements are in place, in order to ensure that GPs have somewhere they can go to for clear advice. More clarity is also needed on the role that NICE guidance, as opposed to NICE quality standards, will play in the development of commissioning guidance by the Commissioning Board. The Department of Health should also take steps to ensure that GPs have access to information on how to manage patients during effective weight loss. In addition, further clarity is needed on the tools that the Commissioning Board will use to promote and extend information to support meaningful patient choices. 26. Will care providers be free to offer new solutions which offer higher clinical quality, better patient experience or better value? 27. CWP programmes can play an important role in supporting the health service to tackle obesity. As well as offering effective and nutritionally sound weight loss at a predictable rate and encouraging patients to take more personal responsibility for addressing their condition, re-education towards longer term healthy eating habits and lifestyle change are essential elements of all CWP programmes. Therefore, they offer a real opportunity to help obese people achieve significant weight loss and, importantly, sustain it in the longer term, thereby improving their overall health and reducing their chance of suffering from obesity related illnesses. 28. VLCDs and LCDs are cheaper than both drugs and surgery, less invasive and without the potential long term consequences of those two therapies. 29. A breakdown of the comparative cost of treating obesity with a nutritional interventional programme based around a very low calorie diet and treating obesity with a course of drugs is below. (a) 12 weeks VLCD (all product and service) x £500 (b) 12 weeks drug treatment x £628 Based on one initial 17.2 minute GP consultation (£52) and one 11.7 minute follow-up with the GP at three months, plus five fortnightly 30 minute consultations with practise nurse (5 x £14 %£70) plus an average drug treatment cost, Orlistat of £40 per week (12 x £40% £480)84 (c) Weight loss in 12 weeks, cost per kg lost — VLCD: 12–18kg £41.60–£27.80/kg 84 Unit Costs of Health and Social Care 2008 compiled by Lesley Curtis, Personal and Social Services Research Unit, University of Kent Weight-loss outcomes: a systematic review and a meta-analysis of weight-loss clinical trials with a minimum 1-year follow-up Franz MJ etal JADA 2007; 107: 1755–1767. Ev w146 Health Committee: Evidence — Drug treatment: 6kg £106/kg 30. An academic review of costs of obesity treatments is currently underway at a major British University and a preliminary report may be available by the end of 2010. 31. CWP does have some experience of providing services to the NHS, and we have a number of partnerships with health services in place around the country. However, to date, commissioners have not fully acknowledged the contribution that private providers of weight management services can bring, meaning that our work within the health service has not yet been developed to its full potential. We would hope that once the new commissioning arrangements are in place, there will be more openness to a variety of providers from all sectors. 32. The new commissioning arrangements need to provide room for new providers to enter the market place, particularly where they are able to offer something supported by solid scientific evidence but that is lacking from the current service provisions. Private weight management programmes, such as CWP, can make a real contribution to correcting the problem of obesity, by providing scientifically proven weight loss and weight maintenance programmes which are cost effective and better value than much of existing provision. 33. How will commissioning interface with the Public Health Service? / What will be the role of local authorities in public health and commissioning decisions? 34. There are a number of questions to be asked about both of these areas. In particular, it would be useful to have further information on the exact role that both the Public Health Service and local authorities will play in commissioning once this becomes the responsibility of GPs. Will the Public Health Service and local authorities have a role in providing information and advice on particular topics, such as obesity? 35. According to Equity and Excellence, health improvement functions currently carried out by PCTs will become the responsibility of local authorities. In addition, Local Directors of Public Health will be appointed and new health and wellbeing boards will work to join up the commissioning of local NHS services, social care and health improvement. 36. This does leave some questions about how the relationship between the Public Health Service and local authorities will work in practice. We would also be interested to know to what extent the responsibility for health improvement functions will allow local authorities to play a role in the commissioning of specific services such as weight management services, or whether their role will solely focus on areas such as public awareness campaigns. 37. The Government should provide further clarification on the role of the Public Health services and local authorities in the new commissioning arrangements, including how much influence they will have over the commissioning decisions made by GP consortia, and what tools Local Authorities will have to ensure that commissioning plans reflect the health needs identified in assessments. 38. Further comments on improving health outcomes 39. One of the most notable features of Equity and Excellence is the focus on improving health outcomes. This is an area where improvements on the current situation could definitely be made. 40. At present, the Quality and Outcomes Framework (QOF) is used as a tool to improve health outcomes, by providing GPs with incentives to take certain actions or achieve certain results. However, the QOF does not work as well as it could in the area of obesity, as the incentives provided in this area are quite weak. GPs are awarded points for keeping a register of patients in their practice who have been identified as obese, but they do not receive points for providing advice to these patients on how to lose weight, or indeed helping them to successfully achieve a healthy weight. This means that they are less likely to actually take action which contributes to patients losing weight. 41. It will be interesting to see how the QOF interacts with the planned Outcomes Framework, which will measure the NHS Commissioning Board against their ability to achieve a set of defined health outcomes. Although obesity is not explicitly mentioned in the draft framework which has been put out for consultation, it does mention conditions such as cardiovascular disease and diabetes; health professionals will inevitably have to deal with the obesity problem in order to have a significant effect on these areas. 42. While this framework could have positive effects in improving health outcomes in a number of areas, it is not yet clear how quality will be guaranteed (and measured) in practice. For conditions such as obesity (and other similar public health issues such as alcohol and tobacco), which are not mentioned explicitly in the framework, the worry is that there may not be sufficient focus on them. Public health issues such as these have an impact on ill health over a long period of time, but with effective weight loss the positive benefits will be detectable within a few weeks. New outcomes, such as weight lost at 12 weeks and weight lost at 12 months are easily defined and measured. Adverse health effects of obesity which are easily measurable such as the number of apnoea and hypopnoea episodes per hour in sleep apnoea are also easily measured by sleep studies—this is another outcome which could be measured and rewarded. 43. It is also not yet entirely clear how GPs will be rewarded for succeeding in improving outcomes, and indeed how they will be held to account if they fail. Health Committee: Evidence Ev w147 44. Separate public health outcomes will be set at a later date in partnership with the public health service. We would appreciate clarification that an issue as important as obesity will be included in this, or that sufficient steps are taken to ensure that all GPs are aware of its importance. 45. Obesity should be specifically included within the Outcomes Framework, in order to ensure that there is sufficient focus on a condition which has knock-on effects on many other conditions. In addition, steps should be taken to ensure that there are real incentives to actually tackle obesity, rather than simply record it as at present. Conclusion 46. We hope that our submission has been useful in identifying some of the problems with the current system of commissioning, as well as highlighting some of the key questions about the proposed new arrangements. While we are yet to see how the new arrangements will work in practice, we are hopeful that they will be able to improve the quality of commissioning, particularly in relation to obesity. October 2010 Written evidence from Mr David Allen (COM 58) — The Coalition Government’s proposals offer both opportunities and challenges with the proposed new way of commissioning services on behalf of patients. — The possibility is opened for decision making about provision of services and the shape of services to more accurately reflect patient’s needs and choices. — However, it is vital that patients have knowledge about the latest advances in treatment, so that they can make an effective decision in conjunction with their healthcare provider. — It is also vital that commissioners whether at a local level or at the proposed Commissioning Board level have access to information about the latest and the best treatment options and so there must be a mechanism for either patients or patient advocate groups (or both) to have effective representation at both levels. — It is vital in areas where patients develop conditions associated with ageing, but at an age which is no longer regarded as “old” (such as my own specialty of cataract surgery), that decisions are made with long-term goals in mind, not simply short term low cost decisions (see particularly para. 13) How GP consortia and the NHS Commissioning Board can best involve patients in improving the quality of health services. 1. I believe that the Coalition Government’s proposed major overhaul of healthcare provision within the NHS and, in particular, the opportunity that the Department of Health’s proposals contained within the White Paper Liberating the NHS: Commissioning for Patients present an excellent opportunity to transform the patient health landscape within the UK for the better over the long-term. 2. In particular, the proposal that GP consortia should commission healthcare on behalf of their patients should lead to the NHS as a whole having a better understanding of their health needs. For example, it is said by non-governmental organisations interested in ageing that the elderly population within the UK, which the Office for National Statistics estimates is currently around 1.4 million people85 and that is projected to rise to 3.5 million accounting for 5% of the population by 2034,86 often have many unmet healthcare needs. 3. Health challenges to particular groups in society can also be enhanced by moving towards a more stakeholder driven system as is proposed. Elderly people face a number of disease challenges such as Musculo-skeletal diseases, Alzheimer’s Disease, Parkinson’s Disease and Cataract. Involvement of elderly advocates and patient groups to understand these threats better can ultimately lead to a more patientoutcome focused healthcare system. 4. In the area of age related diseases, particularly vision age related diseases such as cataract, it can often be said that UK patients do not always have access to all the latest available treatment options. Indeed, current healthcare commissioning procedures under the Primary Care Trust and Strategic Health Authority decision making structures tend to deny the patient the chance to make an informed choice about which cataract treatment might be best for them, especially when it comes to lens implant choice. 85 86 Statistic taken from the Office for National Statistics website on 9 September, 2010, using the website page http://www.statistics.gov.uk/cci/nugget.asp?id%949 on the UK Population and Ageing. Statistic taken from the Office for National Statistics website on 9 September, 2010, using the website page http://www.statistics.gov.uk/cci/nugget.asp?id%949 on the UK Population and Ageing. Ev w148 Health Committee: Evidence 5. For example, patients undergoing cataract operations should be made aware of the additional treatment options and extra services, such as “multi-function” and “spectacle free” lens treatment options (otherwise known as the intraocular lens with additional functions for cataract) that are currently on the market. This is generally not the case and hence cataract patients do not routinely have access to all the treatment options and as a result many need to wear spectacles for the rest of their lives. 6. Indeed, what is sometimes absent in the healthcare commissioning decision making structures is the ability for NHS staff and clinicians to purchase lens treatments that take into account the patients long term eye sight needs and the need to be able to continue to lead a healthy and happy life, where good vision plays such an important part. This is because they are not able to assess individual patients’ requirements on the ground at the GP surgery level. In short, I believe that well informed local GPs and not staff in regional organisations are the best placed people to take on the role of commissioning healthcare for cataract patients. 7. As already outlined, the Department of Health’s White Paper proposals aim to increase patient choice and bring the NHS decision making procedures closer to each patient’s needs and this is very welcome. However, when assessing lens treatment options for cataract patients, NHS staff and clinicians also need to take into account their long term needs, particularly when they are elderly. How GP consortia can work closely with secondary care, community partners and other health and care professionals to design joined-up services that are responsive to patients and the public. 8. Where there is overlap with secondary care and GP consortia’s responsibilities, such as care for the elderly, a grouping of conditions may be helpful. For example a number of conditions that together present a challenge to the elderly such as Arthritis, Alzheimer’s Disease, Parkinson’s Disease and Cataract may be more effectively tackled by considering the conditions together and collaborating with secondary care providers. 9. The Coalition Government has recently announced plans to gradually phase out the compulsory retirement age in the UK,87 suggesting that the elderly population will be working for longer in the near future and that they will therefore require a good level of vision in order to carry out their jobs. This will also require GPs to work closely with secondary care providers, community partners and other health and care professionals who may also have a part to play in terms of the patient’s healthcare needs to ensure that they can continue to lead an active and healthy life while staying in employment for as long as possible. 10. This joined up approach to providing healthcare is particularly important when considering age related visual diseases such as cataract, largely because of the fact that it impedes the passage of light into the eye, having a dramatic impact on a patient’s quality of life. Indeed, as a silently progressing condition, patients often live with a reduced visibility and need frequent prescription changes in spectacles or contact lenses before being appropriately treated by the NHS. How the NHS Commissioning Board and GP consortia can best work together to make effective and efficient commissioning decisions. 11. I believe that the Department of Health’s White Paper proposals on the setting up and functioning of the NHS Commissioning Board must enable it to effectively work together with the GP consortia and ensure that the best commissioning decisions are made on behalf of patients. 12. For example, the patient representatives on the NHS Commissioning Board could ensure that spending on healthcare is seen as an investment in people and human capital and not just a cost. They will also provide a link between the GP and his patients and the Board, further ensuring that commissioning decisions are made as close to the patients’ needs as possible. GP knowledge must be complemented with specialist knowledge when required eg by patient groups and/or ophthalmologists. 13. With the GP consortia, the NHS Commissioning Board and patients or their advocates working together in this way it will be possible for patients successfully treated with the latest IOL implants to be seen as net contributors to society rather than net recipients, because they continue to work and contribute to the UK economy as employers and employees and therefore require less help from the state. Indeed, this approach also chimes in with the drive to keep the UK elderly population healthy and active, ensuring that their long term healthcare needs are fully met. 14. I think that this aspect of elderly social inclusion should be considered by GP consortia and the NHS Commissioning Board when they are working and making commissioning decisions together. Elderly patients must be fully informed about their condition. They should also be made fully aware of all the treatment options available, even if they are not currently made available to them by the NHS. Such information is currently sought by patients on the internet if they are not receiving it from their medical support, where it is often open to misinformation and misinterpretation. 87 Information taken from the Department for Business, Innovation and Skills website on 9 September, 2010, using the website page http://www.bis.gov.uk/retirement-age on the Government’s current consultation on the phasing out of the compulsory retirement age proposals. Health Committee: Evidence Ev w149 15. Indeed, the principle of patients being fully informed about the choice of treatment options available to them is important in ensuring that GP consortia and the NHS Commissioning Board make the most effective and efficient commissioning decisions on behalf of patients. This is also why the tariff structure available when making decisions should be decided by the NHS Commissioning Board in a transparent manner. Ideally, GPs should directly represent to the GP consortia the views of patients whom they meet at practice level and reflect their views in a transparent manner. When patients are interested in or request certain treatments or care this should be reflected in an upward focused push towards provision of them. 16. With a fully informed patient, it will also be easier for both the Commissioning Board and GP consortia to look at the broad range of healthcare challenges that particular groups in society currently face. This approach will also be enhanced by moving towards a more stakeholder driven system of commissioning, as is proposed in the Department of Health’s White Paper. For example, elderly people face a number of disease challenges such as Arthritis, Alzheimer’s and Parkinson’s diseases as well as cataract. The active involvement of elderly advocates and patient groups to help GP consortia and the Commissioning Board to better understand these threats could ultimately lead to a more patient focused, as well as effective and efficient, commissioning decisions. October 2010 Written evidence from the Paediatric Continence Forum (COM 59) Executive Summary — Continence (bladder and bowel) problems affect about one in 12 children and are associated with bullying, loss of self-esteem and family stress, including parental punishment. Bedwetting was a symptom of maltreatment in the tragic death of Victoria Climbie, which was not picked up by healthcare staff. — Services need to be commissioned to treat bladder and bowel problems as one integrated service (usually community-based), each with a trained paediatric continence adviser as “lead”. This would save money–by preventing unnecessary A&E and hospital admissions—and providing better outcomes for families. — We welcome the forthcoming NICE Commissioning Guide on paediatric continence services. This will support the implementation of two NICE Guidelines, on; constipation in children (published May 2010) and childhood nocturnal enuresis (bedwetting) due to be published on 27 October 2010). There is a role for the Commissioning Board to encourage take up of these Guides at local level. — Physical (health), social, psychological and educational elements require a “joined up” approach for effective and cost effective treatment for these conditions. — There should be an identified “lead” allocated within each GP consortium to liaise with each paediatric continence service “lead” — Early identification and effective treatment would prevent additional problems developing and reduce the number of families attending outpatient or A&E Departments. — Improvements to water and toilet provision and access in schools would also prevent bladder and bowel problems from developing. — There needs to be a Quality Standard on bladder and bowel care in children and young people. About the Paediatric Continence Forum 1. The Paediatric Continence Forum (PCF) is a national group of patient representatives and healthcare professionals, supported by industry members, concerned about the poor state of services for children with continence (bladder and bowel) problems. The Forum came together in 2003 to discuss ways forward with policy-makers and the NHS around the formation of the Children’s National Service Framework (2004). It works closely with the national charity ERIC (Education and Resources for Improving Childhood Continence). About Bladder and Bowel Problems in Children 2. Bladder and bowel problems affect about one in 12 children and young people (ERIC 2008) yet are often hidden, due to their social stigma. They can cause children to be bullied at school, result in loss of self esteem—and cause stress to families. Research indicates that about 22% parents punish their children for wetting or soiling episodes (Butler 2005)88 and there is a link with child abuse (as in the case of the late Victoria Climbie). They are mostly treatable conditions. 88 Butler R Child: Care, Health & Development. 31,6,659–667. Ev w150 Health Committee: Evidence 3. This is an area of child health in which coordination between health, education, psychology and social services is particularly essential. Yet the 2004 National Service Framework (NSF) acknowledged that there were “big gaps in service provision for children with continence problems, which lead to inappropriate referrals and wasted resources. It recommended “an integrated, community-based paediatric continence service, informed by Good Practice in Paediatric Continence Service and ensures that accessible, high quality assessment and treatment is provided to children and their parents/carers in any setting” (NSF 2004 Standard 6 p 30). The above policy has been confirmed by “Achieving Equity and Excellence for Children” with a holistic approach to healthcare. 4. A survey of 800 NHS paediatric continence clinics in the UK carried out by the national charity ERIC (Education and Resources in Improving Childhood Continence in 200889 and recent service case histories, indicate that community-based paediatric continence services remain fragmented and inadequate, with few properly trained paediatric continence healthcare “leads”. The situation is being further decimated with PCT savings. This means that children and young people who have more than one continence condition (eg daytime wetting or soiling, as well as bedwetting”) are being passed “from one service to another”, with long delays and a compromised treatment programme. 5. The ERIC research showed that most continence clinics were community-based and run by a maximum of two nurses, usually on a part-time basis; 40% of these clinics treated wetting only and not constipation/soiling. Only 5% dealt with children with physical disabilities and only one in three said that they had easy access to a paediatrician. 6. A key problem is that integrated paediatric continence services are not being properly commissioned. This is due to lack of knowledge of the needs of this group of children at commissioning level (particularly a lack of appreciation of how continence difficulties radically affect children and their families—and the effective treatment available)—and a lack of understanding of what a good services should comprise. 7. In addition, many children who have specialised bladder and bowel surgery are reliant upon the tertiary centres sending out specialist nurses to complete follow up as there is no specialist nurse locally. Domiciliary visits are being reduced and this leaves children with no regular follow up, leaving them vulnerable to post operative complications particularly if they have to catheterise. This can result in infection, reduced kidney function and the need for further high tech intervention. 8. Research by Dr K Price, Sheffield Children’s Hospital 2003 found that a quarter of children attending paediatric outpatient clinics had problems relating to constipation—pre-dating the increased prevalence of breakfast clubs and extended school day,—www.bog-standard.org/adults survey results.aspx This problem could be vastly reduced by improved continence treatment services and improvements to water and toilet facilities and access in schools (cross reference to the work of ERIC/ PCF and the Department of Education in the submission of draft amendments to the 1999 School Premises Regulation May 2010). 9. There is one published NICE guideline in this area of child health ( NICE Guideline on constipation in children, published May 2010). A second NICE guideline, on nocturnal enuresis (bedwetting) is due to be published on 27 October 2010. 10. The PCF welcomes the publication of the first national Commissioning Guide in this area of child health (due to be published early 2011) to complement the publication of the two above NICE guidelines. However there needs to be energy and impetus from government to encourage their take-up at local level. 11. The Department of Health has recently published a Care Pathway (Exemplar) on paediatric continence: The National Service Framework for Children, Young People and Maternity Services— Continence issues for a child with learning difficulties (Published 9 September 2010).90 The PCF welcomes the opportunity to respond to the following consultation questions: Clinical Engagement in Commissioning How will commissioners access the information and clinical expertise required to make high quality decisions about the shape of clinical services? 12. For paediatric continence commissioning, there will be a NICE Commissioning Guide, which will signpost and provide topic-specific information on key clinical and service-related issues to consider during the commissioning process. The guide will contain a commissioning and benchmarking tool that can be used to estimate and inform the level of service needed locally, as well as the cost of local commissioning decisions. 13. For guidance on clinical practice on paediatric continence there are two NICE Guidelines: Childhood Constipation (published May 2010) and Childhood Nocturnal Enuresis (to be published 27 October 2010) 89 90 Published within ERIC Update journal May 2008. Department of Health: National Service Framework for Children, Young People and Maternity Services. (2010) Continence Issues for a Child with Learning Difficulties. Available from: www.dh.gov.uk/prod consum dh/groups/dh digitalassets/ wdh/wen/wps Health Committee: Evidence Ev w151 It is essential that GP consortia know about these resources and use them. It could be part of the role of the NHS Commissioning Board to enable relatively low volume services, such as paediatric continence, be effectively commissioned. How will GPs engage with their colleagues within a consortium and how will consortia engage with the wider clinical community? 14. Most paediatric continence services are run by nurses ( school nurses and health visitors) and others are led by community paediatricians. There is usually a “lead” person for each service. The national charity ERIC (Education and Resources for Improving Childhood Continence) has details of most paediatric continence services nationally. There should also be an identified “lead” for paediatric continence within each GP consortium Accountability for Commissioning Decisions 15. There is very little “parent power” in this area of child health, as parents usually want to protect their child’s “invisibility” due to the associated stigma—and the risk of their child being bullied at school. The charity ERIC has a weekday national Helpline—and interactive website, which provide the means to gauge the views of parents. Integration of Health and Social Care 16. It is essential that service models are commissioned that provide good “join-up” between health, social care, psychological services and education. For example, a treatment plan may require a toileting programme within the school, there may be associated psychological problems that will need to be addressed. October 2010 Written evidence from National Specialised Commissioning Group and NHS Specialised Services Team (COM 60) 1. Introduction 1.1 This document sets out the response of the National Specialised Commissioning Group (NSCG) and the National Specialised Services Team (NSST) to the Health Select Committee inquiry into commissioning. It builds on information already sent as a response to the consultation document Equity and excellence: Liberating the NHS. 1.2 The NSCG was established in April 2007 following the Carter Review91 and its role is to provide oversight and coordination of commissioning undertaken by Specialised Commissioning Groups (SCGs) where the specialised service92 has a catchment/planning population that is bigger than that of a single SCG. 1.3 The 10 SCGs—which are coterminous with the 10 strategic health authorities—commission specialised services for their regional populations, which range in size from 2.8 million people to 7.5 million people. 1.4 The NSST is the national team responsible for the commissioning of specialised services. It supports the work of the NSCG and the 10 SCGs but also commissions about 60 highly specialised services on a national basis. Generally speaking, these are services that affect fewer than 500 people across England or involve services where fewer than 500 highly specialised procedures are undertaken per annum. The Advisory Group for National Specialised Services (AGNSS) was established following the DH consultation Strengthening national commissioning to advise Ministers on which services should be nationally commissioned and the centres that should provide them. It will also work closely with NICE to consider a very small number of highly specialised technologies. The NSCG and NSST have made the Following Points in their Consultation Response 2. Effective Commissioning of the Whole Patient Pathway 2.1 Many specialised services form part of complex patient pathways that involve primary, secondary and tertiary care interventions. It will be essential that the proposed new commissioning arrangements do not undermine the effective functioning of these pathways, particularly where preventative interventions in primary care may mitigate the need for secondary or tertiary care. For example, effective management of obesity in primary care prevents the need for morbid obesity surgery (a specialised service) and more effective management of vascular conditions reduces the need for renal care (also a specialised service). 91 92 Review of Commissioning Arrangements for Specialised Services, May 2006, chaired by Sir David Carter. Specialised services are those services as defined in SI 2002 2375 as those provided in relatively few specialist centres to catchment populations of more than one million people. Ev w152 Health Committee: Evidence 2.2 It will also be important to ensure that the proposed new commissioning arrangements do not create perverse incentives that discourage investment by the NHS Commissioning Board that will result in savings in GP commissioning consortia. For example, recent work93 undertaken by the Muscular Dystrophy Campaign estimates that savings of £81 million per annum could be made on unplanned emergency admissions (which would fall within the remit of GP commissioning Consortia) if a relatively small investment was made in specialised services. 3. GP Influence and Involvement 3.1 Although the membership of the AGNSS (whose role is to advise Ministers on which services should be nationally commissioned and the centres that should provide them) includes a representative from the Royal College of GPs, GP involvement in the commissioning of specialised services would need to be strengthened in the proposed new arrangements. This could be secured through a number of different routes: GP membership on the NHS Commissioning Board; GP involvement in the commissioning of individual specialised services (perhaps through service or programme boards) and the development of new models of care; GP involvement in any regional configuration or at individual provider level, where there are direct relationships between the local pathway of care and a specialised service commissioned by the NHS Commissioning Board. 3.2 The Royal College General Practitioners is currently considering setting up a group of GP commissioners who would be able to provide advice at a national level on new models of care. This would be welcomed. GP involvement would also be essential in networks such as those established for cancer, renal services and coronary heart disease as these services span primary, secondary and tertiary care. Commissioner and provider networks currently play an important role in establishing coordinated care pathways across primary, secondary and tertiary care. 4. The Specialised Services National Definitions Set 4.1 Specialised services are those services as defined in SI 2002 2375 as those provided in relatively few specialist centres to catchment populations of more than one million people. The third edition of the Specialised Services National Definitions Set (SSNDS) was published in phases over 2009–10 and contains 34 definitions (three of which are new). Each definition has been updated/created by an inclusive process involving providers (clinicians, hospital managers, and information and coding staff), commissioners and patients’ groups. Each definition has been endorsed by the NSCG and the relevant professional organisations. In light of this comprehensive review, it is appropriate that the services currently on the SSNDS should form the basis of the specialised services commissioned by the NHS Commissioning Board. It is important to note, however, that specialised services are constantly developing and changing; new specialised services will be provided by the NHS whilst other services will become more commonplace and cease to be specialised. Consequently the production of the SSNDS has to be seen as an iterative process with new editions being produced from time to time. 4.2 There will need to be a transparent and robust process for agreeing which services should be added to and removed from the SSNDS. Anxiety from patient organisations—who may be concerned that the advent of GP commissioning consortia will lead to more fragmented and inequitable services for patients with rare conditions—is likely to lead to increased pressure for services to be added to the SSNDS. 4.3 Some interventions that are currently commissioned by PCTs are inextricably linked with specialised services and it would be advisable for the NHS Commissioning Board to commission these services so as not to hamper effective pathways. One important example is percutaneous coronary intervention. 4.4 The extent to which SCGs commission the services on the SSNDS is variable and no SCG commissions all 34 services. The current budgets allocated by PCTs to the SCGs are not therefore reflective of the full range of specialised services. It will be important to identify any specialised services activity not currently commissioned by SCGs together with the associated budget and to ensure that this is transferred to the NHS Commissioning Board. 4.5 Although the main focus of the 10 SCGs is to commission the 34 services on the SSNDS, their expertise in collaborative commissioning is also utilised to commission other services. This may be for a variety of reasons, for example: the maximisation of purchasing power (for example, HIV drugs); the need to ensure a strategic direction (for example, major trauma services, ambulance services); the need to ensure equitable access to services (for example, management of the newly established Cancer Fund); and the need to ensure access to only clinically effective services (for example, fertility services, hyperbaric oxygen treatment, drug treatment for macular degeneration). 4.6 Some of these commissioning arrangements also involve low volume services. GP commissioning consortia could use the best practice developed through these commissioning arrangements to inform their own practices; they might also ask the NHS Commissioning Board to commission some low volume services on their behalf. In the case of the latter, there would need to be an explicit transfer of funds from GP 93 http://www.muscular-dystrophy.org/ Health Committee: Evidence Ev w153 commissioning consortia to the NHS Commissioning Board. In the event that GP commissioning consortia decide to work with each other to commission low volume services, there would need to be explicit governance arrangements to support such arrangements. 5. Improving the Quality of Data Further improving the SSNDS is dependent on the adequacy of diagnosis and intervention classification systems. The current classification systems used in the third edition are the International Classification of Diseases, version 10 and the OPCS Classification of Interventions and Procedures, version 4.5. These coding systems do not distinguish between complex cases of more common conditions being treated in specialist centres and straightforward cases being treated in local hospitals. This is particularly the case in primarily outpatient-based medical services such as specialised rheumatology. Urgent work is needed to develop systems that allow the extraction of specialised services activity from standard information systems such as HES. High quality data is also needed to support other commissioning activities such as: the measurement of outcomes; tariff development, etc. 6. Quality Standards It will be important to ensure that quality standards are developed for specialised services and that these are given the same credibility as NICE quality standards. Whilst NICE will clearly need to prioritise quality standards for the most common conditions in the first instance, there will also need to be arrangements for developing quality standards for specialised services. Given the level of expertise and the established relationships that commissioners of specialised services have with professional groups and other clinicians, it may be more appropriate for the NHS Commissioning Board to develop clinical criteria for specialised services. There would need to be a robust quality assurance process to ensure that any clinical criteria were developed with appropriate professional and patient input. Clinical criteria will be essential in the development of service specifications, especially where these are used to underpin procurement processes. They are also core to the concept of “designation” of specialised services. 7. Patient Engagement Specialised services commissioners have a well-established track record of involving patients and patient groups in their activities. Many of the national services commissioned by the NSST have active patient groups, who are closely involved in, for example, shaping models of care. In the case of two services—Alstrm syndrome and ataxia telangiectasia—the NSST commissions patient pathway co-ordination directly from the relevant patient group. The NSST also links closely with the two main umbrella groups for patients with rare conditions. One of these, the Specialised Healthcare Alliance (SHCA), is working closely with the 10 SCGs to organise a series of 10 QIPP (quality, innovation, productivity and prevention) workshops—each focusing on a specific specialised service. The workshops bring together members of the SHCA, commissioners and clinicians. It is anticipated that this range of activities, together with standard consultation activities would continue under the new r„gime. 8. Demonstrating Equitable Access to Specialised Services In the current arrangements, the NSST measures geographical equity of access to national services across the 10 SHA areas. For most services, activity over a number of years needs to be used for the results to be valid. SCGs also measure access in their individual areas. In the proposed arrangements, it will be important to be able to demonstrate equity of access to specialised services. There may be too many GP commissioning consortia for this to be a valid population measure for some services and, in addition, some GP commissioning consortia will not be coterminous with “natural” communities and their boundaries may change over time. Other possible comparators might be the nine local government regions and/or the 152 principal authorities. 9. High Quality Public Health Advice to Commissioning Specialised Services The Carter Review recommended that SCGs and the National Commissioning Group (now AGNSS) should be supported by dedicated teams of commissioners—including commissioning, public health, finance, information and administrative staff—to provide sufficient capacity and expertise to support the designation (of providers) programme, develop contracts and ensure compliance. This multi-disciplinary approach—supplemented by pharmaceutical and case management expertise—means that specialised commissioning is effective and has credibility with provider colleagues. Ideally the public health expertise within SCGs would transfer directly to the NHS Commissioning Board to support the commissioning of specialised services. 10. Choice and Competition 10.1 It will be important to be able to demonstrate that appropriate choice has been offered both within specialised services (particularly from secondary to tertiary care) but across pathways that span secondary and tertiary care. The competition rules that set out how these services should be commissioned will need to be clear as there could be a conflict if part of the pathway is commissioned by GP commissioning consortia Ev w154 Health Committee: Evidence through an “any willing provider” process but the rest of the pathway is commissioned using a different commissioning model. Choice will also need to be seen in the context of clinical effectiveness and financial constraint. 10.2 Whilst the NSCG and the NSST understand the strategic direction towards promoting competition and therefore choice, it will be important to maintain and develop procurement systems that take into account the need to ensure clinical quality is maintained, especially when it involves scarce expertise and/or facilities. SCGs use the process of “designation” as defined in the Carter Review to decide which providers are best placed to deliver specialised services. It is recommended that this should continue into the new régime, especially as it is also likely to make economic sense to consolidate services. Discussions with colleagues in the Department of Health have indicated that competition could appropriately be managed through a two-stage procurement process: an initial screening utilising notifications through Supply2Health could be followed by full tendering where necessary. Discussions have also indicated that a number of models currently utilised in national and regional commissioning of services could continue in the new régime: for example, most nationally commissioned services are effectively commissioned as a single service on several sites; the primary malignant bone tumour service operates as a managed clinical network. Similarly, principal treatment centres in children’s cancer networks work closely with more local shared care units and, in another service, an independent clinical lead is being appointed to lead on behalf of a service. 11. HealthWatch The NSCG and the NSST note the establishment of local HealthWatch and HealthWatch England. Specialised services providers will usually be delivering services to a much wider catchment area than that covered by a local HealthWatch. For some specialised services, HealthWatch England would be a more appropriate vehicle for capturing the views of patients. 12. Health and Wellbeing Boards 12.1 The NSCG and NSST agree that there should be strong emphasis on consultation and that there should be a statutory mechanism to take forward joint working arrangements. It will be important for health and wellbeing boards to ensure that there is a strategic view on all services (including specialised) especially where these span health and local authority boundaries, for example, children’s services and mental health services. 12.2 Representation of the NHS Commissioning Board on health and wellbeing boards could mean a significant workload, especially if a board is established for each of the 152 principal authorities. Some specialised services affect very small number of patients and it is conceivable that a health and wellbeing board might only have a handful of patients with a rare condition or none at all. A means to provide input at a more strategic level is therefore needed for specialised services. 12.3 The NSCG and the NSST agree that the scrutiny and referral function of the current OSC should be subsumed within the health and wellbeing board, if boards are created. However, they believe that there should be a statutory requirement for health and wellbeing boards to co-operate in the event that, for example, a major service redesign affects a wider population than that covered by a single health and wellbeing board. They also believe that the NHS Commissioning Board should decide the appropriate level of cooperation if the major service redesign concerns a service commissioned by the NHS Commissioning Board. Finally they also believe that the NHS Commissioning Board should decide whether or not a service change is “substantial”. For some highly specialised services, an overview and scrutiny function might best be enacted through a “national” health and wellbeing board. 13. Regional Sensitivity One of the key successes of SCGs has been the intelligence they have gathered and utilised about their regional health economies. This has meant that they have been able to develop effective relationships with the providers in their areas. In order to maintain this perspective, it will be important that the model chosen for the operation of the NHS Commissioning Board retains regional sensitivity. A regionally-sensitive model is also more likely to ensure: that GP commissioning consortia are fully involved in specialised services commissioning; that patient pathways that span primary, secondary and tertiary care are protected; that there is capacity to drive change where it is needed or to respond to governance issues; that there is capacity to negotiate service specifications and monitor these locally with support from centralised systems; and that there is a senior level contract lead for provider stakeholder relationships and health and wellbeing boards. 14. The Advisory Group for National Specialised Services 14.1 The Advisory Group for National Specialised Services (AGNSS) was established following the DH consultation Strengthening national commissioning to advise Ministers on which services should be nationally commissioned and the centres that should provide them. It will also work closely with NICE to consider a very small number of highly specialised technologies. Discussions with colleagues in the Department of Health have indicated that AGNSS will continue to advise Ministers on which services should be nationally commissioned. Health Committee: Evidence Ev w155 14.2 Mechanisms for commissioning services on a national basis have been in place since 1983, when the Supra Regional Services Advisory Group was established. A national commissioning model: helps patients by improving access to highly specialised services; sustains high levels of expertise by preventing proliferation of too many centres; helps providers by offering a focus for discussion about managing and developing services within limited funds; and ensures that services are commissioned effectively with costs streamlined to ensure good value for money. Given the success of the national commissioning model, it makes sense for it to continue when the NHS Commissioning Board is established. Some nationally commissioned services are part of a pathway of care that has close links with tertiary services (for example, severe intestinal failure). It may make sense for the commissioning arrangements for these services to be more closely aligned. 14.3 AGNSS has a new role, which is to work closely with NICE to consider a small number of highly specialised technologies. In order to maximise the effectiveness of this role—and especially in supporting the policy of value-based pricing—arrangements should be put in place to allow the National Specialised Services Team to work with other relevant parts of the NHS Commissioning Board to directly negotiate with pharmaceutical companies. 14.4 The nature of the services and technologies with which AGNSS is involved means that it has a key role to play in managing innovation. It can help to prevent ‘creep’ by providing a controlled mechanism within which innovations can be assessed whilst ensuring that England does not fall behind other countries in embracing new techniques and therapies. Seed funding of innovative technologies—which may in time lead to advances for mainstream services—can be difficult to identify because it requires a disinvestment in other services. This is also an issue for specialised services in general. The NSCG and the NSST would like to recommend that the NHS Commissioning Board holds an ‘innovation fund’: this would be used to fund specialised innovations in a controlled way supported by robust assessments of clinical and cost effectiveness. 15. Conclusions In order to continue to deliver high quality specialised services commissioning, it will be important to identify dedicated. These will need to be at both a national level and at a more local level, in order to ensure that local intelligence is brought into the commissioning cycle and also to ensure effective linkages with GP commissioning Consortia. October 2010 Written evidence from Assura Medical Limited (COM 61) Assura Medical Assura Medical, now majority owned by Virgin, aims to improve health outcomes for patients by enabling a greater range of services to be delivered in primary care and community settings. We achieve this by partnering with groups of GPs to develop provider companies (GPCos). We have now formed 30 GPCos with GPs representing over three million patients and these are now providing a wide range of services including diagnostics and out-patient day care services, GP surgeries, walk-in and urgent care centres. As well as providing convenient high quality services for patients, our services have also generated significant savings for PCTs. Our GPCos work closely with a wide range of providers from across the NHS, social care and independent sectors. We have formed a range of innovative models to provide integrated services that span primary and secondary care which we see as essential to develop joined up and cost effective services. Summary — Assura Medical welcomes the proposals set out in the NHS White Paper and believes that they represent an opportunity to drive real change within the service. Many of the proposals reflect Assura Medical’s approach of working with GPs and we are therefore pleased that the White Paper reflects the critical role clinical groups play within the NHS. The Assura Medical business model fully supports choice of provider for patients and bringing services closer to home. We wholeheartedly believe that these measures improve quality, patient satisfaction and value for money. — To deliver the vision laid out in the White Paper, a plural market will need to be established which meets agreed quality standards and works in innovative combinations. This will require providers to emerge that can understand and bear operational risk through delivery mechanisms such as the “prime contractor” model, helping unlock savings and changing traditional behaviour. A failure to stimulate the market and encourage new providers will make it difficult for GP commissioners to drive through reform and will result in reduced patient choice and reduced access to quality Ev w156 Health Committee: Evidence services. We believe that Assura Medical and other large-scale providers have a very important role to play in making these reforms a reality, challenging the monopolistic control traditional NHS organisations have exerted until now. — Any Willing Provider sits at the heart of this and must be mandated immediately. A historic problem is that despite it being policy AWP has not been implemented, frustrating reform and locking innovative providers out of the system. A level playing field must be ensured and difficult hurdles such as NHS pensions overcome for these reforms to realise their potential. 1. Opening up the system to new entrants 1.1 Assura Medical believes that the Government’s vision will not be achieved unless there is comprehensive implementation of Any Willing Provider. 1.2 Any Willing Provider needs to be centrally mandated and implemented urgently. Assura Medical’s experience is that interpretation of the current regulations enables it to be left to local determination. This has led to it being very difficult for new entrants to provide services. This is the reason that patients still do not have meaningful service choices in most areas of the country and we are concerned that this situation will be perpetuated unless Any Willing Provider is swiftly and consistently directed from the centre. Above all things, it is this one issue that will determine how quickly we see substantial private sector investment in healthcare as well as transformed outcomes for patients. 1.3 If Any Willing Provider is fully implemented throughout the country then the provider market will flourish. 1.4 We believe that the full implementation of Any Willing Provider, and the associated sharpening of market principles, can be done where appropriate in cooperation with the NHS or any other provider within the clinical community. Competition drives innovative collaboration and new providers bring innovation and challenge to the existing system which is currently not sufficiently responsive to consistently meet patient need. The incentive within the system to achieve this will sit with a better informed patient able to determine their own care pathway and constantly challenging commissioners and providers over the service they are receiving. 1.5 Monitor’s role in overseeing both competition and cooperation will be critical and for the sake of clarity we believe its role should be statutorily defined within the Health Bill. 1.6 Assura Medical believes that it will be important to allow for local tariff setting as a way of responding to market pressures. Assuming that Any Willing Provider is universally applied then it will be possible to introduce local tariff setting based on the market response. 1.7 Assura Medical welcomes the information revolution that the White Paper suggests will be forthcoming and believes it to be integral to the reform agenda. We firmly believe in providing patients with quality information from which they can make an educated decision about which provider best meets their needs. Assura Medical is committed to being transparent with the public so patients can understand what our services can offer them and how they differentiate between us and our competitor organisations. The quality indicators being worked up by the Department of Health will be crucial in delivering this and in ensuring that patients can straightforwardly evaluate the different services on offer to them. 2. Effective commissioning 2.1 Assura Medical takes no view on the size and scale of commissioning consortia since we agree with the Department of Health that this should be left to local determination. In essence however good commissioning is about securing better value for patients from the available resources. If GP Consortia are the organisations with responsibility for delivering this, three key things need to exist to achieve best outcomes: (i) clarity about the outcomes to be achieved; (ii) meaningful information for patients which tells them about the things they care about; and (iii) competing providers incentivised to provide informed patients with the services and experiences they want which meet the outcomes required by the commissioners. 2.2 It is our belief that the combination of informed patients and competing providers will enable GP Commissioning Consortia to achieve the required outcomes for their patients for the best value. The history of healthcare and other industries indicates that it is providers and suppliers which drive innovation in service delivery in response to clear outcomes and informed consumers. 2.3 We would urge the Department of Health to be clear with GP Consortia that their role in securing the best for patients is to define what outcomes need to be delivered and NOT restricting the market from delivering these outcomes. The commissioners’ role is to define what is required at a high level, not who provides it or how it is provided. Health Committee: Evidence Ev w157 3. Regulation 3.1 The consultation documents that accompanied the White Paper went some way to detailing the manner in which providers will be regulated and accredited by the CQC and Monitor but further work will be required for this important element of the new system. 3.2 Assura Medical endorses the division of responsibility between the two regulators though would urge both Monitor and CQC to develop an overlapping approach which reflects the emerging provider market. We think it important that the regulators do not erect unnecessary barriers to market entry by making the accreditation process unnecessarily cumbersome and bureaucratic. 3.3 Monitor’s role will be particularly important, especially their responsibility in managing the market and ensuring a fair playing field for health service providers. Assura Medical believes strongly that Monitor’s role in overseeing the market should be embedded in primary legislation so as to make clear what it is—and is not—responsible for regulating. October 2010 Written evidence from the National Infertility Awareness Campaign (COM 62) 1. The National Infertility Awareness Campaign (NIAC) is an umbrella body established in 1993 with support, which it continues to enjoy, from a wide range of organisations involved in the field of infertility, including infertility charities, patient support groups, healthcare professionals and the pharmaceutical industry. It campaigns for equal access for those with an established clinical need to a full range of services for the investigation and treatment of infertility on the NHS. 2. The Government’s White Paper on Health, and specifically its related consultation document, Liberating the NHS: Commissioning for Patients, does contain a number of proposals, which are likely to have a significant impact upon the future commissioning of NHS services for infertility. We have therefore focussed our response on those proposals. Summary 3. We believe that the changes proposed in the White Paper in relation to commissioning could present a real opportunity for the NHS finally to provide equal access for those with an established clinical need to a full range of services for the investigation and treatment of infertility. For too long, access to services has varied considerably across the country in terms of the number of cycles of assisted conception treatment available and the access criteria being applied. This has meant that many patients have struggled to receive the treatment they need, and indeed, some have not been able to access treatment at all. 4. We believe that the best way to achieve equal access to fertility treatment would be to recognise infertility services as a specialised service and to place them under the responsibility of the new NHS Commissioning Board, working with GP consortia and with the advice of an established national, or regional, commissioning network/networks for fertility, comprising fertility specialists, infertility patient representatives and other health professionals. 5. We do not think that responsibility for the commissioning of these services should be left to GP consortia. We believe that there needs to be active regional commissioning of fertility services, overseen by a national body, accountable to the Secretary of State for Health, that provides standardised guidance and monitors performance in line with a clear set of outcomes and quality standards in order to encourage greater consistency in service provision. 6. Key to this will be to ensure that the NHS Commissioning Board drives forward a national commissioning plan for infertility services, based on the recommendations of the National Institute for Health and Clinical Excellence’s (NICE) clinical guideline on fertility and supporting Department of Health guidance, and which promotes timely access to services. This should be advised on by an established commissioning network/networks for fertility accompanied by a clear process of wider consultation with fertility clinicians and patients. 7. We would also call for the reinstatement of the 18-week waiting time measure for fertility services. This did much to help reduce waiting lists for patients seeking fertility treatment, which previously varied enormously and could require couples to wait for a number of years. Current Situation 8. Around one in six couples seek specialist treatment for fertility problems, and infertility can have a profoundly distressing and devastating impact, something which is often misunderstood. However, excellent results can be achieved in treating infertility if patients are rapidly investigated and referred for appropriate treatment. Ev w158 Health Committee: Evidence 9. Infertility was referred to NICE in 2000 by the Secretary of State for Health, with a view to tackling the inequality of NHS provision of infertility treatment that had existed since in-vitro fertilisation (IVF) first became viable. The aim was for couples to receive fairer, faster access to clinically, cost-effective and appropriate treatments. 10. In 2004, NICE published a clinical guideline on fertility, which included a recommendation, amongst others, that up to three full cycles of IVF be made available on the NHS to those meeting its clinical criteria. A full cycle of IVF is defined as a fresh cycle plus the transfer of frozen embryos where this is possible (Department of Health, Dear Colleague letter, August 2008). The guideline is currently under review, due for publication in 2011. 11. In 2006, Department of Health began work with Infertility Network UK (I N UK), a founding member of NIAC, on a project to liaise with Primary Care Trusts (PCTs) in England to encourage implementation of the NICE guideline through the sharing of best practice. The project involved I N UK carrying out both a survey and a series of one-to-one meetings with PCTs to identify barriers to, and good practice in, implementation. 12. In 2008 the Department of Health set up an Expert Group on Commissioning NHS Infertility Provision in order to support the I N UK project, help NHS commissioners in their decision making on the provision of infertility treatment and encourage progress towards implementation of the NICE fertility guideline. The Group published a commissioning aid in June 2009. I N UK was also asked by the Department of Health to develop a set of standardised access criteria for patients seeking treatment, also published last June. 13. Whilst some good progress has been made towards meeting NICE’s recommendations, there is still a lack of full implementation across England and significant variations continue to exist in the number of assisted conception cycles funded, the definition of a “full” cycle of IVF and access criteria for treatment. 14. In its 2009 report on the project, I N UK highlighted a number of potential barriers to implementation. They included a lack of clarity around responsibility and accountability for the commissioning of infertility services, as well as understanding of the recommendations in the NICE guideline, including the importance of providing a full cycle of IVF. 15. This last point is particularly relevant given plans to move in the near future to a policy of transferring only one embryo at a time during a cycle of IVF for those who are most at risk of conceiving a multiple pregnancy. The Human Fertilisation and Embryology Authority (HFEA) has called for a reduction in the number of multiple births resulting from IVF by recommending a policy of Single Embryo Transfer for appropriate patients: a move, which is more likely to be accepted by patients if they have access to a full cycle of IVF. 16. Moreover, we have recently become aware of a handful of PCTs that have decided to reduce or, in some cases, suspend funding for IVF as a cost-cutting measure. This is completely unacceptable and, in our view, contrary to the principle in the NHS Constitution of using resources for the benefit of the whole community, to make sure nobody is excluded. Clinical Engagement in Commissioning 17. For the reasons given above, we do not think that responsibility for the commissioning of infertility services should be left to GP consortia. The concern with this approach is that it could lead to even greater variability in the availability of services, which would be disastrous for patients. 18. Patients’ access to services could be further affected as GP consortia take time to establish collaborative commissioning arrangements for infertility services, particularly as they are unlikely to have expertise in this area of healthcare. We therefore believe that there needs to be active regional commissioning of fertility services driven at the national level by the NHS Commissioning Board through a national commissioning plan. 19. Clinical expertise should be accessed through national clinical evidence, such as the NICE fertility guideline, and via the etablishment of a national or regional commissioning network/networks for fertility. This network/networks should comprise relevant specialists in the field and infertility patient representatives to advise the NHS Commissioning Board on the development and implementation of its commissioning plan, based on a clear patient pathway. 20. To support this, there should be a clear, standardised process for engagement with clinicians and infertility patient representatives that is applied across the country. The NHS Commissioning Board should work with GP consortia to ensure that there is engagement throughout the commissioning process. Accountability for Commissioning Decisions 21. It is important to involve infertility patients and their representatives in making commissioning decisions. With regard to infertility, this means ensuring that patients are included early on in the commissioning process and not just at the point where a final decision on the structure of services is to be made. This will help to ensure that services reflect patient’s views and needs and that their experience of them is positive. Health Committee: Evidence Ev w159 22. We believe that there should be a clear, standardised process for engagement with patients that is applied across the country so that they are clear about when and how they can make their views known. Currently, it appears to be up to PCTs to decide the level of engagement that they deem is appropriate to the scale of changes in the commissioning/funding of services proposed. However, the interpretation of this seems to vary from one PCT to another so that patients are uncertain as to whether they are entitled to have a say. 23. The NHS Commissioning Board should work with GP consortia to ensure that there is a formal process at the regional level for patient engagement throughout the commissioning process and that, additionally, patients should be represented on the fertility commissioning network/networks, which will advise the Board on the commissioning plan it develops for fertility services. 24. Finally, the Board should work with GP consortia to develop a robust monitoring process for the delivery and performance of fertility services that includes an assessment of patient experience and the need to capture patient views on services. It will be important to ensure that this achieved through liaison with existing systems of engagement such as Local HealthWatch. Resource Allocation 25. This is an area on which NIAC would welcome further information from the Government. At present, PCTs decide on the level of funding to allocate to fertility services, which varies considerably. 26. In order to encourage greater equality of service provision across the country, we would like to see the development by the Commissioning Board of a clear, costed patient pathway for fertility based on a national tariff for services so as to aid better planning in the allocation of the funding needed to provide the full range of services recommended in the NICE guideline. Work is already underway to develop a national tariff for fertility and we hope that this continues to progress. Specialised Services 27. We were extremely concerned by the removal of tertiary infertility services from the national specialised services definitions set, despite the recommendation that these services continue to be commissioned regionally by PCTs. We are anxious that this move presents the danger of individual PCTs deciding to opt out of collective commissioning, leading to even greater variability in the availability of services. 28. We are further concerned that this could be compounded by the proposal in the consultation that it will be up to GP consortia to decide at what level to commission low-volume services not covered by national and regional specialised services. For this reason, NIAC would call for fertility services to be placed under the responsibility of the NHS Commissioning Board. 29. We believe that, in implementing these recommendations, the Government would be aligning fertility services with both the objectives and spirit of the White Paper, which aims to deliver a health service of equity and excellence. Thank you for the opportunity to respond to this inquiry. October 2010 Written evidence from Actelion Pharmaceuticals Limited (COM 63) 1. Actelion is a global, independent biopharmaceutical company that discovers, develops and markets innovative drugs for high, unmet medical needs. Our currently marketed products are primarily focused in the area of orphan or ultra-orphan diseases. 2. An orphan disease is one that affects fewer than 500 people per million of the population; an ultraorphan disease affects fewer than 1,000 patients. Collectively, orphan diseases affect around 3.5 million people in the UK. 3. We are dedicated to discovering and developing innovative medicines to improve or prolong patients’ lives and take a close interest in the service delivery structures of the diseases in which we are involved. We therefore read with interest the Health White Paper and its accompanying suite of consultation documents and have a number of thoughts regarding their potential impact on services for rare diseases. Specialised Commissioning 4. It is important to ensure that specialised services continue to be commissioned at an appropriate level (ie one at which they can be effectively managed given their large planning populations). We therefore welcome responsibility for the commissioning of these services falling to the new NHS Commissioning Board. Ev w160 Health Committee: Evidence 5. We are concerned that not all services contained with the national specialised services definition set (NSSDS) are actively commissioned by the NCG and SCGs under the current arrangements. The White Paper reforms present an opportunity to review the NSSDS to ensure that there is a clear set of services in place, with a clear understanding of what is to be commissioned, at what level and by whom. The definition set should also be regularly reviewed to ensure the services within it are being actively commissioned. 6. We would be keen to know how funding for national specialised services, including those for rare diseases, will be allocated. Ideally, the NHS Commissioning Board should receive direct funding from Government to commission these services, based on clear and costed patient pathways. 7. We would like to see the NHS Commissioning Board working with dedicated multi-stakeholder specialised commissioning networks to develop the commissioning plan for each of the services defined within a revised NSSDS. These networks should be service specific and include representatives of GP consortia and local authorities (social care) as well as appropriate expert clinician and patient representation. 8. The NHS Commissioning Board’s regional offices should be tasked with ensuring the commissioning decisions made by the national board (with the support of specialised commissioning networks) are effectively implemented by maintaining strong links with GP consortia, patients representatives, local authorities and service providers at a regional level. 9. In addition, these offices could carry out at the regional level some of the functions that the proposed health and wellbeing boards would undertake at the local level, ie promoting integration and partnership across areas, including the promotion of joined up commissioning plans across the NHS, social care and public health, and undertaking a scrutiny role in relation to major service redesign. Assessment of Drugs for Rare Diseases 10. We would be keen to establish whether the NHS Commissioning Board will take forward the role of the Advisory Group on National Specialised Services (AGNSS) in assessing some highly specialised drugs as part of national commissioned services. 11. We believe that making decisions about the introduction of these new drugs may best be undertaken within these arrangements, particularly where drugs are introduced into a disease area for which there is no existing therapy or represent a step change in the way that disease is managed, both of which are likely to necessitate significant service development. 12. However, we remain concerned that many orphan drugs (specifically those with potential treatment populations greater than 500) will not fall under this initiative and, because they may be equally unsuitable for assessment under current appraisal methods (ie NICE STA), run the risk of falling through the gap. 13. The now abandoned “innovation pass” was set it in recognition of the fact that there were, “. . . drugs for small patient populations which have the potential to deliver improved patient outcomes but where data to demonstrate cost-effectiveness is so far limited. This may limit the medicine’s market access, denying NHS patients access to certain innovative and effective medicines, and limiting companies’ abilities to bring valuable medicines to the UK market.” This issue of access to such drugs has yet to be adequately addressed and we would welcome the opportunity for it to be looked at within the overall reforms taking place. Improving Patient Quality and Experience 14. A key element of the White Paper is the development of an Outcomes Framework against which the performance of the NHS will be measured. Outcomes will be supported by a suite of disease-related quality standards, to be produced by the National Institute for Health and Clinical Excellence (NICE), which will be used to inform commissioning plans. 15. We would be keen to establish whether NICE will be developing quality standards for rare diseases and if so, whether they would be disease-specific or apply across rare conditions in general. 16. If NICE are not to be tasked with developing quality standards for rare diseases, its imperative that this role falls to specialised commissioning networks involving patients and carers, social services and specialized clinicians. 17. We believe that an integrated approach to commissioning services for rare diseases will be important throughout. The Chief Medical Officer’s Annual Report 2009 highlighted the importance of integrating family, social care and education services in supporting patients with rare diseases and there should therefore be appropriate involvement by representatives in these areas in the commissioning process. Measuring patients’ experience of services would also be important in improving quality. Rare Disease Plan 18. In June 2009, the Council of the European Union published a recommendation for all Member States to establish and implement a plan on rare diseases with the aim of ensuring that patients had access to high quality care. It called for the plans to be adopted by 2013 at the latest and for the European Commission to monitor progress. Health Committee: Evidence Ev w161 19. It will be important to ensure that the UK plan is coordinated with and aligned to the reforms due to be introduced under the White Paper so as to ensure that both maximise their benefit to patients with rare diseases. October 2010 Written evidence from Parkinson’s UK (COM 64) Executive Summary — Carers have not been given the consideration they deserve in this white paper. They play a huge role in delivering health and social care and need to have a central place, with patients, in the new system. — More detail is needed on how patients and carers will be included in GP consortia. Their place in commissioning needs to be an essential part of the new system and not just a token add on. We would like to see patient and carer representation on the boards of GP consortia. — There needs to be patient and carer representation on the NHS Commissioning Board. — Workforce planning is not addressed in the white paper. As this was previously part of the strategic health authority’s role we recommend the NHS Commissioning Board takes over this responsibility. — More detail needs to be given on the NHS Commissioning Board. We think that there should be devolvement to at least eight regional bodies. — Quality indicators on neurological commissioning need to be produced urgently to fill the gap left by the National Service Framework for long term neurological conditions. Unless this happens, neurological services will deteriorate. — Evidence based quality indicators need to be requirements for commissioning. This will give patients and carers entitlements to good quality health and social care. — There need to be sanctions and levers in place to protect services in the transition period. As it currently stands, there is hardly anything to steer commissioners for neurological services. These services are not strong enough to survive without support over the next two or three years. — Local and national HealthWatch need to be independent from the bodies they are monitoring. — GP consortia need to be coterminous with local authority boundaries if there is to be integration between health and social care. — More detail is needed on what the Coalition Government propose to do with low volume services. We would like to see this omission addressed by the health select committee’s inquiry. Accountability for Commissioning Decisions Patient representation 1. There is a lack of detail in the white paper about patient involvement. It is easy to say that patients will be involved, but the proposals give no detail about how this will happen. 2. We are concerned that the views of carers are not being considered as part of the Coalition Government’s proposals. Carers contribute substantially to the delivery of health and social care. Carers are estimated to save the Government between £67 and £87 billion a year yet receive scarce consideration in the white paper. This needs to be addressed and we would like to see the committee’s inquiry give consideration into the needs and views of carers. 3. We are a partner in Neurological Commissioning Support. In their evidence to the last select committee’s inquiry into commissioning they explained how patient representation within PCTs can sometimes be tokenistic. We think that this tokenism is likely to continue unless measures and guidelines are in place to address it. 4. The white paper does not give any indication that the views of patients and carers must be included, rather that GP consortia will probably include them. Patient and carer representatives need to have a place on the board of GP consortia. We know of examples where the view of the voluntary sector is already being sidelined. In one area we have been working with a multi-sector neurology network. This network has been lead by the voluntary sector with strong patient and carer involvement. We have tried to engage with the four GP consortia that will be taking over. We have been unable to persuade them to come to any of the network meetings and have been so far unsuccessful in being able to attend consortia meetings to explain the work of the network. In conversation with the minister he has told us that we do not have to wait for permission from the Department of Health to being conversations with GP consortia. We would like to express that these conversations are not always easy to arrange. Ev w162 Health Committee: Evidence 5. However, patient and carer representation needs to go beyond committee involvement. This needs to include a variety of involvement techniques such as focus groups, internet social networks, telephone interviews, house visits and visits to community places such as libraries. It is not enough to have a survey and a place on a committee. 6. We are also concerned that the proposed arrangements will make it extremely difficult for the voluntary sector to engage with commissioners. We currently someone working part time in each region (aligned to the strategic health authorities) working with people with people with Parkinson’s and their carers on developing services. It is difficult enough for them to develop relationships with each PCT in their area. When this fragments further down to GP consortia some areas will lose out. This is at a time when the voluntary sector is facing increasing funding difficulties. We are concerned that this will mean GP consortia who are not interested in taking account of the views of patients and carers will be able to sideline them unchallenged. The role of the NHS Commissioning Board 7. The white paper makes no mention of workforce planning. As this is something which currently falls within the remit of strategic health authorities, it needs to be addressed. We think that that NHS Commissioning Board could fulfil this function as GP consortia will be too small to address it. 8. In order to do this and if it is to fulfil its other functions adequately, it needs to have a regional structure in place. The proposals to have a national commissioning level and a local commissioning level leave too big a gap. There are a lot of specialised services commissioned at a regional level and this has not been addressed in the white paper. 9. The NHS Commissioning Board needs to produce requirements on commissioning neurological services. About 10 million people live with a long term neurological condition in the UK and they account for about 20% of acute hospital admissions. The previous administration produced the National Service Framework for long term neurological conditions. It contained sound, evidence based commissioning guidelines but unfortunately lacked the support needed to implement it. In this new world of commissioning, GP consortia need enforceable outcomes that support excellent neurological commissioning. Parkinson’s UK have skills and expertise to help in this. 10. If the new structure is to succeed in having integration across health and social care, the commissioning board needs to reflect this in its composition. We would like to see strong representation from local authorities, the voluntary sector, patients and carers. These groups need to have a place on the board. HealthWatch 11. We are concerned that the current proposals lack the independence necessary for effective monitoring and scrutiny. At a local level having Health Watch sitting within local authorities mean they are reliant on funding from the body they are supposed to be scrutinising. This is the same situation at a national level where they sit within the Care Quality Commission. We think this needs addressing for commissioning to work well. Integration of health and social care 12. We think the new structures could make integration between health and social care more difficult. If GP consortia are free to form across local authority boundaries we do not see how this will promote integrated working. 13. We have raised this concern with the minister who said that if GP consortia wanted to work across different local authority boundaries they should be free to do so. Our difficulty lies with how local authorities will engage with GP consortia, rather than how GP consortia will engage with local authorities. Social care is often the poor relation of health care. If local authorities, facing 25% budget cuts and a huge reorganisation of health services, have several GP consortia to try and negotiate with, people will fall through the gaps. 14. It will also make the scrutiny functions of HealthWatch and health and wellbeing boards extremely difficult. Instead of monitoring one GP consortia, they could be trying to scrutinise several. Some will likely to be easier to engage with and providing better services and some could be performing badly. The inequity of service provision is likely to be far worse, even within the same local authority. How will vulnerable groups of patients be provided for under this system? 15. We are concerned that vulnerable groups of patients will be worse off under the new system. PCTs have a duty to commission for everyone, whether they’re on GPs registers or not. This lacks this. Vulnerable groups are less likely to engage with services and more likely to need them. 16. The previous select committee inquiry found that PCTs weren’t using the available data effectively. We don’t think that GP consortia are likely to improve this. Instead, that monitoring role across patient groups will be lost. There will be no central monitoring of demographic data and vulnerable groups could fall out of the system entirely. Similarly, people in residential homes, who are currently hidden within the social care system, will stay hidden. Health Committee: Evidence Ev w163 Transitional arrangements 17. We know that the transition between the two systems is already causing difficulties. As mentioned previously, we are trying to start conversations with GP consortia and we are not always being listened to. 18. With many PCTs we have spent time developing relationships and putting our case forward for service development that will save money. One of the main areas we do this is with Parkinson’s nurses. In the example we quoted before, the PCTs had accepted our evidence and agreed that Parkinson’s nurses do save money and make a huge difference to the quality of life for people with Parkinson’s. We are now having to start from the beginning and this is causing delays to nurses being put in post. These changes are impacting on the purse strings of the NHS and causing further distress to people with Parkinson’s. 19. In evidence to the previous health select committee, the Neurological Commissioning Support explained how frequent staff changes within commissioning meant it was difficult to build relationships and that expertise was lost. These changes are exacerbating existing hurdles to good quality commissioning. 20. We are also concerned that the foundations for neurological commissioning are too weak to see health and social care services through the transitional period. The Coalition Government have abandoned the National Service Framework for long term neurological conditions without putting in place anything to replace it. Even with the National Service Framework in place, neurological services were often not meeting the quality requirements. Without it, we worry that the services that are in place will not continue to be commissioned by GP consortia. In two or three years time, neurological services could have fallen away with little impetus to replace them. Low volume services 21. The white paper fails to address low volume services in any detail at all. Some thought is given to specialist services and some thought is given to services used by many people at primary care level. However, “low volume” services are being treated as an afterthought. As a charity that represents people likely to fall within this category we are worried at how this will be resolved. It is difficult to comment as no detail is given in the white paper on proposed arrangements. We would like to see the inquiry address this issue. 22. We need to make sure that health and social care services are commissioned at the best level. Consideration has been given to what level specialist services should be commissioned at but not low volume services. October 2010 Written evidence from the Joint Epilepsy Council (COM 65) Introduction The Joint Epilepsy Council (JEC) is the umbrella body for 26 epilepsy organisations operating in the UK and Ireland. The JEC also provide the secretariat to the APPG on Epilepsy (APPGE). Epilepsy is a common serious neurological condition characterised by recurrent, unprovoked epileptic seizures, controlled for many, but not cured, with anti-epileptic drugs. Surgery works in some cases but is rarely available. There are about half a million people with epilepsy in the UK, that is one in every 131 or 705 in an average constituency. 990 people in England die every year of epilepsy-related causes. About 365 of those deaths are young adults and children. Of the total number of deaths about 400 per year are avoidable. A shameful 59% of childhood deaths are considered avoidable. Please note that we fully support the separate submission of our member organisation, the National Centre for Young People with Epilepsy. Commissioning Failures to date and the Response of Government There has been a deep and widespread failure to commission adequate services for people with epilepsy, examined and identified on many occasions and over a number of years, most recently in January 2009. The half a million people with epilepsy, their family, friends and carers will judge the White Paper reforms by how much improvement there is to the NHS service to them, a natural position given the poor service currently received. A very particular concern is that during the period of implementation of the White Paper reforms and subsequent evidence gathering, the small steps already undertaken by the Department in recognition of this acknowledged problem under the previous Government have stalled. In January 2010, the Department and the Joint Epilepsy Council in partnership, with support from a pharmaceutical company, arranged a London conference for NHS commissioners specifically concentrating on the problems of epilepsy commissioning. The then Minister Ann Keen spoke at the conference, as did Ev w164 Health Committee: Evidence the Minister now responsible for commissioning, the Earl Howe, who was then the Chair of the All-Party Parliamentary Group on epilepsy. At the conclusion of the conference he asked delegates to “go away and make a difference”. Ann Keen subsequently proposed a comparative study of the efficacy of Epilepsy Specialist Nurses (ESN) by comparing outcomes from a hospital with an ESN and one without. The new Government have declined to proceed with this study. The new Minister responsible for long-term conditions, Paul Burstow, has declined to meet with us to discuss these or any other aspect of the widespread failure to deliver an acceptable service to people with epilepsy. We therefore fear that it is the current Government’s intention to avoid the issue of epilepsy commissioning failures during this period of White Paper reform. The potential for no improvement in services to people with epilepsy over the next four or five years is not a position we can easily accept, given the urgent need to save lives, quality of life and the money squandered in providing a dysfunctional service. We recognise that our criticism of current commissioning failures is strongly put. Please see below the basis for that criticism. None of the following reports have led to a substantial improvement in the service. The Chief Medical Officer’s Report of 2001 called for a genuine commitment to put right “serious and long-standing weaknesses in the standard of care for people with epilepsy.” The NICE-funded National Sentinel Audit of Epilepsy-related deaths of 2002 showed that 39% of adult deaths and 59% of childhood deaths were potentially or probably avoidable. The Government’s Action Plan for Epilepsy was published in 2003. The Action Plan, which lacked targets or provision for monitoring outcomes, languished. The National Institute for Health and Clinical Excellence (NICE) published its clinical guideline on the epilepsies in 2004. Commissioners have not put in place the service structure that would allow clinicians to follow the NICE guideline. A service structure that did so enable clinicians would eliminate many of the difficulties. The National Service Framework on Long-term (Neurological) Conditions of March 2005, which remains in place under the new Government, whilst not dealing directly with the key challenges, did in theory offer to deliver some improvements. In 2007, the All-Party Parliamentary Group on Epilepsy (APPGE) warned that “progress towards success must be monitored or risk catastrophic failure”. A requirement that all Trusts and the NHS needed to demonstrate progress at the end of the planning period in 2008 was not met. Finally, a mid-term review of the NSF was announced in Summer 2009. The new Government has so far declined to make progress with this review. The key initiative that would directly address the failures in the service to people with epilepsy is the NICE clinical guideline on the epilepsies however the evidence is that the services have simply not been commissioned. In January 2009, clear proof was supplied in the form of a survey of Primary Care and Acute Trusts entitled “Epilepsy in England: time for change” published by Epilepsy Action and subsequently endorsed by the then relevant Minister, Ann Keen MP, in her letter to Strategic Health Authorities (SHAs) of July 2009 (see Appendix for copy letter). The headline figure in the survey amongst many other disappointing results was that more than 90% of the responding Trusts failed to meet the two-week guideline for first appointment with specialist, in some cases by a very wide margin. It would be wrong to view this as merely a ‘process target’, and it is worth noting the reasons why NICE considered this first appointment to be a matter of urgency. A specialist is required to diagnose epilepsy and no treatment is offered before diagnosis. The consequence is that many people suffer serious injury and even death before being offered treatment. The APPGE Report of July 2007 entitled “Wasted Money, Wasted Lives” (WMWL), again endorsed by Minister Ann Keen MP in her letter to SHAs of July 2009, drew upon figures from NICE and other sources to clarify that £189m was wasted each year in delivering the poor service to people with epilepsy. A misdiagnosis rate of 20-31% led to £22m wasted each year in clinical costs alone. Service failures and delays lead to many further calls upon NHS resources. It is also estimated that about 60,000 people with epilepsy claiming Disability Living Allowance could be returned to employment with good treatment. We remain concerned that these are not the sort of efficiency savings commissioners will be looking to achieve under the White Paper reforms. The clear and obvious service and commissioning failures need to be addressed directly and without further delay. Direct responses to some of the Committee’s specific questions: Health Committee: Evidence Ev w165 Clinical Engagement in Commissioning How will commissioners access the information and clinical expertise required to make high quality decisions about the shape of clinical services? A large part of this information will be available from NICE. Of course, much of this information is already available. In the case of the NICE clinical guidelines for the epilepsies of 2004, this has not led to the sufficient commissioning of services to enable clinicians to follow the guidelines. The question for us is how we can ensure that commissioners actually put into practice the clinical expertise available to them. The Department acknowledges failures in epilepsy commissioning. In January 2010, the Department, in open and full collaboration with ourselves, organised a conference for NHS commissioners specifically to address those failures. This conference generated a set of information which commissioners would find very useful if they were to act on it however, under the new Government, the momentum gained has been lost. Some further planned activity has not been acted on and the Minister responsible has declined to meet with us. Accountability for Commissioning Decisions How will patients make their voice heard or their choice effective? This will remain a difficult area. The proposed involvement of Local Authorities and Health Watch gives little encouragement to the low-volume, high needs patient groups to think that their needs will be taken into account any more than they are now. Much expertise rests in national patient bodies and they are better able to make the case to commissioners than local bodies. What will be the role of the NHS Commissioning Board? The National Commissioning Board will retain commissioning responsibility for defined specialised services. Surgery for children with epilepsy is included in this list. Our experience of current commissioning for this is that it is another area of failure. Epilepsy surgery (the only curative treatment) is conducted on around 100 children annually in the UK yet research demonstrates that there are around 400 suitable cases each year. Each year, another three hundred children miss out on potentially life changing surgery and the wasted costs of their treatment continue to accrue. How can we ensure that the National Commissioning Board will perform better than the existing arrangements? Where will the “buck stop” when commissioners face hard choices? It is inevitable that, whatever intermediate barriers are put in place, Government must accept the final responsibility for delivering an adequate service. Responsibility for the expenditure of such a large part of the public purse cannot ultimately be devolved. Integration of Health and Social Care How will any new structures promote the integration of health and social care? It is not clear to us whether the new structures will promote integration however there are particular problems in the specialist commissioning for the low volume, high needs group of people with epilepsy who require residential accommodation which Government could address now and which would smooth some of the barriers to integration. It is not reasonable to expect local commissioning of the specialist residential and nursing care services which these patients need and it is unlikely that such services will exist locally. The current recommended approach is for PCTs to group together to commission these services. In the main, this is not happening. The “solution” adopted by many PCTs is to place the service-user into cheaper but inappropriate non-specialist residential care. It is an issue faced by many charities supporting specific disability groups where needs are high but numbers are relatively small. Additionally, and increasingly in the current economic climate, the pressure on budgets has led to commissioners regularly offering fees which fail to meet the cost of providing the care that is needed and, on occasions, threatening to remove a patient correctly placed in a specialist setting to an inappropriate, less specialist care setting. There are instances where this threat has been carried out. Wasted Money, Wasted Lives in 2007 recommended that Government develop a National Plan for specialist residential care. These service users cannot wait to find out if the White Paper reforms will improve the position. The damage is occurring now. There is another issue faced by those in a residential care setting and this relates to the “ordinary residence” rules. When a patient has, through the care provided in specialist residential accommodation, become more able to live independently, the rules of ordinary residence create bureaucratic difficulties when people wish to leave residential care. Such patients may have been in residential accommodation some time and often wish to move to supported housing in that area. Ev w166 Health Committee: Evidence The consequence of the ordinary residence rules is that the duty to fund their needs now falls on the receiving local authority, rather then the one who placed the patient in the residential accommodation. This can create an unfair burden on local authorities where these rare specialist centres are located and, for the patient, commonly leads to extensive delays and uncertainty. There are only negative consequences flowing from these problems. Whilst the move to much cheaper supported housing is blocked and delayed, the overall costs to the State are increased. Equally, for the patients used as pawns in this way, their right to live independently and self-manage their condition asserted by Government policy as laid out in 2006 in the White Paper “Our Health, Our Care, Our Say” and elsewhere is denied. Wasted Money, Wasted Lives recommended that Government bridge the gap between policy and practice by developing guidance to local authorities to ensure resources follow the individual when moving from residential care into supported housing. This would avoid both negative consequences described in the previous paragraph at a stroke. Intervention by Government now would eliminate these wasteful inequities and lay a much firmer basis for sensible residential accommodation commissioning in a future under the White Paper reforms. How will the New Arrangements Strengthen Commissioners against Provider Interests? How will vulnerable groups of patients be provided for under this system? Some method of oversight from the National Commissioning Board needs to be provided to ensure that low-volume on a local level does not equate to a lack of priority. Transitional Arrangements Who will drive innovation during the transitional period? We perceive a very real danger that innovation during the transitional period will stall as Government and relevant agencies strongly focus on delivering the reforms. These very substantial changes will take several years to be fully functional and there will be a period following that when new evidence will have to be gathered to demonstrate any failures. We are discouraged by the discontinuance of Departmental support for improving epilepsy commissioning and further discouraged by the inability of the responsible Minister for long-term conditions Paul Burstow to meet with us to discuss these issues. Specialist Services What arrangements are proposed for commissioning of specialist services? The National Commissioning Board will retain commissioning responsibility for defined specialised services. For example, surgery for children with epilepsy is currently included in this list. Consideration should be given to including all children’s and some adult services for epilepsy in order to drive up standards on a national basis before devolving them, where appropriate, to local consortia. Despite concerns that current specialised commissioning has been failing children with epilepsy, a revitalised national commissioning strategy could be the way to drive improvements. October 2010 APPENDIX COPY OF LETTER OF JULY 2009 FROM HEALTH MINISTER ANN KEEN MP TO STRATEGIC HEALTH AUTHORITIES SHA Long-Term Conditions Leads July 2009 Dear I would like to draw to your attention the report Epilepsy in England: Time for Change, which was published by Epilepsy Action earlier this year. Epilepsy in England: time for change, which is available on Epilepsy Action’s website at www.epilepsy.org.uk/timeforchange, reports on the results of a survey of acute trusts and Primary Care Trusts (PCTs) in England as well as a survey of people with epilepsy. The results of these surveys revealed wide variations in the provision of epilepsy services, as well as variations in the collection of information and the quality of care provided. Particular problems indentified in the report included: — access to specialists in epilepsy; — waiting times for a first appointment; — access to diagnostic tests; and — the lack of care plans and transition services. Health Committee: Evidence Ev w167 These problems principally stem from low levels of implementation of the National Institute for Health and Clinical Excellence (NICE) clinical guideline on the diagnosis and care of children and adults with epilepsy. Epilepsy in England: time for change follows an earlier report, Wasted Money Wasted Lives, published by the All-Party Parliamentary Group on Epilepsy in 2007. This report raised similar issues in terms of variable implementation of the National Service Framework (NSF) for Long-term Conditions and NICE guidance and highlighted the social, economic and personal cost of not implementing this guidance. I know that many PCTs are working towards full implementation of the NICE clinical guideline, as well the NSF for long-term conditions, and I would like to reinforce the importance of the NICE guidance and NSF in delivering high quality, accessible services to this client group. Investing in the services envisaged in both the NSF and NICE guidance will help people live more independently, improve their quality of life and be a more cost effective way of providing services. The Epilepsy Action report’s recommendations are directed at NHS organisations as well as the Department of Health. I hope that, with your partners, you give appropriate attention to the messages contained in the report to ensure better outcomes for service users and their carers. Thank you in anticipation of your support for this important area of work. With best wishes, Ann Keen Parliamentary-Under Secretary of State for Health Written evidence from the National Housing Federation (COM 67) Integrated working across health and housing results in better health outcomes for communities and achieves significant cost savings for the NHS. Summary of Conclusions and Recommendations — Housing associations’ work lightens the burden on health services, facilitates hospital discharge, tackles inequalities and promotes good health for the most vulnerable people in society. Housing related support delivers cost savings of £315 million to the health service in a year. — Genuinely joined up commissioning across health, social care, public health and housing should be valued as a mechanism for securing the right services for the most vulnerable people in society. — The National Housing Federation’s evidence shows that there is currently a lack of collaborative working by Primary Care Trusts (PCTs), with only 20 out of 152 PCTs scoring level three (out of four) under the relevant World Class Commissioning (WCC) competency. Opportunities are being missed to deliver key preventative outcomes by working with community partners. — Health commissioners need to do more to realise the significant potential benefits and savings to be made by commissioning across housing, health and social care. This will involve more positive risk taking, and strong transitional arrangements as reforms take effect. — As responsibility for commissioning shifts, the transitional period should be used to preserve and build upon any progress which has been made. The Department of Health (DH) should take a leadership role in drawing PCTs and GP consortia together as they form, to ensure that institutional knowledge and experience is not lost when it comes to joint commissioning. — The Government should ensure that appropriate outcome indicators are in place to encourage the health sector to pursue effective integrated commissioning. This should include discharge from hospital into appropriate settled accommodation—never, in the case of homeless people, to the streets. In addition, the proportion of adults with learning disabilities and mental health problems living in settled accommodation should be monitored, in line with proposed parallel indicators on employment for these groups. — Housing related support is facing significant funding cuts which could incur costs for the health sector. This makes the case for more integrated commissioning all the more urgent. — In order to maximise government investment in housing related support, action should be taken to track funding allocation and local spending for these services in the future. — Smarter, longer term commissioning practice is needed across health, local authorities, public health services, Supporting People (SP), and social services. This would result in less bureaucracy for commissioners and more stability for clients. — To meet the ambition of personalised services, commissioners need to take a role in managing local markets, in terms of the availability of the range of different services to which people may want to have access. Ev w168 Health Committee: Evidence — The Joint Strategic Needs Assessment (JSNA) process should be aligned to the Strategic Housing Market Assessment, or any successor assessment of housing need. — Local health and wellbeing boards should ensure that they fully link with housing decision makers to deliver the joined up priority setting which can deliver more coherent commissioning. In addition, Directors of Public Health could report to housing committees. — As National Institute for Health and Clinical Excellence (NICE) quality standards are developed, there is an opportunity to recognise the role that housing solutions can play in helping commissioners to achieve against these standards. Introduction 1. The National Housing Federation represents 1,200 housing associations. Collectively, our members provide two million homes and community services for five million people. Approximately 700 Federation members provide care and support services for some of the most vulnerable people in society, including many people who have no contact with statutory services. 2. The services offered by housing associations deliver a range of health benefits through specific community health initiatives and by providing housing related support to improve people’s health, wellbeing and independence. This includes work with a range of client groups such as people with learning disabilities, people with mental health problems, ex-offenders, women fleeing domestic violence, older people and many more. 3. Housing and housing related support can improve health and reduce demand for health and social care services, enabling the full benefits of other services to be realised.94 At the same time as improving the health of individuals, the Government’s own analysis shows that housing related support delivers major cost savings to the public purse. 4. More consistent engagement and integrated delivery between health and housing care and support is a practical way of preventing ill health, tackling health inequalities, and saving health service expenditure. Housing Associations’ offer to the Health Sector 5. Housing acts as a health intervention, as well as a delivery mechanism for health services. The work of housing associations effectively: — reducing the burden on health services, including preventing admissions to hospital; — supports discharge from hospital by making sure that homes and support services are ready for people to return; and — forms an important part of care pathways.95 6. Our members achieve this by providing: — high quality, suitable accommodation; — direct health advice and support through community health workers and healthy living initiatives; — supported housing and care and support services for older people to help them live independently; — specialist accommodation and floating support to help people with mental health needs stabilise their lives, recover or maintain a tenancy and live more independently; — support for homeless individuals with complex and multiple needs; — refuge and support for victims of domestic violence; and — handy-persons services, which provide a trusted home repairs service for older and vulnerable people, and can prevent falls. Delivering Value 7. More than offering better value to the health service, housing related support delivers in-year cashable savings to the public purse through this work. A Department for Communities and Local Government (CLG) study of the benefits of the Supporting People (SP) funding programme estimated that £1.6 billion of funding for housing-related support services generated savings of £3.41 billion to the public purse, including £315 million of savings to the health service, by avoiding more costly acute services.96 94 95 96 Bolton J, The use of resources in adult social care: a guide for local authorities, DH, 2010. National Housing Federation, Health and housing: worlds apart? Housing care and support solutions to health challenges, 2010. CapGemini, Research into the financial benefits of the Supporting People programme, CLG, 2008. Health Committee: Evidence Ev w169 8. Housing associations across the country are delivering cost savings to the health service through the pursuit of effective and innovative community-based programmes. DH’s Care Service Efficiency Delivery unit (CSED) argues that commissioners must now move on from acknowledging the interdependence between housing, health and social services, and make it a reality.97 Durham County Council, Three Rivers Housing Association and the Richmond Fellowship have jointly developed a supported living service to help people step down from psychiatric hospital to independent living, including four weeks of floating support to help reduce the risk of rapid readmission through relapse. CSED estimates that the Three Rivers Housing Association project saved £135,000 for the NHS in one year of its work with eight clients.98 Threats to Health of Vulnerable People 9. The housing sector is expecting significant cuts to the SP funding it receives to provide housing related support. The National Housing Federation estimates that a cut of 40% to housing related support funding could that mean up to 438,000 vulnerable people could lose the support on which they currently rely.99 This includes a wide range of clients such as 14,729 people with mental health problems, 12,709 people with learning disabilities, and 3,765 people with drug and alcohol problems. 10. At the time of writing, the outcome of the Government’s Spending Review is not yet known, and we do not yet know the full extent to which SP funding will be cut. However, it is important to remember that local authorities have freedom over funding for housing related support, so the level and focus of cuts will vary locally. The Federation believes that action should be taken to track funding allocation and local spending for these services in the future. 11. Such cuts to funding for housing related support could put under threat the significant savings it delivers to the health service, which total £315 million in a year. In fact, the Federation estimates that in losing the cost benefits which would otherwise exist, cuts of 40% to housing related support for people with mental health problems could cost the health service an additional £1.3 million, and similar cuts to services for people with learning disabilities could cost £6.8 million to the NHS.100 12. Even those areas of spending that are protected, such as health, will face a real terms cut and will struggle to keep up with increasing demand coupled with the increased costs of new technologies and pharmaceuticals, as previously highlighted by the Health Select Committee.101 The NHS can and should manage the demand for those forms of care which have a higher cost, and housing and housing related support can do this. Preserving Housing’s Contribution Through Commissioning 13. SP provides a good example of how a range of voices within a local area can be brought together effectively. In doing this, a variety of partners can make difficult local decisions about priorities between client groups. 14. There is a risk that as the health landscape undergoes a major period of reform, and as commissioning responsibilities shift, any progress which has been made in joined up commissioning could be lost. PCTs will cease to exist in the new health world, so it is vital that the current transitional period is used to ensure that expertise, relationships and evidence are preserved. The DH should take a role in drawing PCTs and GP consortia together as they form, to ensure that institutional knowledge and experience is not lost when it comes to joint commissioning. This could involve hosting events and promoting good practice, for example. 15. Positive risk taking is needed on the part of health commissioners. Currently, very strong evidence of clinical outcomes is required, which doesn’t allow for interventions which have a positive health outcome and deliver results for the health service, but for which the evidence available is not of a clinical nature. There is a need for commissioners to accept different types of evidence in order to reflect social and community level outcomes. 16. Furthermore, the Government has committed to delivering for the most vulnerable people in society, so health commissioners need to consider the role they play in meeting these commitments. To deliver for these groups of people, local needs ought to be fully understood, and services should be commissioned from a broad base. Marginalised groups may require highly specialised services to promote inclusion and help them access health services. These go beyond the boundaries of traditional health services. 97 Care Service Efficiency Delivery, Support related housing: incorporating support related housing into your efficiency programme, DH, 2009. Ibid. 99 National Housing Federation research, 2010, based on CLG SP data collection. 100 National Housing Federation research, 2010, based on CLG SP data collection and on CapGemini, Research into the financial benefits of the Supporting People programme, CLG, 2008. 101 House of Commons Health Select Committee, Public expenditure on health and personal social service, 2009. 98 Ev w170 Health Committee: Evidence Joint Commissioning: the current picture 17. The existing performance management system for health sector commissioning, World Class Commissioning (WCC), offers opportunities to understand how commissioners are performing and how they are engaging with local partners. Although the programme will no longer be used, it gives a picture of current local commissioning. Working Collaboratively 18. Effective joint working demands a genuinely collaborative approach to commissioning which has so far been lacking. In a score range of between one and four (where one is low and four is high), only 20 out of 152 PCTs scored level three in the competency measuring collaborative working, with the majority (124) only achieving level two.102 19. Even with such mechanisms as SP in place to provide encouragement, there is still some distance to travel towards integrated working. The Audit Commission noted in 2009 that despite the capacity of SP to bring together different commissioning interests, there was still a lack of joint commissioning taking place.103 20. It is worth noting that there have been some improvements made—the NHS Confederation PCT Network’s analysis shows that an average score of 2.11 in 2008–09 rose to 2.65 in 2009–10.104 It is vital that as health service reforms are realised, steps are taken to preserve the progress that is being made in collaborative working between the NHS and its partners. Analysis by CSED shows that this can be achieved by gathering an accurate picture of local needs, and by agencies coming together to pool funding to meet this need.105 Place-based Budgeting 21. Place-based budgeting is a valuable attempt to encourage integrated working and could in part explain the increase in performance outlined above. Unfortunately, the Federation’s research found that there appears to be no relationship between those PCTs involved in the Total Place pilot scheme and the score awarded against competency two which measures collaborative working.106 22. The principle of place-based budgeting has the potential to act as a good way of integrating health and social care services with the new public health service. But the development of other health and housing mechanisms is needed in order to meet this ambition—particularly as responsibility for public health shifts and as commissioning is opened up to community organisations. NHS Commissioners’ Priority Setting 23. NHS commissioning has the potential to open up health service provision to the voluntary and community sector, and thus deliver cost effective, expert services which meet health objectives. 24. Under the current WCC system, there are several indicators that are particularly pertinent to working with community partners,107 such as reducing delayed transfers of care, unscheduled hospital admissions in people aged 75 and over, and adults in contact with secondary mental health services who are in settled accommodation. 25. The Federation’s analysis shows that around a third (36%) of all PCTs selected three or more of these relevant indicators in year one of World Class Commissioning.108 Leicester City PCT, for example, has prioritised five issues which fit well with the joint working agenda. Housing associations help NHS commissioners to achieve these priorities, and some PCTs have recognised this by commissioning housing care and support services. While the NHS will soon move away from this target system, analysis of current practice helps to understand what motivates health partners. Wakefield and District Housing: health equality workers As a housing association, Wakefield and District has close contact with vulnerable residents, many of whom may not be inregular contact with health services. The PCT therefore saw a need to fund five health workers for two years to offer intensive health support to tenants, such as stopping smoking and addressing low-level mental health needs. This is a new initiative, and evaluation is expected to show that the scheme delivers effective preventative and early intervention health services. 102 National Housing Federation, Bringing health and housing together in the new world, Health Mandate, 2010. Audit Commission, Supporting People Programme 2005–09, 2009. 104 NHS Confederation’s PCT Network, PCT World Class Commissioning assurance results 2009–10, 2010. 105 Care Service Efficiency Delivery, Support related housing: incorporating support related housing into your efficiency programme, DH, 2009. 106 National Housing Federation, Bringing health and housing together in the new world, Health Mandate, 2010. 107 Relevant WCC indicators include: reducing delayed transfers of care; independence for older people; health improvement in deprived areas; rate of hospital admissions per 100,000 for alcohol related harm; adults in contact with secondary mental health services in settled accommodation; unscheduled hospital admissions of people aged 75 and over per 100,000 population; reducing acute inpatient admissions to mental health units. 108 National Housing Federation, Bringing health and housing together in the new world, Health Mandate, 2010. 103 Health Committee: Evidence Ev w171 26. There is, however, considerable variation in PCT performance when it comes to those areas which can benefit from community interventions. The Federation has found that there are significant differences between PCTs when it comes to the mean length of hospital stay, with delayed discharge ranging from 0 to 90 days. These variations can be explained in part by appropriate care not being available in the community.109 Housing associations, working together with PCTs, can help to improve discharge practice. The Safe and Sound scheme run by Brighter Futures helps older people in Stoke on Trent to live safely and independently for as long as possible. Initially, many customers first came to the scheme at the point of discharge from hospital, and from October 2010 the scheme forms an integral part of the Frail Elderly Assessment Unit’s care pathway at University Hospital North Staffordshire. Clients are offered practical support to improve their health and wellbeing. Safe and Sound is jointly funded by SP and NHS Stoke as a way of preventing the need for health services and preventing readmissions to acute services. 27. The NHS should take action to open up the health market to voluntary and community sector providers. In particular, more commissioning bodies should prioritise those areas above as a way of preventing further ill health and saving the NHS money. Improving Commissioning Practice 28. Smarter commissioning practice is also needed in order to improve outcomes and ensure that value for money is realised. This should be reflected in tendering and contracting processes which encourage stability and reduce bureaucracy. 29. The Federation’s survey of SP commissioning and funding highlighted an environment of short term contracts alongside cuts in contract prices, resulting in uncertainty for vulnerable client groups.110 Our survey found that 36% of the contracts included in the survey were of less than three years in length, including 22.8% which were a year or less. This constant cycle of retendering means added bureaucracy for all involved. Health commissioning can draw parallels from these experiences, in order to encourage organisations to continue to act as providers. 30. Furthermore, as local authorities take on further responsibility for public health, it is vital that lessons are learned from experiences in commissioning and contracting, and that health commissioning follows existing good practice. Without this learning, there is a risk of uncertainty for clients, added bureaucracy for commissioners and poorer value for money. Personalisation: making choices effective 31. The personalisation agenda is here to stay and organisations are no longer asking whether they can ensure services offer genuine choice, but how service users can be put in the driving seat for the support they receive. To achieve the aim of choice, control and flexibility, it is important to foster partnership across different sectors. 32. Personalisation is about more than passing money directly to service users—there is still an important role for commissioning to play here. As the Institute of Public Care notes, there are significant challenges posed in balancing the need for efficiency, effectiveness and individual choice, including ensuring sufficient investment in service development and innovation.111 In considering these challenges, it is important that a range of contracts are in place and that a diversity of provision is sought out. Commissioners need to take a role in managing local markets, looking at the availability of the range of different services to which people may want to have access. Assessing Local Needs 33. Assessing and understanding the entirety of local needs is key to making sure joined up commissioning is effective, therefore bringing local health improvements as well as cost benefits. 34. The Joint Strategic Needs Assessment (JSNA) is a powerful opportunity to bring this needs assessment together and to develop the right conversations and relationships across sector boundaries. Using the JSNA process to determine the need of specialist and supported housing in an area will help to connect planning, housing, health and social care in the area. In order to realise the benefits of links between health and housing, the JSNA process should be aligned to the Strategic Housing Market Assessment— which all local authorities must carry out in order to get a comprehensive picture of the need for housing— or any successor assessment of housing need. 109 110 111 Ibid. National Housing Federation, Supporting People commissioning and funding survey, 2009. National Market Development Forum, How will “personalisation” change the way services are procured?, Institute of Public Care, 2010. Ev w172 Health Committee: Evidence Future Mechanisms for Change NHS Outcomes Framework 35. The Government should ensure appropriate outcome indicators are in place to encourage the health sector to pursue effective integrated commissioning. The indicators which form the new NHS outcomes framework should ensure they create opportunities for local health bodies, at both commissioner and practice level, to work across different sectors to deliver to local needs. This should include discharge from hospital into appropriate settled accommodation, and the proportion of adults with learning disabilities and mental health problems living in settled accommodation. The draft NHS Outcomes Framework rightly includes an indicator to measure the proportion of adults in these client groups who are in employment, and a parallel indicator to reflect the importance of settled accommodation should also be developed. A public health service 36. There are concerns that the planned three-way split in health between the National Health Service, a public health service, and social care, could create further silos. Housing and housing related support offer solutions in all three of these key areas and can act as the pivotal point in delivering access to a range of local services for vulnerable people. Again, transitional practice and relationships with organisations across the spectrum of local service provision will be key here. 37. Local health and wellbeing boards should ensure that they link fully with housing decision makers to deliver the joined up priority setting which can bring about more coherent commissioning. In addition, Directors of Public Health could report to housing committees. Quality standards 38. As the suite of NICE quality standards are developed, there is an opportunity to recognise the role that housing solutions can play in helping commissioners to achieve against many of these standards. The acute mental health standard, for example, should look toward housing and ensure that the care pathway does not end when a patient is discharged from secondary care. October 2010 Written Evidence from the South East Coast Specialised Commissioning Group (COM 68) Summary — This submission of evidence to the Health Select Committee is from the South East Coast Specialised Commissioning Group. — It focuses on themes in the invitation to submit that relate to the commissioning of specialised services. — We broadly support the proposals in the White Paper with regard to the proposed future arrangements for Specialised Commissioning which will potentially bring benefits to both patients and provide a more efficient way of commissioning Specialised Services. — The proposals do create a number of challenges that need to be worked through in order that the proposals for Specialised Commissioning can work effectively within the commissioning landscape described. These are largely about: — risks of creating perverse incentives across the Specialised:Non Specialised healthcare interface associated with which body is responsible for paying for healthcare; — risks of disjointed planning by different commissioning agencies where there are interdependencies between services commissioned by different bodies; and — an inherent policy conflict between the White Paper’s vision of a deregulated and marketised provider landscape and the Government’s commitment to continue with Sir David Carter’s recommendations relating to Specialised Commissioning (which call for restricting healthcare markets for specialised services in order to achieve critical mass of patients to provide services that are safe and sustainable). Introduction 1. This submission of evidence is from the South East Coast Specialised Commissioning Group (SECSCG) to the Health Select Committee Inquiry into Commissioning. 2. SECSCG is one of ten Specialised Commissioning Groups that are coterminous with the ten Strategic Health Authorities (SHAs) in England. Formally, it is a joint sub-committee of the Primary Care Trusts within the South East Coast SHA area, and supported by a specialist team of commissioning managers; finance staff; informatics staff; a consultant in public health medicine; and a pharmaceutical adviser. The Role of the SCG is to commission specialised services (and other services delegated to it) on behalf of the constituent member Primary Care Trusts. Health Committee: Evidence Ev w173 3. This submission focuses on the themes articulated in the invitation to submit written evidence that relate to the commissioning of specialised services. As such, it does not address all of the questions posed in the invitation. 4. The future commissioning arrangements for Specialised Commissioning are subject to significant proposed changes outlined in the NHS White Paper—Equity and excellence: Liberating the NHS. The direction of travel articulated in the White Paper, and the detail of implementation are outside of the control of SECSCG. As such, the evidence that we are providing is our reflections on the White Paper and the opportunities and challenges that arise relating to the commissioning of specialised health services. Opportunities 5. Our view is that the proposal in the White Paper to align national and regional specialised commissioning arrangements within the new NHS Commissioning Board is a helpful one, which will contribute significantly to the effectiveness of specialised commissioning by enabling a more consistent approach to specialised healthcare thus enabling a reduction in regional variation in the availability and range of specialised services and thresholds for access. 6. This will be hugely beneficial to patients and will also see greater efficiencies in terms of reducing duplication in some functions that are currently replicated across 11 Specialised Commissioning Teams (the 10 SCGs and the National Specialised Commissioning Team). 7. This streamlining of accountability for Specialised Commissioning will also free-up a not inconsiderable amount of management resource, as managing accountability relationships with each individual PCT for specialised services has been a process that has, at least in some areas, involved a significant workload. 8. This proposed approach could also offer greater synergies in terms of the planning of (regional) specialised and (national) highly specialised services that are currently commissioned independently of each other. This will be possible because: — In future, they will both be commissioned by the same organisation. — The 50 nationally designated Highly Specialised Services are, almost without exception, incorporated into one of the 34 Specialised Services National Definition Sets. — The Secretary of State will decide on the scope of both the portfolio of Highly Specialised Services and the scope of the SSNDS. 9. The proposal to commission on the basis of outcomes is a helpful one that has a real potential to improve the quality of healthcare, but if this is to be fully realised there is a need to ensure that, in relation to specialised services that, these outcome measures are specific and tailored to the rare and unusual conditions that specialised commissioning is set up to meet the needs of. To meet this requirement it will be important to ensure that there is good and directed public health support to specialised commissioning structures in the future to enable this to be developed. The nature of specialised services being low volume often means that there is a somewhat limited evidence base and availability of good outcome data. This directly reflects the low patient numbers which make is difficult to obtain statistically significant evidence. It is also because these services have not been the subject of work by NICE or any other national body and often requires review of international best practice. This key difference relating to Specialised Services requires a high degree of Public Health input in order to inform complex commissioning decisions in an evidence light area of healthcare. This also pertains to the development of standards where NICE has mainly focused on more mainstream areas of healthcare provision. We strongly support that payment to providers is based on outcomes in the future, to increase quality. Challenges 10. Specialised services do not operate in isolation from other Healthcare activities and generally form part of a broader pathway of care. As such, consideration needs to be given to how the planning and procurement of specialised services fits into the wider commissioning landscape to facilitate the creation of effective pathways of care for patients. 11. In the current NHS configuration, Specialised Commissioning Groups (SCGs) act as an agent of Primary Care Trusts who hold the vast majority of resources for securing health services for their population, and as such expenditure on Specialised Commissioning by SCGs comes out of the same financial allocation as for other health services. In this context, it has not been essential to have a clear delineation of the functions of Specialised Commissioning from those of other commissioning functions as “the money ultimately comes out of the same pot”. This has resulted in SCGs commissioning a different range of services from each other; or in some cases, largely for historical reasons, SCGs commissioning different services for different Primary Care Trusts within their patch. 12. Even when considering individual Specialised Services, there are variations in terms of threshold for access to a Specialised Service (eg for Morbid Obesity Surgery, funding is granted on the basis of Body Mass Index—different SCGs will fund at different levels) and variations in terms of what patients can access (eg Assisted Conception—where some PCTs will fund up to three cycles of IVF whereas others (like Warrington and North Staffordshire) have taken a view that they will not fund this at all). Less apparent is the Ev w174 Health Committee: Evidence relationship between Specialised and non-Specialised services where onward referral to a tertiary (specialised) service from secondary care may be more influenced by the experience and confidence of the secondary care clinician than a clear definition of what activity should be commissioned by and delivered from a SCG funded service arrangement. 13. In future, where the resource allocation for Specialised Services is likely to be held separately from that for healthcare services that will be planned and commissioned by GP Consortia, it will be essential to end this ambiguity for a number of reasons: — Risk of duplication or overlap between services resulting in poor patient care. — Providers will need clarity on who to code as responsible commissioner in SUS data returns and therefore invoice for activity. — To minimise transaction costs (particularly where providers have relationships with more than one commissioner) there needs to be consistency. — Increased scope for perverse incentives to develop around cost-shifting from one resource allocation to another. 14. A lack of clarity about the entry threshold for Specialised Services could create a number of perverse incentives in the system as follows: — Providers referring on, or not accepting the more complex/more resource intensive non-specialised patients in favour of these being admitted into specialised services. — Providers that undertake both specialised and non-specialised care attributing activity to Specialised Commissioning funding streams where this is more financially rewarding. — GP Consortia choosing not to prioritise the commissioning of effective Secondary Care services in favour of patient flows towards Specialised Services (and therefore not a cost to their commissioning budget). — The gradual de-skilling of the clinical workforce in secondary care as a result of any or all of the above could have a compounding effect and result in greater numbers over time being referred onto Specialised Services. 15. On the basis that Specialised Services are often more expensive than Secondary Care, the result of any of these scenarios would result in the NHS as a system achieving less Health Utility from its expenditure. Furthermore, for many areas of healthcare provision there would be opportunity costs given that the capacity of Specialised Services are not unlimited and every bed occupied by one patient is a bed unavailable for another. 16. Similarly, the separation of Specialised Commissioning from the commissioning of local services could exacerbate perverse incentives with regard to the discharge of patients from Specialised Beds. 17. Patients with continuing healthcare need but who are fit for discharge from a Specialised Commissioned service could be overlooked or have discharge arrangements delayed as “someone else is paying” while they remain in their current setting. 18. Consideration needs to be given to what levers can be put in place to minimise delayed discharge from services commissioned by the NHS Commissioning Board. 19. Many Specialised Hospital Services for Adults require episodes in Intensive / Critical Care as part of a hospital spell. This activity is commissioned separately and reimbursed under Tariff. In the current commissioning structure, this is ultimately all funded from PCT Revenue Allocations, however the direction of travel suggests that this will not be the case. 20. If the arrangements for funding Adult Intensive Care remained unchanged within the new commissioning landscape, a situation would be created where providers of Specialised Commissioned Activity would be committing resources of GP Commissioners. This could potentially create conflict in the system in future. 21. Intensive/Critical Care for Highly Specialised Services is often within the contractual arrangements for that Highly Specialised Service. 22. Consideration should be given as to what the commissioning arrangements should be in future for Adult Intensive Care where the underlying reason for the episode is within the scope of the Specialised Services National Definition Set. 23. Many Specialised Commissioned services have interdependencies with or require co-location with services that are non-specialised (eg Specialised Orthopaedics will require infrastructure also used to provide secondary Orthopaedics and will draw on the same range of disciplines—such as Physiotherapists). Any change to the commissioning arrangements of a non-specialised service could have a knock on effect on the viability of a Specialised Service (or vice-versa). 24. As such, there is a real need for local intelligence and relationship management with other commissioning stakeholders at local level to ensure that there are no unintended consequences created in the system by the commissioning decisions of one body impacting on another. Health Committee: Evidence Ev w175 25. Sir David Carter’s review of Specialised Commissioning introduced a process for “designation” of specialised services similar to the role undertaken by Secretary of State in designating Highly Specialised Services. Carter recommended that a programme of designation of services within the SSNDS be undertaken with all services being designated within five years and re-designation to take place on a fiveyearly cycle. 26. The purpose of designation is to assure the commissioner (and the patient) of the quality of service, whilst at the same time, managing/restricting the market in order to achieve the necessary critical mass of patients to enable a clinically and cost effective service to be provided. 27. The issue of ensuring a critical mass for clinical effectiveness is a key one for many specialised services where there is a need to maintain clinical skill and knowledge and provide an effective platform for training in rare sub-specialties which can only be maintained with a sufficient volume and casemix of work to provide sufficient exposure and experience. 28. Resolving the inherent policy conflict between the direction of travel outlined in Carter and the wider NHS Policy around a competitive market has been problematic, and has proved a barrier to SCGs moving forward with this agenda, and to date limited progress has been made by any SCG on designation. 29. Consideration needs to be given to how the NHS Commissioning Board will identify providers of Specialised Services in future, and what mechanisms will be necessary to ensure that issues such as critical mass of activity balanced against geographical access are resolved. Conflicts between policy objectives to widen and restrict the market need to explicitly be resolved in order not to paralyse the future direction of Specialised Commissioning. 30. There are particular challenges facing commissioners of specialised services from an information perspective. Many areas of specialised healthcare provision suffer from inadequate granularity in terms of the underlying coding (as a result of lack of specificity in terms of OPCS Surgical Codes and ICD-10 Medical Codes) and problems with the integration of necessary bespoke datasets to support specialised services with mainstream healthcare informatics systems (such as the Secondary Uses Service of the NHS Spine), this will need addressing in order to deliver the information required to support the Governments intent to better care, better outcomes and reduced costs. We would suggest that as part of the forthcoming NHS Information Strategy that there needs to be a particular focus on the information needs of Specialised Commissioning to enable this area of commissioning to operate in a data rich environment in the future. October 2010 Written evidence from Brook (COM 69) Introduction — Brook is the country’s leading sexual health organisation for young people, offering young women and men free, confidential sexual health services and advice from a network of Centres throughout the UK and Jersey. Brook has 45 years’ experience of providing services through specially trained doctors, nurses, counsellors, and outreach and education workers to over 260,000 young people each year. — This document represents the Brook network’s corporate response to the call for evidence by the Health Committee for its inquiry into commissioning. — This response concentrates on the potential implications of the recent proposals for young people’s sexual health services, and contributes to the debate on how to ensure effective commissioning for young people’s services. Short Summary of Response — We are concerned about the proposals to dismantle the current PCT commissioning framework and develop new commissioning frameworks through GP consortia. A significant amount of work has been undertaken in recent years to improve the quality of commissioning, and significant progress been made towards achieving the world class commissioning competencies. The impact of this radical change, in our view, will be twofold. — Firstly we believe PCTs and SHAs will divert their energies into supporting the development of GP commissioning consortia and Commissioning Board/s and thus the quality of commissioning for young people’s sexual health services will suffer and, — Secondly as a significant number of GP consortia have little or no experience of commissioning young people’s sexual health services, young people’s sexual health services will either be consumed into age services, or be de-commissioned, as GP consortia, like PCTs before them, begin their long journeys along the commissioning learning curve. Ev w176 Health Committee: Evidence — We are concerned that the experience and expertise that PCTs have gained in commissioning, service design and performance management, could be lost as a result of the abolition of PCTs, particularly as a great deal of progress has been made, and as new consortia take over commissioning and require time to build up their own expertise. — As a number of PCTs move quickly to respond to the proposed radical changes, and to balance budgets, by outsourcing some or all of their major contracts, we are concerned that full and proper consideration is not being made to the processes required to enable any willing provider to participate in commissioning. — We are concerned that without a mandatory requirement for consultation on proposed service specifications and a mandatory requirement which ensures any willing provider can participate in a dialogue with both potential lead bidders and commissioners, Brook along with other third sector organisations will be unable to participate effectively in commissioning. Without these requirements Brook will therefore be excluded from providing future public services. Overall Response 1. Current levels of specific services for young people must be maintained if we wish to reduce STI and pregnancy rates amongst young people. All evidence suggests that providing confidential sexual health services specifically for young people has a demonstrable impact on reducing these rates. This is even more pertinent when we consider these services are often regarded as easy targets when there are pressures to balance budgets, and as it is being proposed to move commissioning to GP consortia and contraception is obtainable from general practice. 2. Investing in sexual health services saves the NHS money by preventing unwanted pregnancies and sexually transmitted infections. An analysis of the economic value of Brook’s work alone estimates that it saves the state over £11 milion each year.112 Overall it is estimated that for every £1,000 spent on contraceptive services £11,000 is saved113 while the NHS saves over £1,800 for every teenage conception averted.114 3. We are concerned as contraception is also obtainable from general practice, that GP consortia will commission their colleagues in GP practice to provide sexual health services for young people. This may be due to a belief that they can do it even though all evidence suggests that young people, particularly younger clients and those who are most vulnerable or service averse, will not access traditional NHS services, but will access confidential service developed specifically for them. 4. We welcome the confirmation that services should be commissioned from any willing provider as we believe the third sector has a great deal to contribute to the provision of health services. 5. The current commissioning framework and the proposed framework, currently do not ensure any willing provider can participate in the commissioning process, particularly if a commissioner is looking for one lead provider to manage a large diverse public sector contract. 6. Brook has a number of examples where they have been effectively excluded from the commissioning process, including the commissioning of an integrated sexual health services across multiple PCT areas and the commissioning of community services including sexual health services across 2 PCT areas. 7. Where a commissioner is looking for one lead provider to manage a large diverse public sector contract, and no mechanisms are in place for involving willing providers, the willing provider is required to contact the potential lead provider and make a case for inclusion in their bid. 8. As information about bidders is confidential, unfortunately it is difficult for willing providers to make a case to be included in potential lead provider bids if it is not known who they are, and if there is no mechanism in place, to make a case to commissioners too, and therefore be included in the commissioning process. 9. As PCTs increasingly move to divest themselves through commissioning processes of their provider arm services this trend in commissioning large scale public sector contracts is set to continue. And therefore only large private sector organisations or NHS trusts will be able to effectively participate, and organisations such as Brook, who have previously provided valuable public sector services, will continue to be excluded from the process, and thus the delivery of public services. 10. Processes need to be made mandatory within any future commissioning arrangements that enable a consultation with any interested party on the development of the specification, and processes need to be made mandatory which either enable any willing provider to have a dialogue with commissioners through the process, or place a requirement on potential lead bidders. Particularly when outsourcing large public 112 nef consulting (new economics foundation). The social and economic value of Brook’s preventative sexual health services— summary report. 2010. McGuire A, Hughes D, The economics of family planning services—a report prepared for the Contraceptive Alliance. FPA 1995. 114 Teenage Pregnancy Strategy Evaluation Final Report Synthesis 2005. 113 Health Committee: Evidence Ev w177 sector contracts there needs to be equity in the evaluation criteria to ensure that third sector organisations can bid for parts of contracts rather than a process to enable only large private sector or trusts for the contract in its entirety. 11. We recommend that services should be commissioned from organisations with a proven track record of delivery, and that commissioning evaluation criteria are weighted accordingly. 12. We recommend that commissioning evaluation criteria should give due weight to the quality of a bidders dialogue with other potential willing providers particularly where a commissioner is seeking a lead provider to manage a number of diverse public sector contracts. 13. We recommend the development of quality standards for dedicated young people’s sexual health services to ensure that young people’s needs are properly reflected in both local area specifications and in commissioning evaluation criteria. 14. Commissioning of young people’s sexual health services needs to maintain open access to services so that young people are offered a genuine choice of providers. In our experience it is increasingly common for contraception and sexual health services to be commissioned for local residents only. This takes no account of the fact the young people may prefer to attend services close to where they are studying or working or may simply prefer to use services outside their own area where they feel they are less likely to meet people they know. 15. The principle which allows people to use any Genito-Urinary Medicine clinic that they find convenient should be extended to all contraception and sexual health services and be recognised in commissioning guidance. 16. In the absence of a well developed, functioning commissioning environment, which takes account of our experience and recommendations, and is defined by clear accountability, based on robust needs assessment, the proposed arrangements will not support the commissioning of young people’s sexual health services, and thus some of our most vulnerable young people will lose access to services they need. 17. We believe changing the commissioning framework will reverse the progress that has been made so far to improve the quality of commissioning of young people’s services. We believe it will adversely impact on young people’s sexual health services and that this change is therefore not in the best interests of young people. October 2010 Written evidence from the British Dental Association (COM 70) 1. Executive summary 1.1 The challenges of oral health commissioning have been well documented since 2006. The BDA welcomes the opportunity to contribute to the ongoing work of the Health Select Committee and the new inquiry into commissioning. 1.2 The new arrangements proposed in the White Paper “Equity and Excellence” pose opportunities and threats to the delivery of high quality dentistry and oral health services to all members of society. This response describes some of the potential benefits of the proposed changes and also the concerns that the BDA has about the transition period and beyond. 1.3 Despite an increased focus by PCTs on improving access to NHS dental services, access by vulnerable groups remains an issue which the BDA is seeking to address through its ongoing programme of work on commissioning. It is an area that we will be urging the NHS Board not to neglect. A strong programme of public and patient engagement that recognises the valuable input of vulnerable groups will be fundamental to progressing improvements in access to these groups 1.4 A significant challenge for Primary Care Trusts (PCT) since 2006 has been to ensure system stability of dental services and this will be equally challenging during the transition period. Only recently has PCT local commissioning demonstrated improvement against the World Class Commissioning competencies yet the new proposals suggest that the NHS Board will not be fully operational until 2012, leaving much uncertainty and instability in the meantime for both PCTs and the dental profession. 1.5 Full and meaningful engagement with the dental profession will empower clinicians to drive forward care in the best interests of patients whilst keeping patients at the centre of their oral healthcare. It will be important for those commissioning dental services to use the dental public health expertise available although this must be fully and appropriately resourced. Ev w178 Health Committee: Evidence 2. Introduction and Background 2.1 The British Dental Association (BDA) is the professional association and trade union for dentists practising in the UK. Its 24,000-strong membership is engaged in all aspects of dentistry including general practice, salaried services, the armed forces, hospitals, academia and research, and includes students. 2.2 Improving the well being of the nation through good oral health is an aim that the dental profession strives towards. In 2006 NHS dental services were adversely affected when contracts were changed from national contracting arrangements to “local commissioning” with PCTs. The dental profession is facing yet another period of uncertainty and we have concerns that the process outlined in the White Paper must be managed carefully with the involvement of the profession. 2.3 The White Paper states that general practice dentistry will be commissioned by the NHS National Commissioning Board, although there remain considerable gaps in the detail on the intended infrastructure to support this across England. This new vision removes many of the existing structures through which oral health and dentistry is commissioned and we are concerned about the removal of relationships and services that are working well. 2.4 Moving total commissioning responsibility for dentistry to the NHS Board is our preferred option although we do stress the need for the NHS Board to commission the three strands of dentistry separately but centrally. Each strand of dentistry—primary, community and secondary care—is distinct in its role and function and we would urge that care is taken to preserve this distinction. 2.5 Much specialist care, such as cleft palate, is currently commissioned on a supra-regional basis and it is vital that such services are not lost or commissioned inappropriately when responsibility transfers to the NHS Board. There are other similar services that are not easy to reconcile in the new framework. 2.6 Commissioning for good oral health is based on robust data and intelligence, a comprehensive assessment of need and a well-designed service with a clear focus on prevention. A well-designed service will have in-built systematic reviews and an evaluation of the service design to ensure that the identified needs of the population are met. The Joint Strategic Needs Assessment (JSNA) process is a vital part of the commissioner’s information toolbox, and understanding the oral health of a given population is a vital element. Our view is that commissioning is “an extremely specialised role, requiring huge skill and expertise on the part of the commissioning team”115 and this is equally going to be the case for those commissioning services in the NHS Board. 2.7 Commissioning for good oral health is more than a simple focus on current service delivery and restorative treatment for existing populations. It requires a strategic overview of service needs and how they will change as the population changes and ages. There are three key areas to address when commissioning oral healthcare services: — commissioning for existing patient demand and existing but unfulfilled service need reaching out to those who do not access care; — commissioning for prevention and future service needs; and — commissioning for education and workforce to meet those needs now and in the future. 2.8 Professor Jimmy Steele undertook an independent review of NHS dentistry in 2009116 and, as part of this work, identified that different cohorts of patients require different styles of dental treatment throughout their life-span. The BDA welcomed Professor Steele’s work and is working with the Department of Health to drive forward many of his recommendations. Commissioning services to follow this approach will require intelligent and strategic planning by the NHS Board for both existing and future needs, and must be undertaken in conjunction with the annual JSNA process. High quality dental services are delivered by a skilled and appropriately trained dental workforce. The present system of vocational and postgraduate training provided and supported by the NHS must not be reduced although thought will need to be given to planning of the future workforce to enable the profession to meet the challenges of predicted demographic trends such as an ageing population and its effects on oral health. Commissioning services for changing demographic trends is a vital element in understanding and planning for prevention. 3. Clinical Engagement in Commissioning 3.1 Those commissioning services will need to take a holistic view of both supply and demand sides of the commissioning cycle. There is a rich pool of dental knowledge and expertise: Consultants in Dental Public Health, Dental Practice Advisers, Local Dental Committees, Oral Health Advisory Groups and individual clinicians. Our recent research on local dental commissioning has shown that 80% of PCTs that responded had a dental strategy in place and of those, 77% of contributors to that strategy were Dental Practice Advisers and 69% were Consultants in Dental Public Health.117 The new arrangements must include input from all of these groups locally. 115 Drinkwater, Professor C (2009) BDA’s Independent Local Commissioning Working Group Report. http://www.bda.org/ Images/local commissioning report.pdf Steele, Professor J (2009) NHS dental services in England. http://www.dh.gov.uk/prod consum dh/groups/dh digitalassets/ documents/digitalasset/dh 101180.pdf 117 BDA Local Commissioning Survey 2010 http://www.bda.org/dentists/policy-research/bda-policies/local-commissioning/ local-commissioning-research.aspx 116 Health Committee: Evidence Ev w179 3.2 National data sets are available on the oral health of adults and children across the UK. The Adult Dental Health Survey takes place every ten years and audits the oral health of the adult population in England, Northern Ireland and Wales. The 2009 survey was delayed and is due to report at the end of 2010.118 Nationally collected data can be interpreted and analysed on a local level by Consultants in Dental Public Health providing valuable intelligence to help inform dental commissioning. 3.3 Since 2006 the monitoring of clinical practice, contract and performance management has been the responsibility of the PCT and the new arrangements must continue to have these mechanisms in place to deal with issues as they arise. The Care Quality Commission (CQC) will be responsible for registering dental practices (April 2011) and will undertake targeted practice inspections. The GDC will remain the regulator for individual practitioners and other members of the dental team. We would like to see a stronger role for the National Clinical Advisory Service (NCAS) as this body has the expertise to help managers and clinicians understand, manage and prevent performance concerns. Their service includes providing advice on good practice and performance management and is held in high regard by the dental profession. 4. Accountability for Commissioning Decisions 4.1 Patient and public involvement ensures that commissioners understand current problems in care delivery, monitor impacts of quality improvements and demonstrate accountability to the public and taxpayers. The value of patient and public involvement is covered in detail in the BDA local commissioning working group report 2009. We stress however the danger of neglecting those parts of society that are hidden from view and are unheard and vulnerable. Older people in residential care, those in prisons, homeless people, BME communities and those in low socio-economic or deprived areas are all ‘unheard voices’ and their needs must be catered for. Those who contribute to the local HealthWatch or online at NHS Choices, are likely to be those people who are routinely accessing services with little or no input from the vulnerable groups to help improve services to those sections of society. We anticipate that the new Public Health Service will draw on the experience of many of the dental clinical experts outlined in paragraph 3.1 and it is important that commissioners design services in close liaison with the Public Health Service. 4.2 Making local authorities responsible for the commissioning decisions made by GP consortia is problematic in itself. Maintaining a central budget will undermine the capacity of local authorities to respond to the concerns of patients, as they have little or no “real” power in actually commissioning services. Commissioning decisions will be taken nationally and yet responsibility will be felt locally. 4.3 Good IT systems will enable some patients to make and exercise their choice of care. Significant populations are however at risk of being further disenfranchised, should the majority of health information and appointments move online. A new and clinically managed commissioning process necessitates an interlinked clinical communications system. We are awaiting the publication of the Information Strategy which will, we hope, illuminate how the existing structures are to be strengthened to support clinicians in the absence of PCTs. 4.4 The NHS Board will commission dentistry based on input from HealthWatch. Almost three quarters of the PCT dental contract leads we surveyed in 2010 felt that they needed additional support in their commissioning teams and the most commonly cited areas of support required were administration, contract management and consultants in dental public health. We believe that the Board will need some form of regional presence to support its commissioning function and a balance must be struck between central determination and local flexibility. 5. Integration of Health and Social Care 5.1 Our 2009 work highlighted the importance of evaluation as part of the commissioning process as key to meeting the needs of the local population. The process of system evaluation must not be confused with service and contract management. The purpose of the JSNA is not to set and assess outcomes. Instead alternative evaluation of service design must be undertaken. 5.2 The BDA is encouraged by better integration of health and social care although we are concerned about the pooling of health and social care budgets. Poor oral health is strongly associated with deprivation119, 120 and other social care services such as housing and transport all affect the environment in which the patient can or cannot access care. We would like to see a more integrated approach to service planning across health and social care that focuses on the patient. Identifying local barriers, such as lack of public transport in rural areas, will ensure that complementary health and social care are commissioned. 5.3 Many of our members work in primary care delivering oral healthcare to a variety of citizens in a variety of settings: residential care homes, prisons and those living at home. The same patient may often be seen by practitioners and clinicians in both the health and social care settings but currently these two spheres of care delivery are viewed entirely separately with a lack of focus on the patient. We are pleased that the 118 NHS Information Centre http://www.ic.nhs.uk/news-and-events/news/nhs-information-centre-award-adult-dental-healthsurvey-2009-contract-to-ons-led-consortium McMahon AD, Blair, Y, McCall, DR, Macpherson, LMD, (2010) “The dental health of three-year-old children in Greater Glasgow, Scotland”. British Dental Journal. 209:E5. 120 British Association for the Study of Community Dentistry (2005) “The dental caries experience of five-year-old children in England and Wales (2003/4) and in Scotland (2002–03). Community Dental Health, Vol 22:44-56. 119 Ev w180 Health Committee: Evidence focus of care delivery puts the patient at the heart of their care as opposed to individuals being viewed as passive recipients of health and social care. An integrated health and social care service design should ensure that many of the barriers to care that currently exist because of this distinction will be removed. 5.4 For our members, many questions remain about the distribution of power, the authority of and accountability between the local authority, the NHS Commissioning Board and the local health and wellbeing board. Our questions focus on the power balance between these organisations; which will undertake and “own” the JSNA and who will provide the resources? 5.5 Some of the recommendations in Sir Ian Kennedy’s recent report121 on healthcare services for children and young people have given a new urgency to the focus on children’s services across health and social care. This report highlights some of the lack of coordination of service delivery and recommends a significant shift of resources across the NHS to support services for children and young people. The report notes that many of the children at risk of maltreatment grow up with multiple disadvantages of which dental disease is an integral part. Throughout the transition period and beyond, integrated and well commissioned services that recognise the needs of particular segments of the population, such as children, are vital to commissioning high quality oral health services for the future. These services must be fully resourced. 5.6 It is important not to overlook vulnerable groups when assessing need or (re)designing services. 6. Transitional Arrangements 6.1 There is bound to be uncertainty amongst PCT staff causing instability in the system which will affect good practice and the improving standards of commissioning. Many PCT activities, such as providing local intelligence, supporting clinicians in the implementation of new NHS requirements, providing and facilitating education and training are roles that need to be filled. A loss of corporate knowledge during the transition will threaten services to patients. Clinical engagement has never been more important and Local Dental Committees are one of the few sources of local NHS corporate knowledge that will remain under the new arrangements and will be invaluable in supporting service providers during the transition period. 7. Resource Allocation 7.1 With the new proposals for much of the NHS to be commissioned by GP consortia, family health services, including dentistry, must not be overlooked. Our recent survey has shown that PCT commissioning leads for dentistry spent on average 81% of their time devoted to dentistry highlighting the complexity of dental commissioning. Resources must be fairly allocated to, and between, GP commissioning consortia based on robust assessment of need and prioritisation. The NHS Board should ensure that the remaining family services are resourced appropriately to ensure stability of provision and the provision of valuable local services. 7.2 Unique to dentistry is the interdependence between education, training and service delivery that is undertaken in dental teaching hospitals. These contain specialist units for training and educational purposes that are not found in other acute hospital settings and include oral pathology, oral medicine, oral radiology, restorative and paediatric dentistry. Within dental hospitals there is shared infrastructure supporting academic training of undergraduate dental students and dental care professionals alongside clinical training for both undergraduate students and postgraduate dentists. They also provide a service to patients via a referral process from general dental practitioners. The dual nature of dental teaching hospitals requires two distinct and specific funding streams. This enables high quality training of the workforce of the future, while simultaneously providing a specialist service to patients on referral. To ensure a highly trained dental workforce of the future and the provision of specialist services to patients, dental teaching hospitals must be fully and appropriately resourced and not overlooked when commissioning dental services. 7.3 The BDA would like to see an equal balance between commissioner and provider interests. We welcome the move towards a clinician led system that lets clinicians care for their patients and work together to provide the most clinically appropriate treatment. 7.4 Dentistry should be appropriately resourced to contribute to the holistic care of children, young people, vulnerable adults, older people, those in prisons and secure settings and those who do not routinely access NHS dental services, whilst still maintaining the good oral health of those who do use these services. The JSNA must recognise the contribution of all healthcare professionals to the health and social care of an individual and commissioners must ensure that this is resourced appropriately to meet that need. October 2010 121 Kennedy, Sir Ian (2010) Getting it right for children and young people, overcoming cultural barriers in the NHS so as to meet their needs. http://www.dh.gov.uk/prod consum dh/groups/dh digitalassets/wdh/wen/wps/documents/digitalasset/dh 119446.pdf Health Committee: Evidence Ev w181 Written evidence from Rare Disease UK (COM 71) Summary — There are many issues facing commissioning of specialised services currently, most notably the inequitable provision of services and a “postcode lottery”. — The changes proposed in the NHS White Paper pose both threats and opportunities to services for patients with rare diseases. — Due to the insufficient knowledge of rare conditions at a local level, the NHS Commissioning Board should be responsible for those specialised services currently commissioned at a regional and national level. — The budget for specialised services must be allocated directly to the NHS Commissioning Board specifically for specialised services. This budget must be flexible to allow for expansion of the number of specialised services. — It is crucial that engagement is facilitated between the NHS Commissioning Board and GP consortia to ensure that services commissioned at both levels are integrated and that there are no gaps in service provision. About Rare Disease UK 1. Rare Disease UK (RDUK) is the national alliance for people with rare diseases122 and all who support them. We have over 550 registered members including: over 130 patient organisations, clinicians, researchers, academics, industry and individuals with an interest in rare diseases. 2. It is estimated that one in 17 people will be affected by a rare disease at some stage in their lives. This amounts to 3.5 million people across the UK. Collectively, rare diseases are not rare. 3. RDUK was established by Genetic Alliance UK, the national charity of over 130 patient organisations supporting all those affected by genetic conditions, in conjunction with other key stakeholders in November 2008 following the European Commission’s Communication on Rare Diseases: Europe’s Challenges. 4. Subsequently RDUK successfully campaigned for the adoption of the Council of the European Union’s Recommendation on an action in the field of rare diseases. The Recommendation was adopted unanimously by each Member State of the EU (including the UK) in June 2009. The Recommendation calls on Member States to adopt plans or strategies for rare diseases by 2013. 5. RDUK is campaigning for a strategy for integrated service delivery for rare diseases. This would coordinate: research, prevention and diagnosis, treatment and care, information and commissioning and planning into one cohesive strategy for all patients affected by rare disease in the UK. As well as securing better outcomes for patients, a strategy would enable the most effective use of NHS resources. 6. Robust commissioning structures enabling the effective service delivery for patients with rare diseases should form a key element of a strategy for rare diseases. As a result, we welcome the opportunity to submit evidence to this document. Specialist Commissioning for Rare Diseases 7. Patients with rare diseases are likely to need access to health services commissioned at different levels, from local health services and social care which a patient is likely to use most frequently, to specialised services commissioned on a national basis, and from both a chronic and acute position of need. An effective commissioning structure for rare diseases needs to ensure effective integration of those commissioning services at the local level and those commissioning specialised services. Issues Currently Affecting Commissioning of Services for Patients with Rare Diseases 8. RDUK established a multi-stakeholder Working Group on Commissioning and Planning. The findings of the Working Group, along with four others, will be published in a report on a strategy for rare diseases next year. The initial findings of the Group are as follows. 9. Apart from those services commissioned on a national level by NHS Specialised Services, there is a wide variation in the services available for patients with rare diseases across England due to the decisions taken at different levels of the commissioning structure. Care is not of an equal quality for all patients with any particular condition throughout the UK. The “postcode lottery” still exists whereby some patients are provided with a carefully planned programme of support and treatment (including drugs and other interventions where appropriate) and others are not, purely as a consequence of variations in the pattern of services locally or regionally planned and commissioned. 10. The Specialised Services National Definitions Set (SSNDS) sets out definitions of 34 specialised services each with a planning population of more than one million. The SSNDS exists to identify those services that are specialised and therefore should be subject to collaborative commissioning by Primary Care Trusts (PCTs) through the ten regional Specialised Commissioning Groups (SCGs). Many of the services 122 A rare disease is defined as a condition affecting less than five in 10,000 people in the UK. Ev w182 Health Committee: Evidence outlined in the SSNDS will be accessed by patients with rare diseases. These arrangements have proved ineffective as currently none of the regional SCGs commissions all the services in the SSNDS; and not one SCG commissions the same services as another. This therefore results in unequal levels of care for a particular condition throughout the country. 11. There is often a lack of transparency, communication and structure in commissioning guidelines and what should be funded by whom. This leads to confusion and can result in a delay in patients receiving the necessary services at the best time. 12. Funding for specialist services for patients with rare diseases is perceived by some to be diverting resources away from local services. Rather this is a mechanism to ensure that patients with rare diseases have access to the services and expertise they need, planned and commissioned at the appropriate level, whilst ensuring local bodies do not have to bear a disproportionate financial burden. This negative perception could pose a threat to specialised services at a time of efficiency savings as those commissioning services at a local level look to protect their budgets at the expense of good-quality, cost efficient care for specialised services. This negative perception is aggravated by the current funding method for national and regional commissioning ie the top-slicing of funds for national commissioning and the pooling of funding by PCTs for regional commissioning. 13. Patients who have access to a specialised service for their condition have better experiences than those that don’t. However, there are not specialist services available for every rare condition, and this can result in inequitable levels of care depending on which condition a patient has. It is not possible to designate a specialised service for every rare condition, especially as there are over 6000 rare conditions and some rare conditions are too rare or insufficiently well understood. But this should not preclude patients from being able to access good-quality care. 14. Specialist services for rare conditions have developed in an ad-hoc fashion. Services often gain national designation as a result of proactive moves by a strong patient organisation and interested clinicians. We have heard from our members that the application process is also becoming increasingly burdensome. This is clearly inequitable as in particular, most patient organisations for rare diseases (if they exist at all) are small and do not have the resources to undertake this work. Specialised Commissioning Post-White Paper 15. Whilst the detail of the proposals in the Government’s White Paper, “Equity and Excellence: Liberating the NHS” and the supporting consultation document “Commissioning for Patients” is not completely clear, the proposals do provide both opportunities and threats to services for patients with rare diseases. 16. The White Paper has a strong emphasis on the benefits of localism. However, this is not always best in order to understand the health needs of the patients we represent. The strength of GPs lies in their understanding of a broad range of conditions that they see on a regular basis. There are over 6000 rare diseases and GPs may only come across some of these conditions once (if at all) in the duration of their careers. Many patients with rare diseases have complex needs and GPs do not have the knowledge necessary to understand what services are necessary to meet these needs the majority of the time. 17. The most “common” single rare disease will affect around 25,900 people123 in England (the vast majority of rare diseases affect far fewer people). If this maximum figure is distributed evenly across the current 151 PCTs then each PCT would have 171 patients with this condition.124 If GP consortia cover smaller population bases than PCTs do currently, then they will cover even fewer patients with that condition. It seems doubtful whether the expertise will be available to commission all the services necessary for the most “common” rare diseases, let alone the majority of rare diseases which affect far fewer people. There is a real danger that these conditions could be overlooked. 18. The proposals do not indicate what population bases GP consortia will cover, although we understand that they are likely to be smaller than PCTs currently. This means that a large number of services could fall in the area between being too low-incidence to be commissioned by individual GP consortia and too high volume to require a planning population greater than 1 million as the SSNDS currently provides for. The commissioning of those services that fall between these thresholds should be carefully monitored to ensure they are available equitably to people across England. A key component of the duty of the NHS Commissioning Boards to hold consortia to account should be to ensure that patients of consortia have access to services commissioned at the level above a consortium-unit volume of population. 19. For these reasons, RDUK strongly endorses proposals for the NHS Commissioning Board to take responsibility for commissioning specialised services. We believe that the Board should have responsibility for commissioning those services currently commissioned at a national level and those services listed in the Specialised Services National Definitions Set (SSNDS) currently commissioned by regional specialised commissioning groups (SCGs). 123 124 Based on the Office of National Statistics Population Estimates June 2010—http://www.statistics.gov.uk/pdfdir/pop0610.pdf In reality the distribution would not be even due to greater prevalence in certain populations eg some conditions are more common in population sub-groups. Examples include thalassemia in Mediterranean populations, and the increased prevalence of recessive single gene genetic conditions in people of Pakistani origin. Service planning should take into account any such local needs. Health Committee: Evidence Ev w183 20. The establishment of the NHS Commissioning Board provides the opportunity to address some of the issues inherent in the commissioning of specialised services currently, most notably the weaknesses of the SCGs in delivering equitable service provision across England. 21. While we regard the positioning of all specialised commissioning responsibilities in the NHS Commissioning Board as sensible, we recognise in practice this may need a devolved regional structure that allows proper understanding of regional variations and to help ensure integration between services commissioned by GP consortia and specialised services. However, any regional system must be under tighter central control by the Board to avoid the present situation which has led to wild inconsistencies in service provision. 22. The budget for specialist services that are currently commissioned must be allocated directly to the NHS Commissioning Board specifically for specialist services. This budget must take into account that, as the SCGs do not currently commission all the services in the SSNDS, their expenditure may not adequately reflect the budget that the National Commissioning Board will need to provide an equitable service across England. 23. The budget for the NHS Commissioning Board must also be flexible to allow for new services to be commissioned when evidence shows a need for services to be commissioned at this level in order to provide good quality and equitable services. 24. In reality, there will never be a specialised service for each of the 6000 plus rare diseases. However, commissioning structures should be flexible to allow patients to access services, not specifically designated for their condition, but that they would benefit from nonetheless as many of the effects or services needed may be similar. 25. It is crucial that engagement is facilitated between the NHS Commissioning Board and GP consortia to ensure that services commissioned at both levels are integrated and that there are no gaps in service provision. 26. Rare Disease UK believes there should be a designated expert accountable for commissioning for rare diseases on the NHS Commissioning Board. This member should work closely with the National Clinical Director for Rare Diseases (as proposed in the Chief Medical Officer’s report of 2009) who RDUK would like to oversee the implementation of a strategy for rare diseases. October 2010 Written evidence from the British Heart Foundation (COM 73) 1. The British Heart Foundation (BHF) is the UK’s leading heart charity. We are fighting against heart and circulatory disease—which is the UK’s biggest killer and claims around 200,000 lives each year.125 Our vision is of a world where no-one dies prematurely of heart disease. Summary — Partnership working between public sector commissioners and the voluntary sector is vital. Charities can: — provide a wealth of intelligence on patients’ needs and wishes; — facilitate the engagement of patients, carers and health professionals in commissioning; — provide valuable support and advice to commissioners on service design; — and help disseminate evidence on best practice and innovation. — Commissioning policy should recognise the role of charities as co-commissioners and co-investors in the health and wellbeing of local communities, and should involve charities throughout commissioning processes. — Clinical networks also engage patients, carers and health professionals in commissioning, promote coordinated, innovative, and cost effective care, and can provide a valuable bridge during the period of transition. Their vital work must continue and develop. — Patients and carers should be involved in shaping services along the whole patient pathway; the NHS Commissioning Board should have representation from and genuine engagement with patients, carers, and voluntary sector organisations. — Research and education and training should be given appropriate status in the new system, and there should be research representation on the NHS Commissioning Board. — The crucial role of the NHS in promoting healthy lifestyles and preventing ill-health must be reflected in the NHS Outcomes Framework and commissioning frameworks. 125 www.heartstats.org Ev w184 Health Committee: Evidence — Investments in the health and wellbeing of local communities by charitable organisations that are currently administered by PCTs should not be put at risk during the period of transition to alternative organisational structures. — Patients and carers should be fully engaged in specialised commissioning to ensure integrated health and social care services for small and scattered patient groups. Q. How will commissioners access the information and clinical expertise required to make high quality decisions about the shape of clinical services? 2. Clinical networks play a valuable role in engaging patients and carers in commissioning, as well as providing expert clinical advice and support for commissioners. This support will be particularly important as GP consortia and the NHS Commissioning Board take on their new roles. We would urge the Government to ensure that the increasing competition between providers and the financial challenges facing the NHS, do not threaten the vital work of cardiac and stroke networks. 3. Multi-professional engagement in commissioning will be crucial to delivering high-quality, patientcentred, cost-effective care. Charities that support and engage with health professionals can help to facilitate this. The BHF fully funds 112 specialist cardiac health professional posts, and part funds 361 posts,126 and supports these professionals to become expert practitioners. We believe that specialist cardiac nurses and Community Resuscitation Development Officers (CRDOs) could make a particularly valuable contribution to commissioning. BHF Specialist Nurses 4. BHF specialist heart nurses cover a range of specialties such as heart failure, acute coronary syndrome, paediatrics, arrhythmia, adults with congenital disease, genetics and palliative care. BHF specialist heart failure nurses, for example, monitor symptoms, titrate medication, and support patients to understand and manage their condition and to stay in their homes. An evaluation found that heart failure nurses reduce all cause admissions by an average of 35%, saving approximately £1,826 per patient.127 Specialist heart nurses would be well placed to advise GP consortia on the commissioning of high-quality, patient-centred, costeffective, multi-disciplinary services, and to achieve the best outcomes across acute, chronic, and palliative care. Community Resuscitation Development Officers 5. The BHF has established new Community Resuscitation Development Officer (CRDOs) (or “responder manager”) posts within emergency services to improve survival from out of hospital cardiac arrest. Most cases of sudden cardiac death are potentially reversible by giving the heart a type of electric shock (defibrillation), but treatment is needed within four or five minutes of the event. Ambulances rarely reach a victim in this time but the window of opportunity can be doubled if bystanders give “basic life support” in the form of chest compressions and rescue breathing. 6. CRDOs assess a local community’s capacity for resuscitation, ensure the placement of defibrillators in public places, provide training and support for volunteer community first responders (trained to use defibrillators), and deliver emergency life support training for the public. Evaluation has shown that CRDOs are dynamic and enthusiastic developers of community capacity for resuscitation,128 recruiting volunteers and boosting initiatives such as emergency life support training. They also have an important role in developing information systems, sharing best practice, conducting research, promoting innovations, and encouraging partnership working. The involvement of CRDOs in commissioning community resuscitation services would enable their valuable knowledge and expertise to be shared, and would ensure services are properly specified and costed, explicitly contracted for, and integrated into NHS services. Q. How will commissioners address issues of clinical practice variation? 7. Access to robust and comparable data is crucial to identifying and addressing variations in care. Data will need to be available on a local basis so population outcomes can be compared between different areas, and so the NHS Commissioning Board can hold GP consortia to account. We have concerns about the impact the new right to free choice of GP will have on the comparability of geographical population data. 8. The use of benchmarking techniques, such as the Advancing Quality programme begun in the North West Strategic Health Authority region and now extending to other regions, can also help to identify variations in practice. 9. Clinical networks can also play a crucial role in enabling patients, clinicians, managers, and commissioners from different organisations to work together to standardise the quality of services through joint quality assurance, audit and benchmarking. The Government should also ensure that support is made available so the valuable work of national independent, clinically-led audits can continue. 126 127 128 For more information see BHF Specialist Nurses—Changing face of cardiac care. BHF (2010), BHF Specialist Nurses—Changing the face of cardiac care. For more information please see: Matrix Research and Consultancy (2006), British Heart Foundation and the Department of Health, An evaluation of the Community Defibrillation Officer role. Health Committee: Evidence Ev w185 Q. What arrangements will be made to encourage the Third Sector (both) as commissioners (and as providers)? 10. Charities can play a valuable role in providing advice and support to commissioners on service design and innovative models, and in disseminating evidence and best practice to professionals. The BHF recently joined with nine other leading health charities to present consensus solutions to delivering coordinated, highquality, patient-centred, cost-effective care that supports self-management, delivers effective prevention, early diagnosis and intervention, and provides emotional, psychological and practical support.129 The NHS Commissioning Board should have representatives from, and genuine engagement with voluntary organisations. 11. The BHF has also recently worked closely with the Department of Health (DH) and NHS Improvement on a cardiac rehabilitation commissioning pack for commissioners and a patient friendly document to sit alongside it. This is an excellent example of a charity working to improve the commissioning pathway in a vital area that has previously been overlooked. 12. In addition, leading charities like the BHF play a key role as co-commissioners and co-investors in the health and wellbeing of local communities. Although the BHF does not supply services under contract to the NHS or local authorities, we are a significant contributor to the health and well-being of local populations. For example, we have invested £9 million in selected communities across the UK through our Hearty Lives programme which aims to reduce the high levels of cardiovascular disease in targeted communities. 13. Hearty Lives is a valuable example of joint commissioning between a charity and the NHS. However, at present, commissioning policy often fails to take sufficient account of this, focusing instead on charities as providers of services under contract. The NHS Commissioning Board should ensure that commissioners involve charities throughout commissioning processes. 14. The Hearty Lives programme has also highlighted the need for commissioning policy to more clearly distinguish between taxation and charitable expenditure as sources of funding. Charitable work is funded to a large degree through donations from people, businesses and philanthropic organisations, and these funds should not be subject to undue bureaucracy which negates the flexibility and speed of response for which the voluntary sector is valued. Q. How will patients make their voice heard or their choice effective? 15. The BHF welcomes the aspiration in the NHS White Paper to promote a local voice for patients, and to create an NHS which is more responsive to patients’ needs and wishes. The work of the NHS Commissioning Board should be informed by patients and carers’ experiences. The Board must have representation and genuine engagement with patients, carers, and voluntary sector organisations. Charities like the BHF can share a wealth of information on patients’ needs and experiences, and can facilitate engagement with patients and carers.130 16. The new local HealthWatch services should be fully independent, whilst having adequate authority and sufficient resources to carry out their functions. It will also be important that there is absolute clarity about the remit and mandate of HealthWatch, and that they are recognised by commissioners as the legitimate voice of patients. Awareness raising will be needed to champion their role among local people. 17. Local HealthWatch should build on learning from LINks. In many places LINks are not yet properly established, and we would like assurance that the new structures will be given time to embed—continuity is essential to maintaining public confidence in patient and public involvement processes. 18. Advocacy work can be demanding, time-consuming and high profile. It is essential that this does not detract from patient and public involvement in designing and developing services. 19. Many heart patients are already involved in shaping services through cardiac and stroke networks. Local HealthWatch should establish close links with clinical networks, and ensure that relevant information about services is communicated to National HealthWatch within the Care Quality Commission. 20. The move to a mixed economy of providers and the extension of personal health budgets will make it even more essential that patients receive support in making choices about providers. Patients need advice about what to look out for when choosing providers, clear information about the full range of services available, support in understanding, interpreting and translating this information, and practical advice about how to access services. This support is particularly important for vulnerable groups. Information must be accessible to all patients, whatever their literacy skills and mental capacity, and should be available not just online but also face-to-face and via the telephone. 129 130 Kings Fund (2010), How to deliver high-quality, patient-centred, cost-effective care, Consensus solutions from the voluntary sector. The BHF has a network of more than 300 affiliated Heart Support Groups, set up by patients for patients. We also run Hearty Voices programmes, free one-day training courses delivered across the country that help heart patients develop the knowledge and skills to confidently represent the voice of heart patients and carers and to get involved in influencing the health service, both locally and nationally. Ev w186 Health Committee: Evidence 21. We believe that patients are likely to seek advice about providers and treatments from their local GP or other health professional, who they deem to have the appropriate clinical knowledge and with whom they already have a relationship, rather than from staff at local HealthWatch. The role of HealthWatch should therefore be to drive and support progress locally with clinicians, including GPs, and to link with any national initiatives. Local HealthWatch may also have a role in providing practical information, for example about transport to services. Q. What will be the role of the NHS Commissioning Board? 22. Clinical research is critical to improving the quality of patient care, and the NHS Commissioning Board should have a role in ensuring that research is given appropriate status in the new system. There should be research representation on the NHS Commissioning Board, and participation in research should be reflected in the NHS Outcomes Framework and commissioning frameworks. 23. The role of the NHS Commissioning Board in providing strategic oversight of national workforce planning and of healthcare providers’ funding plans for training and education, will also be essential. 24. We have concerns about how the NHS Commissioning Board will hold GP consortia to account for their performance, and also provide the necessary support for consortia in taking on their new roles. A great strength of clinical networks is their ability to provide independent expert advice and support to commissioners. We urge the Government to ensure that the financial challenges facing the NHS do not threaten the vital work of cardiac and stroke networks (for more information, see our response to the question on access to information and clinical expertise). Q. How will commissioning interface with the Public Health Service? 25. It is essential that the creation of the Public Health Service and the greater role for local authorities in public health do not result in NHS commissioners and staff no longer seeing public health as part of the role of the NHS. The crucial role of the NHS in promoting healthy lifestyles and preventing ill-health must be reflected in the NHS Outcomes Framework and commissioning frameworks. 26. While we welcome the Government’s proposal to establish a Public Health Service, there is a risk that this will perpetuate the disjunction between public health-led needs assessment, and service planning and delivery. Effective joint planning and integrated delivery should be a requirement placed on both GP consortia and the new Public Health Service. Joint Strategic Needs Assessments should produce useable results at GP consortia level, and commissioning plans should demonstrably flow from the needs assessment. Q. Will the new arrangements safeguard current examples of good practice? 27. Through the BHF Hearty Lives programme, the BHF has invested £9 million over three years in selected communities across the UK with the aim of reducing the high levels of cardiovascular disease in targeted communities. This investment has largely been through posts and projects currently administered by PCTs. Investments in the health and wellbeing of local communities by charitable organisations that are currently administered by PCTs should not be put at risk during the period of transition to alternative organisational structures. Q. Who will drive innovation during the transitional period? 28. During the transitional period, there should be significant engagement with charities to help disseminate and mainstream voluntary sector innovations in service delivery. 29. The BHF is the single biggest funder of heart-related research in the UK, contributing more than the Medical Research Council and the Wellcome Trust put together. The BHF invests a total of £28 million in prevention and care programmes each year consisting of public education, professional training and support, and new service model research, pilot testing, evaluation and audit. 30. The BHF recently joined with nine other leading health charities to present consensus solutions and innovative examples of delivering coordinated, high-quality, patient-centred, cost-effective care.131 Q. What arrangements are proposed for the commissioning of specialist services? 31. At present there is significant variation between regions in terms of the commissioning of specialised services, with the same service being commissioned at a local level in some regions and at a regional level in other regions. The DH should conduct a survey to establish a clear national picture of what services are currently being commissioned at what level. 131 Kings Fund (2010), How to deliver high-quality, patient-centred, cost-effective care, Consensus solutions from the voluntary sector. Health Committee: Evidence Ev w187 32. If GP consortia are to take on new responsibilities for commissioning specialised services which are currently commissioned regionally, the DH should ensure that during the transitional period they are equipped with the necessary skills to do this. The DH should take into account that where a specialised service is currently being commissioned by a lead PCT for a region, the burden of transferring skills to GP consortia will fall on this PCT (as the others will not have the necessary experience and knowledge). 33. Patient and carer involvement is crucial to specialised commissioning. At present, specialised commissioning is mainly clinician led, and there is insufficient involvement of patients and carers. Involving patients and carers in specialist commissioning is essential to ensure that health, social care and other services for small and scattered patient groups are still developed and delivered in a holistic way and around the needs of patients. For example, patients could be involved in developing contract service specifications. The NHS Commissioning Board should also build on the work of the National Specialised Commissioning Group to bring together disparate user involvement groups at a national level. Children and Young People with Congenital and Inherited Heart Conditions 34. The BHF estimates that there are 32,000 young people between 12 and 19 currently living with a heart condition in the UK.132 At a local level, Children’s Trusts are currently working towards holistic commissioning of health, education and social care within a local area. However, children and young people with heart conditions are scattered in small numbers across the country, and health services are therefore currently commissioned at multiple levels, including nationally and regionally. This can make it difficult to ensure that health, social care, and education services are properly integrated. The NHS Commissioning Board should work with charities like the BHF to ensure that small and scattered patient groups do not suffer from fragmented care because they do not all live in one community. People with Inherited Heart Conditions 35. Inherited cardiac conditions are estimated to result in between around 140–540 deaths in England every year among those aged under 65.133, 134 In 2009, the House of Lords Science and Technology Committee report on genomic medicine found significant inequalities in the provision of genetic services in the NHS in England with regards to tests for single-gene disorders and for single-gene subtypes of common diseases due to the lack of a national policy on commissioning of genetics services. 36. A DH-led initiative for inherited heart disorders is now underway. One component of this is the joint DH and BHF Genetic Information Service (GIS) which helps families to get an expert assessment in a specialist clinic for inherited heart conditions, and to deal with being diagnosed with an inherited heart condition or losing a loved one. It is not clear whether the commissioning of genetic testing will rest with the NHS Commissioning Board, or whether it will be part of the new Public Health Service. We are calling for a single national system for cascade screening and would be very concerned about any arrangements which make screening more fragmented and less effective. 37. The BHF is providing detailed responses to the NHS White Paper consultations which will be available on our website from 11 October.135 We would welcome the opportunity to support the Committee in its enquiry and would be pleased to provide any more information. If you have any questions please contact Beatrice Brooke, Policy Manager. (brookebwbhf.org.uk). October 2010 Written evidence from The LIFT Council (COM 74) The LIFT Council The LIFT Council is the representative body for private sector investors in the Local Improvement Finance Trust (LIFT) programme. The Council currently comprises 11 organisations and represents more than 95% of the market. Our role is to provide private sector investors in LIFT with a platform for debate and decision-making on all issues relating to LIFT. The LIFT market is now very mature, having been in existence for seven years, delivering over 250 projects to the value of over £2 billion with a further £2 billion in the pipeline. LIFT is also an effective procurement vehicle for a wide range of infrastructure requirements including social care services, Children’s Centres, libraries and public health facilities, enabling services to be co-located near to people’s homes. 132 Stefanie Lillie, Diane Card. MeetwTeenHeart: Working with teenagers with heart disease. British Journal of Cardiac Nursing, Vol 3, Iss 5; 7 May 2008, pp 190–192. Bowker TJ et al (2003) Sudden unexpected cardiac or unexplained death in England: a national survey. Q J Med 96:269–279. 134 Behr ER et al (2007) Sudden arrhythmic death syndrome: a national survey of sudden unexplained death. Heart 93:601–605. 135 www.bhf.org.uk 133 Ev w188 Health Committee: Evidence Summary of our Response — Our comments focus almost exclusively on the future management of the NHS estate, an issue integral to the success of the proposals set out by the Government in the NHS White Paper Equity and Excellence and which underpin effective commissioning. — The LIFT Council believes that for commissioning to work effectively, a Joint Venture (JV) publicprivate partnership needs to own and manage the primary and community care estate, mandated to work with commissioners to map estate around service need. If left to providers to control the estate then it will be virtually impossible to change provider and develop a commissioning system capable of evolving at the appropriate speed for local service requirements. — Commissioning freedom, whether at NHS Commissioning board level or GP Commissioning Consortia level, is also enhanced by removing infrastructure issues from decisions about the delivery of clinical care. — LIFT represents the most effective way of managing the NHS estate through bringing in asset management expertise and capital along with an ability to integrate services along defined commissioning pathways that are in the best interests of the patient and with the advantage of a contractual framework that can overcome historic procurement and financial barriers to encourage integration of services. LIFTCos are also well placed to realise financial value from estate—crucial in the current climate—and to develop estate that meets future energy and carbon reduction commitments. 1. Commissioning the NHS estate 1.1 NHS estates commissioning has always been fragmented, with premises standards too often falling short of those required for the services delivered. This problem has been particularly acute within primary care, hence the importance of infrastructure investment. 1.2 Managing the estate to ensure that only the minimum amount of estate is provided, that it is in the right locations, is fully statutorily compliant, is properly maintained and fully utilised requires all infrastructure assets to be in the control of a specialist expert property asset manager. 2. Competition and cooperation 2.1 At the heart of effective commissioning is the drive for choice and contestability amongst providers. If commissioning is weak and the provider market limited then genuine choice cannot be offered to patients and service standards risk stagnating. That is why The LIFT Council supports and endorses Government policy which brings in new providers, allows them to compete on a level playing field and which puts quality at the heart of the service. 2.2 Whilst not at the forefront of the commissioning debate, NHS estate is a crucial part of the system and can help or hinder real reform. 2.3 For a variety of reasons we believe the acute sector estate can legitimately be owned and managed by providers but we firmly believe that the primary and community care estate must be owned by expert asset managers independent of providers with a JV vehicle being the most appropriate solution. 2.4 Encouraging providers to own and manage the primary and community care estate risks frustrating the Government’s reforms and distracting commissioners from clinical care in the event of a failing provider owning strategically important assets. Any Willing Provider necessitates changing providers when service standards fall and the estate must not act as a barrier to contract flexibility. 2.5 Even if surrender terms for the estate used by the provider are included in contract arrangements the transaction costs of changing providers will increase substantially 3. Commissioning consortia 3.1 Commissioning consortia will play a crucial role in improving outcomes in healthcare and with their in-built clinical focus, will be well positioned to meet the needs of their patients. 3.2 Their functions will differ from those of a PCT however and it is important that their resource is dedicated towards improving standards of care and not distracted by functions that lie outside of their core skill-set. This is brought into stark focus by the likely 45% cost reductions that commissioning consortia will have for administration as compared to their PCT predecessors with the result being consortia will simply not have the resource to manage estates on the scale required, particularly in light of the myriad of statutory compliance duties, including carbon reduction targets, that are needed for managing assets. 3.3 The LIFT Council therefore believes that the estates management functions currently handled by a PCT’s estates department, but also in some cases by the local LIFTCo, need to be streamlined and transferred either to a LIFTCo where one exists or to a new form of JV partnership. Health Committee: Evidence Ev w189 4. Joint Venture vehicles for estates management 4.1 Placing responsibility for providing suitable infrastructure in the right location at the right time in the hands of the property company JV will support the contestability of providers and secure the realisation of actual value from the existing NHS primary and community care estate. 4.2 Building on LIFT’s Strategic Services Development Plan (SSDP), from which it is possible to identify where the current infrastructure provision is constraining the delivery of improved services, commissioners will be better informed as to infrastructure requirements and have a dedicated partner to help fill in the gaps. Drawing on local population data the SSDP underpins the estate development and management plan and allows the local NHS and Local Authority to point to areas where investment is required or where shifts in service patterns may be needed. 4.3 From this infrastructure reform come new models of care and facilities that can often be used by a large number of providers including acute trusts. With a LIFTCo contractually obliged to work in a given locality for 25 years this means LIFT can play the long game and flex the system as required no matter what happens on the provider side. 4.4 Improving patient outcomes, promoting patient choice, improving the patient experience and levels of satisfaction, improving efficiency and productivity, increasing the numbers of co-located services and delivering overall improved utilisation are most likely to be secured if clinical staff, commissioners and providers are freed from the burden and distraction of property management. 4.5 In addition to the benefits ascribed above, this expert asset management service can provide significant support to commissioning consortia as they focus in on Quality, Innovation, Productivity and Prevention, a central tool to drive up standards. Conclusion Overall we therefore believe that the success of commissioning and commissioners, whether at NHS Commissioning board level, GP Commissioning Consortia level or Local Authority level, is interlocked with effective asset management and can be best achieved through existing LIFTCos or the establishment of new JV vehicles where a LIFTCo is not in existence. October 2010 Written evidence from Samaritans (COM 75) Key Recommendations — Before taking on commissioning responsibilities, GPs need to receive more support to improve their knowledge and expertise of mental health issues including a detailed understanding of the needs of people experiencing feelings of distress and despair including those which could lead to suicide. — New commissioning processes should ensure better communication between primary care and secondary care, such as for example ensuring that A&E departments and GPs work together to provide follow up treatment for people who have presented to A&E following an act of deliberate self harm. — GPs must be equipped and supported to carry out the strategic leadership role that will be required to implement the government’s aim of enabling a joined up approach across health, social care and public health improvement. — Indicators in the new NHS Outcomes Framework need to be more clearly defined in order to incentivise clinicians to take urgent action to provide follow-up support for people who have received treatment following an act of deliberate self harm. — Public mental health measures should have a prominent role in the new public health service, including specific measures for suicide and self-harm prevention. 1. Introduction 1.1 Samaritans is a registered charity, founded in 1953, which provides confidential, non judgmental emotional support 24 hours a day, seven days a week to anyone experiencing feelings of distress or despair. Our service is provided by over 15,000 active listening volunteers operating from 201 branches across the UK and Republic of Ireland. In 2009, Samaritans received a total of 2,696,762 contacts, by phone (2,349,538) email (170,722), text message (130,097), face-to-face (45,036) and by letter (1,369). Samaritans Vision is that fewer people die by suicide. We work to achieve this Vision by making it our Mission to alleviate emotional distress and reduce the incidence of suicidal feelings and suicidal behaviour. We do this by: — Being available 24 hours a day to provide emotional support for people who are experiencing feelings of emotional distress or despair, including those which may lead to suicide. Ev w190 Health Committee: Evidence — Reaching out to high risk groups and communities to reduce the risk of suicide. — Working in partnership with other organisations, agencies and experts to achieve our Vision. — Influencing public policy and raising awareness of the challenges of reducing suicide. 1.2 Samaritans is pleased to have the opportunity to comment on this Health Select Committee inquiry into NHS commissioning. Over 4,000 people die by suicide each year in England and suicide is the second commonest cause of death in men under the age of 35. In addition, it is estimated that there are at least 170,000 presentations to general hospitals following an act of deliberate self harm (DSH) in England each year.136 It is important that people who have attempted or are contemplating suicide or who have engaged in an act of deliberate self harm have the opportunity to receive immediate follow-up help and support from the appropriate agencies and so the ability of NHS services to provide interventions and on-going support to individuals who are at a high risk of suicide/DSH must be maintained and improved throughout this period of commissioning reform. 2. Suicide Rates in England 2.1 There has been a promising downward trend in suicide rates in England over most of the past decade with official Office for National Statistics (ONS) figures showing a steady decline from 4,889 deaths in 1999 to 4,011 deaths in 2007. However the most recent ONS figures show a year-on-year increase from 4,011 deaths in 2007 to 4,301 in 2008. This may turn out to be a normal fluctuation. However given the strong research evidence of a link between economic recession and suicide137, 138, 139 it is also possible that this is the start of an upward trend in suicide which could continue until there is an improvement in economic conditions and the employment market. 2.2 At Samaritans we remain concerned about the impact of the current challenging economic circumstances on people’s emotional health and we have been keen to highlight the consequent risk of an increase in suicide rates. In addition to the research evidence which shows that economic recessions tend to be accompanied by a higher rate of suicide, we also know that debt problems are often associated with mental health problems and suicidal thoughts.140 Financial issues have been shown to be at the heart of many of our callers’ anxiety and distress during the recent period of recession. Analysis undertaken in conjunction with several Samaritans branches in July 2009 found that around 10% of all calls that were received were related to money worries. Of these calls 41% were from people worried about employment, 25% were concerned with housing issues and 24% related to debt issues. 2.3 Against the background of economic difficulty and high unemployment, it is particularly important that suicide prevention is maintained as a priority for the NHS at a national, regional and local level. We note the strong emphasis in the White Paper on the agreement of priorities locally and the shifting of decision-making as close as possible to individual patients and from a suicide prevention perspective we would agree that there are advantages in developing local initiatives in a way that is tailored specifically to the needs and demographics of the local community. However, a coherent national action plan is also nevertheless required in order to provide a strategic framework and a strong mandate to facilitate suicide prevention activity at a local level. With this in mind, the refreshed suicide prevention plans for England need to be applied and implemented in a way that will link the evidence-based interventions and best practice directly to the new local commissioning structures and the new public health service. 3. GP-led Commissioning 3.1 As the first professional point of contact for many people who are seeking medical help for feelings of emotional distress, GPs have always played a crucial role in supporting people following an episode of deliberate self harm or who are at risk of suicide, providing treatment in primary care such as by providing advice and support, prescribing anti-depressant medication or by providing referrals into talking therapies or secondary care services. However, GPs will now have a more pivotal role than ever before by also assuming responsibility for commissioning the services to which they are able to refer their patients particularly if, in addition to acute and community-based mental health services, this is also to include the commissioning of the Improving Access to Psychological Therapies (IAPT) programme which is an vitally important part of improving NHS services for people suffering from common mental health problems such as depression or anxiety. 3.2 While some GPs have excellent awareness and knowledge about suicide risk and self harm, and are therefore likely to be well placed to commission services that meet the needs of their patients, we remain concerned that at this stage not all GPs yet have necessary knowledge and skills to effectively perform this task. While we appreciate that GP consortia will be able to buy in some specialist advice and support from 136 Kapur, N, House, A, Creed, F, et al (1998) Management of deliberate self poisoning in adults in four teaching hospitals; descriptive study. BMJ, 316, 831–832. 137 Stack, S, Work and the Economy, in Comprehensive Textbook of Suicidology, R W Maris, A L Berman, and M M Silverman, Editors. 2000, The Guildford Press: New York. p. 193–221. 138 Viren, M, Suicide and business cycles: new empirical evidence. Applied Economics Letters, 2005. 12: p. 887–892. 139 Berk, M, S Dodd, and M Henry, The effect of macroeconomic variables on suicide. Psychological Medicine, 2006. 36 (2): p 181–189. 140 Stack, S and I Wasserman, Economic strain and suicide risk: A qualitative analysis. Suicide and Life-Threatening Behavior, 2007. 37(1): p. 103–112. Health Committee: Evidence Ev w191 external organisations we remain concerned that the government is yet to set out how in any detail how it will be possible to ensure that skills gaps in specialist areas will be addressed in all areas of the country. We believe that the most effective way of achieving this would be the development and resourcing of national training programmes which could rolled out across the country to ensure high quality support from GPs at primary care level and to underpin high quality commissioning which enables the provision of effective interventions and treatments for patients at risk of suicide or self harm. 3.3 GPs will also need to be equipped with skills to carry out the strategic leadership role that they will need to perform locally if the government’s aspiration of well integrated health, adult social care and health improvement services is to be realised. The management of patients prone to self-harming behaviour often requires interventions which may include the involvement of several different partners from various sections of health and social care services. We therefore agree that the delivery of joined up services should be a important priority but this relies heavily on GP consortia being willing and able to engage with partners across health, local authorities and the local voluntary sector and to approach commissioning with the strategic objective of creating clear care pathways and appropriate, innovative services. 3.4 In addition to the integration of services across health, social care and health improvement, we also believe that the introduction of GP-led commissioning provides an opportunity to improve communication and pathways between primary care and secondary care services to ensure that appropriate information is always transferred and acted upon in the best interests of patients. Many GPs will be keenly aware of the challenges of long delays and the limited availability of services when seeking help for patients who are in emotional distress. The report Self-harm, suicide and risk: helping people who self harm141 published earlier this year by the Royal College of Psychiatrists following input from a working group of which Samaritans was a member, found that following episodes of self harm or a suicide attempt some patients “are often discharged from the A&E department with no or minimal communication to primary care”.142 This is contrary to the NICE clinical guideline on self harm143 and occurs despite the fact that someone who has deliberately harmed themselves is between 50 to 100 times more likely to die by suicide in future when compared to the general population.144 With improved channels of communication and pathways between primary care and secondary care, developed by the GPs who are a position to oversee and improve these processes in their roles as both primary care providers and secondary care commissioners, there is the potential to ensure that more patients who have presented to A&E following an act of deliberate self harm, or have sought help from their GP, do not fall through the gaps of the system and are instead placed on individual management plans and guided into appropriate services and clearly defined care pathways. However, as previously discussed, such improvements rely heavily on GPs having a well developed understanding of mental health issues, self harm and suicide prevention. 4. NHS Outcomes Framework 4.1 Suicide prevention work in the NHS had previously been prioritised through Public Service Agreement 18 and the Vital Signs performance indicator system and backed up by the National Suicide Prevention Strategy for England which provided a framework for action across government departments. When the National Suicide Prevention Strategy was first published in 2002 it included a national target to reduce suicide by 20% by 2010. While we understand and accept that targets such as this are a rather blunt measure of the success of health initiatives or strategies and that there are legitimate concerns about the potential for targets to distort clinical priorities, we do feel that the target was useful in focusing effort on suicide prevention. 4.2 Our concern is not so much that certain targets should be set and achieved but that mechanisms are in place to ensure that important interventions and follow up treatment for people who are at risk of suicide are not sidelined as a consequence of not being prioritised. Moving forward with the new NHS Outcomes Framework, it is therefore important that the outcome indicators focus commissioners and clinicians on ensuring that people receive interventions and treatments of a high quality that enables their recovery. We believe that the indicators relating to suicide and self harm proposed in the government’s consultation document Transparency in outcomes—a framework for the NHS could be improved in a way that could contribute towards achieving this. 4.3 The main indicator relating to suicide in the consultation document simply measures “mortality from suicide and injury of undetermined intent” and while we agree that it is important for this outcome to be measured and monitored as part of the Outcomes Framework we are concerned that this indicator alone would not be enough to hold healthcare providers to account for ensuring that evidence-based interventions are in place to support patients who have engaged in deliberate self harm or are at a heightened risk of dying by suicide. As previously referred to in paragraph 3.4, there is evidence that following episodes of self harm or a suicide attempt patients are, in some cases, discharged from A&E departments with no or minimal communication with primary care despite the greatly increased risk of that patient consequently dying by 141 http://www.rcpsych.ac.uk/files/pdfversion/CR158.pdf Self harm, suicide and risk: helping people who self-harm—Final report of a working group, 2010, Royal College of Psychiatrists College Report CR158, p 12. 143 National Clinical Practice Guidelines Number 16 (2004), National Institute for Clinical Excellence, http://www.nice.org.uk/ nicemedia/live/10946/29424/29424.pdf 144 Hawton, K, Zahl, D & Weatherall, R (2003b) Suicide following deliberate self-harm: long-term follow-up of patients who presented to a general hospital. British Journal of Psychiatry, 182,537–542. 142 Ev w192 Health Committee: Evidence suicide. Ideally we would therefore want to see the implementation of a performance indicator which measured the percentage of such cases where the patient went on to promptly receive a full risk and psychosocial needs assessment and appropriate aftercare as recommended by the NICE clinical guideline on self harm. However, such a measurement might be considered to be too much of a process-based indicator rather than an outcomes-based one and so in cases such as this we think that it would be beneficial to give consideration to alternative outcome measures that are not too prescriptive about processes but at the same time are not so imprecise that they fail to adequately incentivise effective interventions. A possible solution in this case might, for example, be to measure the number of emergency re-admissions to hospital within a certain period of time after discharge following treatment for an act of deliberate self harm. This would incentivise clinicians to take urgent action to provide follow-up support for people who we know to be in a group with a very high suicide and self-harm risk but would not unnecessarily impose specific process targets and would be broadly similar to other proposed indicators under Domain 3 (helping people to recover from episodes of illness or following injury) of the Outcomes Framework. It may also be useful to consider service users own indications of what constitutes recovery and a quality outcome in addition to measuring the cessation of self-harming behaviour. 5. Role of Local Authorities 5.1 The new role of local authorities in the delivery of public health services opens up the opportunity to deliver services aimed at improving public mental health and well being, designed specifically around the needs of the local community. Poor physical health is often linked to poor mental health and mental health is strongly related to social and economic factors, education, social networks and community, as well as contributing to life outcomes and healthy, productive communities. Thus the improvement of mental wellbeing and addressing health inequalities needs to be a key element of public health reforms and the placing of public health in local authorities provides the opportunity to link public health with community development and address health inequalities. From a suicide prevention perspective, on average only 26% of people who die by suicide in the UK each year have been in contact with mental health services in the 12 months prior to their death,145 which highlights the importance of local initiatives to improve mental wellbeing and to encourage help seeking behaviour for people in distress. In addition, as has been recognised in previous suicide prevention strategies, effective suicide prevention requires a range of interventions across sectors such as schools or the police service, linked in to the provision of appropriate health services and Directors for Public Health may be well placed to facilitate multi-agency suicide prevention work at a local level. 5.2 As previously stated, the management of people who self harm as well as support for people with various mental health problems often requires treatment which may include the involvement of several different partners from various sections of health and social care services. We therefore support the joint working arrangements for Health and Well-Being boards being put on a statutory footing, thereby improving the uptake of opportunities to develop joint commissioning arrangements and ensuring that the wider public health agenda, the tackling of health inequalities and suicide prevention needs inform the commissioning process. The government’s emphasis on localism in the development of these commissioning structures must also enable local voluntary organisations to engage with decision making through easily accessible channels which allow them to feed their expertise and local knowledge into the commissioning process. We therefore welcome, in principle, the strengthening of these arrangements through the new HealthWatch structures provided that this proves to be an effective mechanism to allow local individuals and organisations to have a genuine impact on local commissioning priorities and hold local service providers to account. October 2010 Written evidence from Tunstall Healthcare (COM 76) The Role of the NHS Commissioning Board to Assist Effective Commissioning 1.1 A key duty of the NHS Commissioning Board will be to develop a choice strategy, including guarantees of choices of particular interventions. This should encompass choice of provider, team, treatment and location. Choice for patients needs to be assessed at three levels: — A theoretical ability to make a choice. — An ability to practically make a choice. — An active promotion of choice by GPs. 1.2 Patients should have a clear choice of where they are treated and where treatment at home is an option this should be fully explained and offered to the patient. 145 National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Annual Report, (July 2010) University of Manchester, p.21 http://www.medicine.manchester.ac.uk/psychiatry/research/suicide/prevention/nci/inquiry annualreports/AnnualReportJuly2010.pdf Health Committee: Evidence Ev w193 Tunstall believes the key questions of choice for patients should be: — What are the choices of treatment available? — Where can the options of treatment be received? — Who is able to deliver the treatment available? 1.3 Telehealthcare can help care for patients with long term conditions such as chronic obstructive pulmonary disease (COPD) in the community, providing more personalised care for patients and freeing up much needed NHS resource. 1.4 Working in partnership with GP consortia, the NHS Commissioning Board should support commissioners in redesigning specific care pathways when taking into account the use of telehealthcare equipment. For example, while traditional pathways would see the ongoing contact for a patient with a nurse or doctor in a primary care setting, telehealthcare allows NHS staff to monitor a patient’s care remotely and reduces their time spent travelling. In terms of managing primary care performance an audit trial of all inputs and outputs is available which makes safeguarding the individual patient and clinical decision making very easy to measure. This can be done on a per practice level if needed. 1.5 For old people and those with long term needs, making patients feel empowered and confident in making decisions about their care is critical in maintaining their independence. At North Yorkshire County Council, for example, telecare was commissioned to support the council’s Adult and Community Services. Findings from satisfaction surveys conducted by the Council in August 2009 found: — 95% of patient felt telecare gave them more confidence/peace of mind. — 95% of patients felt telecare equipment made them feel safer. — 87% of patients believed telecare helped them carry on living at home. North Yorkshire County Council’s Commissioning Strategy outlines a 15 year strategy and approach to delivering services to support the well being of individuals and communities. Telecare is a component of commissioning aim 7 to enable people to be supported to live as independently as possible in their own homes through innovative design and equipment. 1.6 The NHS Commissioning Board could assist GP consortia by identifying and advising those consortia who could benefit from the introduction of particular practices and specialisms. The Board could help signpost consortia looking to introduce new practices to sources of third party expertise; for example, other commissioners, providers and appropriate stakeholders. This will be particularly important in relatively new areas of care delivery such as telehealthcare. 1.7 A recent analysis by Health Mandate has suggested that prioritisation by commissioners can be particularly effective in improving health outcomes, whilst containing costs. 1.8 GP consortia may be reluctant to make the initial investment when commissioning for new treatments and services. The NHS Commissioning Board should have a role in encouraging the development of health markets that local consortia are not able to or are reluctant to facilitate themselves. This will be particularly important in relatively new health markets such as telehealthcare, which can generate significant efficiency savings in the delivery of health and social care services after initial expenditure. The Board will have a role in ensuring that such markets are developed and are rolled out more widely, particularly when there is compelling evidence to do so. The Buying Solutions, National Framework Agreement for telehealth, telecare and telemonitoring is an excellent example of transparent procurement, avoiding the need to go to tender. 1.9 For telehealthcare the Whole System Demonstrator programme being run by the Department of Health and due to report in April 2011, should provide a wealth of information on the benefits of telehealthcare to assist the Board in its attempts to develop and widen the scale of current provision. GP consortia should also be able to seek advice and expertise on best practice from local authorities, charitable organisations, commissioners and the private sector when commissioning. The Importance of the Commissioning Outcomes Framework 2.1 The commissioning outcomes framework should support the five domains of the NHS Outcomes Framework to help improve patient outcomes. Given the need for the NHS to save £15–20 billion by 2014, it will be important that commissioners are rewarded for commissioning services efficiently. New methods of care delivery in the community such as telehealthcare can deliver significant savings in care costs and improve patient care. 2.2 The commissioning outcomes framework will have a key role to play in ensuring that appropriate outcomes are applied to appropriate disease areas. It is important that the commissioning outcomes framework encompasses the outcomes from commissioning at each stage of the patient pathway, including: — Diagnosis. — Treatment. — Follow-up. — Rehabilitation and aftercare. Ev w194 Health Committee: Evidence — End of life care. 2.3 Tunstall’s ICP (integrated care pathway) can assist commissioners and clinicians by measuring and improving outcomes, as patients proceed through the patient pathway. The integrated system allows multiple stakeholders to share common adult care practices in order to enable more high quality and cohesive care delivery. 2.4 The commissioning outcomes framework should also take greater account of Patient Related Outcome Measures (PROMs). PROMs provide a means of gaining an insight into the way patients perceive their health and the impact that treatments or adjustments to lifestyle have on their quality of life. Clinical outcomes alone will not be sufficient to accurately assess the quality of care received by patients with long term conditions. 2.5 PROMs should therefore have a central role in measuring patient outcomes for those patients managing long term conditions. Integration between Health and Social Care 3.1 Health and well being boards will be important forums to help build co-operation and integration between local authorities and GP practices on commissioning issues. Telehealthcare is well positioned to help the Government make health and social care services more integrated. 3.2 Technology is a great enabler for integration and also acts as a catalyst for change. Tunstall is working with a number of local authorities and health trusts to deliver a single view of the patient so all stakeholders are joined up in a way that has never been possible before. 3.3 For example, working together with Milton Keynes Primary Care Trust and Milton Keynes Council, Tunstall has provided an integrated telehealth and telecare initiative for local people suffering with COPD. Whilst previously working separately—therefore doubling the amount of data entry and making for incomplete health assessments—telehealth and telecare systems are now monitored and combined into a single source. As a result, the same monitoring centre will be able to receive and view information from telecare and telehealth equipment together. 3.4 In addition, Tunstall’s ICP (integrated care pathway) system allows processes and working practices to be streamlined and consistent. An added benefit is the fact that there is an audit trail and every activity is logged and timestamped, enabling managers to produce management reports to ensure outcomes are being delivered. 3.5 However such integration is being hampered as access to telehealthcare is unequal across the country. Whilst some local authorities and Primary Care Trusts, such as North Yorkshire and York have embraced it, generating better patient care and financial savings, many others continue to lag behind. It is important that the creation of GP consortia does not increase the existing fragmentation of the system. 3.6 Getting patients back into the community and returning to normal life quickly and safely is essential to improving the quality of care patients receive. Such re-ablement practices will be a key test of better integrating health and social care services. 3.7 Telecare “smart homes” such as those run by Chelmer Housing Partnership in Chelmsford, Essex, help patients who have recently been discharged from hospital. The homes, equipped with telecare technology, provide residents with a level of support which enables them to be discharged from hospital earlier than would otherwise be possible, helping to reduce the pressure on the NHS. October 2010 Written evidence from Action Duchenne (COM 77) Executive Summary — Duchenne Muscular Dystrophy is a serious, progressive, high cost condition with no cure. — Action Duchenne believes there has to be a budget for Rare Diseases, to ensure ring-fenced resource for rare conditions such as Duchenne. — The DOH white paper Liberating the NHS: Commissioning for Patients and Achieving Equity and Excellence for Children makes no reference to how rare, serious, high cost conditions such as Duchenne will be managed. — Action Duchenne has grave concerns regarding both the provision and standards of care for boys with Duchenne Muscular Dystrophy under the proposed changes to the NHS outlined in the White Paper. — As highlighted in Achieving Equity and Excellence for Children, Standards of Care are generally poorly met. Within the UK there is extreme variability in Standards of Care, costing the lives of Duchenne patients and adversely affecting quality of life. Life expectancy for those living with Health Committee: Evidence Ev w195 Duchenne in the UK is half of that for those living in Denmark. Within the UK there are significant differences in life expectancy, with those living in the south west facing significantly poorer outcomes than those in the north east, where life expectancy is the highest. — The only way to improve this is through specialist led multi-disciplinary services, ring fenced budgets and high quality, ring-fenced commissioning of the services required. The White Paper gives no indication of how this could be achieved with the GP consortia model. — Due to the rarity and complexity of the conditions GPs are inexperienced and ill-equipped to manage or commission care for boys with Duchenne Muscular Dystrophy. — Lack of any proposals for how to manage rare and costly conditions such as Duchenne in the new structure, can only lead to reductions in what is already a poor quality service, costing quantity and quality of life in patients and their families. 1. Rare Diseases—Duchenne Muscular Dystrophy 1.1 Duchenne Muscular Dystrophy is the most common lethal genetic disorder, affecting one in 3,500 male births. There are between 1,500 and 2,500 boys and young adults living with the condition in the UK, which is a severe and degenerative muscle wasting disease. It is caused by a defect in the gene which produces dystrophin, essential for muscle function. The disease progresses with weakening of the proximal muscles, ultimately leading to complete paralysis. The lack of dystrophin in the respiratory and cardiac muscles leads to a life expectancy in the late teens or early twenties. There is no cure or treatment to halt or reverse the onset of Duchenne which is predictable, progressive and life-limiting. 2. Standards of Care 2.1 Care for boys with Duchenne is complex and varied. Recently published standards of care (published in the Lancet Neurology in Jan/Feb 2010) by Prof. Kate Bushby et al, a top UK specialist working with a team of over 80 specialists, indicate the breadth and depth of multi-disciplinary specialities required at even a basic level of care. These range from provision of consultant time, physio and hydro-therapy and steroid treatment in the younger boys, to spinal surgery, EPIOC wheelchair provision, PEGs, ventilation, cardiac management, and full time care for adolescents and young adults. Emergency admission procedures must be adhered to, to prevent unintentional mistreatment. Given the nature of emergency admissions, appropriate and timely treatment is critical. It is Action Duchenne’s experience, that not only are some hospitals woefully uninformed about Duchenne, but they are also unwilling to take advice from specialists. This has resulted in patients receiving painful and needless procedures (had proper treatment been given initially) like tracheostomys and in the particularly high profile case of Arvind Jain (that hit the press this summer) premature death. 2.2 Patients receiving joined up care following the standards laid out can have their life expectancy raised by ten to fifteen years. Where the multi-disciplinary approach to care has been adopted, for instance, in Denmark, those with the condition live to their 30s and 40s where as in the UK life expectancy is late teens, early 20s. 2.3 The Minister for Care Services, Paul Burstow is reported as wishing to see the NHS compare more favourably with EU nations care in its treatments of various medical conditions and as Shadow Secretary of State for Health has personally authored work in this field, criticising the previous government’s failure to support neurology services. This report included a range of conditions including Muscular Dystrophy. 3. Commissioning 3.1 The Select Committee has asked “How will vulnerable groups of patients be provided for under this system?” The complexity of the care required means that commissioning high quality joined up services is vital. It is of high concern that the proposed GP consortia will not have the experience or resources to commission the fully integrated service that these boys require to lead as long and as dignified a life as possible. 3.2 It is noted that the NHS Commissioning Board will be able to “commission certain services that are not commissioned by consortia , such as the national and regional specialised services” (paragraph 2.8 of Commissioning for Patients). Referring to national and regional specialist commissioning, paragraph 3.3 of Commissioning for Patients states that: “(national and regional specialised commissioning) will ensure that patients with rare conditions can be sure of high-quality and cost-effective treatment and are treated equitably with people who have more common conditions.” 3.3 An assurance must be provided by the government that care services and future treatments for Duchenne Muscular Dystrophy will be delivered through specialist commissioning. 3.4 At the same time, there are concerns that the proposed reforms increase the risk high cost centres for rare conditions such as neuromuscular centres will be squeezed out by centres for more prevalent, easily managed disorders. Given the lack of experience in commissioning and possible reduction in specialist centres, Action Duchenne wishes to understand precisely how these specialised services will be Ev w196 Health Committee: Evidence commissioned effectively and equitably across the UK? The Select Committee has asked “What arrangements are proposed for commissioning of specialist services.” The White Paper and supporting documents, rushed through over the summer months, provides an alarming lack of detail in this respect. 3.5 A failure to provide a sufficiently robust funding model, set at a national level, will not only be to the detriment of those patients requiring care now, but will most likely result in the loss of the experience and highly skilled clinicians and researchers who will migrate to better funded centres outside of the UK. 4. Specialist led services 4.1 The Select Committee has asked “How will vulnerable groups of patients be provided for under this system?” Specialist consultant support is vital, and key to managing the condition well. Due to the rarity of the condition, it is unlikely that most GPs will come across a sufferer in his or her career. The lack of exposure to and experience in managing the condition means that under the proposed system, most GPs will not be adequately informed, equipped, trained or prepared to manage boys with Duchenne. Small variations in clinical judgement can cost lives. Action Duchenne believes that specialist led services are vital and the White Paper does not give any clarity on how specialist led conditions will be managed giving a scant reference to care for rare conditions being commissioned by the NHS commissioning board, which would be the only way to effectively fund the management of the condition. 4.2 Many PCTs have already failed to provide appropriate standards of care in many patients across the UK, as highlighted in Sir Ian Kennedy’s report Getting it right for children and young people: Overcoming cultural barriers in the NHS, and Action Duchenne is alarmed that GP consortia will have a lower level of knowledge of the condition and of commissioning processes and therefore be even worse than the current state of care. 4.3 The Select Committee have asked “Will the new arrangements safeguard current examples of good practice?” With the emphasis on budget controls within the White Paper, there is the concern that without ring-fenced funding the current “centres of excellence” for neuromuscular conditions in Newcastle and Great Ormond Street Hospital will lose out to other higher profile diseases that are more prevalent. 5. Costs 5.1 The Select Committee have posed a number of questions about resource allocation. Duchenne Muscular Dystrophy is an enormous cost to the NHS. No UK study exists yet but an equivalent Australian study that was carried out in 2007 by the Muscular Dystrophy Campaign (Australia) indicates a cost of AU$1.5 billion per year (£915 million), which could be an underestimate. 5.2 Emergency admissions, often due to poor standards of care, are extremely expensive to the NHS. While care for a non-ambulatory boy with Duchenne is high, an emergency admission is a far greater cost. In Wales alone, there are some 1,355 emergency admissions146 each year at a total cost of £3.92 million, whereas to provide the required baseline neuromuscular service to people with neuromuscular conditions would amount to £471,000. Extrapolated across England—given the gaps in this basic level of service outside of the two main neuromuscular centres in London and Newcastle—the savings would be vast in delivering care which is preventative, improves quality of life, is more compassionate, supports care in the community and reduces emergency admissions and long term stay. In short, it would result in better quality of life for the patient. 5.3 There are new treatments emerging which could be of a high cost. There is considerable anxiety that the proposed GP consortia would not be able to meet the costs of either management or treatment, and could deny patients treatment they need as influence from NICE decreases and could even exclude them from their practice lists. Action Duchenne believes that clear reassurance needs to be provided that if no national commissioning budget exists, all the costs of caring for the condition can and will be met by GP consortia across the whole of England, as well as across the devolved nations. Action Duchenne believes there has to be a budget for Rare Diseases, to ensure ring-fenced resource for rare conditions such as Duchenne. 5.4 Perversely, there is a strong likelihood that any more informed and enlightened consortia willing to meet the costs of Duchenne care would soon be overwhelmed by Duchenne patients from further afield, exercising their right to choose their GP and wishing to avoid the postcode lottery which currently blights the care of Duchenne in the UK. 6. Unanswered questions 6.1 Action Duchenne would like to know: How will the GP Consortia and the NHS Commissioning Board ensure that Standards of Care for Duchenne patients are met, given that with the PCT system, half the country have been without proper care? 6.2 We have seen without exception that GPs do not have the knowledge and experience of a rare disease like Duchenne to commission services. Therefore, how will services be commissioned? Will this be through National Commissioning? 146 The Thomas Report: Access to Specialist Neuromuscular Care in Wales. Health Committee: Evidence Ev w197 6.3 If this is not to be the case, will a budget for the treatment of care of patients with rare diseases like Duchenne be set? 6.4. How will the new GP consortia refer patients to Specialist Services and who will pick up the bill? 7. A note on the government’s consultation standards 7.1 The government has been criticised for the excessive speed with which it is seeking to introduce major reforms to the National Health Service and the failure to provide adequate time for stakeholders to respond to key White Paper document such as Commissioning for Patients and Achieving Equity and Excellence for Children is considered to be unacceptable. 7.2 Achieving Equity and Excellence for Children was published on 16 September 2010 with responses requested by 5th October. This is a very short time frame for such an important response and falls well short of the minimum 12 week requirement set out in the government’s own Code of Practice on Consultation. 7.3 It is also noted that the Code of Practice on Consultation seeks a longer than 12 week period for consultation, where such an exercise takes place over the summer break; this has not been the case with the Health White Paper. There are serious concerns that the government has failed to provide adequate time for a full and meaningful “conversation” with patient groups, clinicians, nurses, GPs and other key stakeholders. About Action Duchenne Action Duchenne was set up by Duchenne families in 2001 to promote new research for a cure for Duchenne. The charity has a strong record in funding research The Charity has directly funded or supported projects in partnerships for over £4 million since 2003. Action Duchenne has worked with the MDEX consortium, Department of Health, Medical Research Council in the UK to deliver new clinical trials for Duchenne drugs. These projects have enabled much needed early work to be completed on exon skipping and other therapeutic approaches. Action Duchenne holds an international conference every year to bring together researchers and families to exchange new research developments and provide a vital meeting venue for scientists. Action Duchenne provides direct services to those living with Duchenne. In 2005 Action Duchenne launched the Duchenne Registry, the first National Duchenne database that holds gene information of people living with Duchenne and can be used to speed up the recruitment of patients for clinical trials. In 2006 Action Duchenne launched a comprehensive learning and behaviour toolkit for use by parents and education professionals. In 2007 the Charity with support from the Big Lottery and Children in Need launched an Inclusive 500K education project that has supported younger boys with learning and behaviour problems across 85 UK schools. In 2008 the Charity developed the Genius project with young volunteers 16–25 to develop exciting events invloving Duchenne young men. This included an award winning photography exhibition and a film making project. October 2010 Written evidence from the Health Foundation (COM 78) 1. About the Health Foundation 1.1 The Health Foundation is an independent charity working to continuously improve the quality of healthcare in the UK. 1.2 We want the UK to have healthcare systems of the highest possible quality—safe, effective, personcentred, timely, efficient and equitable. We believe that in order to achieve this, health services need to continually improve the way they work. 1.3 We are here to inspire and create the space for people to make lasting improvements to health services. Working at every level of the system, we aim to develop the technical skills, leadership, capacity and knowledge, and build the will for change, to secure lasting improvements to healthcare. 1.4 The Health Foundation submitted evidence to the Health Committee’s recent inquiry into commissioning.1 We would be pleased to give oral evidence to the Health Committee so that members can speak directly to experts who have developed these insights. Ev w198 Health Committee: Evidence 2. Executive Summary 2.1 Health Foundation research has shown that commissioning led by primary care can have a beneficial impact on primary and intermediate services through improved responsiveness and innovative working practices. However, primary care led commissioning has had less impact on hospital provision. 2.2 Commissioning has struggled in the past to engage patients effectively. The Health Foundation has pioneered a new process for engaging local communities in setting commissioning priorities and making disinvestment decisions. 2.3 The transfer of commissioning responsibilities must include clear lines of authority and accountability. Peer review across consortia could provide a mechanism for avoiding the potential conflicts of interest if GP consortia are to performance manage GP practices. Care must also be taken to avoid local services being managed too remotely. 2.4 Primary care led commissioning will only be effective if significant levels of management support are provided, including investment in developing new skills. 2.5 The new NHS Commissioning Board must take the in lead inspiring and communicating best practice in patient safety and develop mechanisms to encourage quality improvement and engagement so that advances in these areas are maintained during the transition to the new arrangements. 3. Evidence and Learning from the Health Foundation Concerning Commissioning Commissioning in the wider context of the White Paper 3.1 We welcome the Government’s focus on putting the patient at the centre of health services. To realise its vision, evidence shows we need to focus on changing relationships between people and services, inspire improvement through clinicians and transform organisational approaches to patient safety. The proposals for a National Commissioning Board and GP commissioning have profound implications for the health service. It is important that the best available evidence informs preparations for these changes. The Health Foundation’s research on commissioning 3.2 The Health Foundation has commissioned extensive in-depth research to examine the available evidence on commissioning. This has led to: — a clear understanding of what can and cannot be achieved by commissioning; — knowledge of the essential prerequisites for successful commissioning; — development of a systematic approach to community engagement that produces fair, transparent, evidence-based decisions on commissioning priorities and disinvestment; and — insights into the impact of commissioning on costs and efficiency. 3.3 We have focused this submission on evidence from our research—published and unpublished. Our key findings on the limits and potential of primary care led commissioning 3.4 In 2004, the Health Foundation commissioned a review of the evidence on the effectiveness of primary care led commissioning.2 This research has withstood the test of time and is highly relevant to the White Paper’s proposals. It clarifies what can be achieved through effective commissioning; which outcomes are beyond the influence of commissioners; and the essential prerequisites for successful commissioning. Primary care led commissioning can: — secure improved responsiveness from hospitals such as shorter waiting times for treatment and more information on patients’ progress; — make its greatest impact in primary and intermediate care, eg in developing new practice-based services, stimulating new forms of peer review and quality assessment, enabling new forms of specialist primary care, and building new community-based alternatives to hospital care; — where managers show high degrees of determination this can enable innovations that change longstanding working practices; — effect change in prescribing practice, with financial incentives playing a key role, as demonstrated through GP commissioning and fundholding; — the Health Foundation’s 2004 report found little substantial evidence to show any commissioning approach has made a significant or strategic impact on secondary care services, except in relation to very specific indicators such as waiting times; and — the report further showed that primary care led commissioners have struggled to engage patients and the public in any significant way. Health Committee: Evidence Ev w199 Essential elements for successful commissioning 3.5 This research found a number of replicable characteristics of successful primary care led commissioning, including: — different population bases are needed for commissioning different services—there is no single “ideal” size for commissioning organisations; — adequate levels of management support are vital, and schemes with higher levels of support tend to produce better outcomes; — timely and accurate information is required for effective commissioning; — real clinical engagement is crucial; — there is a balance to be struck between clinical engagement and appropriate public and management accountability; — as well as maintaining effective strategic relationships, commissioners need to be able to shift activity to different providers; — commissioning organisations need a degree of stability in the wider policy context; and — new and more advanced forms of support are required such as the stratification of patients according to risk, commissioner-led advanced case management and predictive modelling of highintensity service users. Engaging communities in commissioning priorities and disinvestment decisions 3.6 Informed by the 2004 review, the Health Foundation commissioned a project on the Isle of Wight3 to engage health partners and local communities in the process of developing commissioning priorities. This work set out to achieve a shared understanding of the issues and sense of common purpose, while preserving differences of opinion and allowing for differences in the individual paths taken. 3.7 This systematic process for engaging health partners developed approaches that would: — provide an audit trail; — empower senior managers to justify difficult decisions based on relevant evidence; — enable decisions that take account of the greatest potential impact on the health of the population; and — engage the local community. 3.8 The process achieved this through: — continuous engagement with the public and patients to shape services and improve health following techniques developed by Professor Gwyn Bevan of the London School of Economics; — partner workshops to identify and assess the cost and value of different initiatives to improve population health and quality of life; and — multi-criteria scoring, including the numbers of people who would benefit, “visualisation” of beneficiaries and the scale of individual health benefits. 3.9 The process resulted in a clear set of health priorities with specific recommendations for reallocating resources. 3.10 Following the success of this initiative, further research is now underway with NHS Sheffield to develop these processes further to inform disinvestment decisions. It is of course absolutely critical that the NHS manages disinvestment effectively and fairly so that it can make the most of efficacious innovations while phasing out legacy, less productive services. The research at NHS Sheffield is developing clear methods to make fair comparisons between different treatments and services in terms of their impact on health outcomes. 3.11 The Health Foundation’s work in the Isle of Wight and Sheffield shows how systematic engagement can be achieved by commissioners to ensure fair, justifiable decisions that lead to the greatest potential impact on the health of the population. Commissioning for outcomes and the impact on efficiency 3.12 The 2004 evidence review suggests that primary care led commissioning increases transaction costs. 3.13 Evidence also suggests that effective commissioning for outcomes can have varied and unexpected effects on efficiency. Recent research4 by the Health Foundation shows: — throwing money at a problem will not necessarily fix it: efficiency is strongly negatively correlated with allocations in excess of targets. What this means in practice is that there are diminishing marginal returns on health expenditure. Overall efficiency is likely to drop as additional funds become available; — PCTs with higher levels of deprivation tend to be less efficient; and Ev w200 Health Committee: Evidence — achievement on some Quality and Outcomes Framework indicators, for example chronic obstructive pulmonary disease, correlates with efficiency levels. Other indicators including those that relate to diabetes and coronary heart disease show a negative correlation. This may be because achievement in these domains takes time to show through in improved mortality. This suggests that perversely, improving health outcomes does not always lead to more efficient health costs. 4. Answers to Questions Posed by the Committee Clinical engagement in commissioning 4.1 Clear lines of accountability and authority to manage poor performance across local health economies are vital. This includes power for commissioners to ensure all elements of the local health community act coherently. Ultimate responsibility needs to rest with lead commissioners, which under the proposals in the White Paper means GP consortia. 4.2 The White Paper is ambiguous in relation to ultimate responsibility for driving up the quality of primary medical care. On the one hand it is the NHS Commissioning Board (NCB) that commissions practices but on the other hand consortia may well carry out on its behalf some aspects of this work. The Health Foundation urges clarity of role and responsibility in relation to this matter and suggests that although it may take time for consortia to develop the appropriate skills to carry out these responsibilities this is where they should ultimately lie. 4.3 Peer review processes could be developed across consortia as a mechanism to avoid conflicts of interest. The Health Foundation’s 2004 review of evidence described in paragraphs 3.5 to 3.11 identified new forms of peer review as one of the innovative and successful approaches arising from primary care led commissioning. 4.4 Given the findings of the 2004 research set out at paragraph 3.5, there does not appear to be any logic in placing commissioning responsibilities for maternity services with the NCB. As an essentially local service, this should be with GP consortia. 4.5 The 2004 research also identified the need for new and more advanced forms of support such as the stratification of patients according to risk, commissioner-led advanced case management and predictive modelling of high-intensity service users. While the World Class Commissioning initiative has made some progress here, it is important that this progress is not lost through the transition to the new arrangements and that consortia are suitably supported. How open will the system be to new entrants? 4.6 As we have set out above, there are a number of replicable characteristics of successful primary care led commissioning that are particularly relevant to the reforms proposed in the White Paper: — Different population bases are needed for commissioning different services—there is no single “ideal” size for commissioning organisations. The proposals give consortia significant local flexibility to respond to local population need, but it is not clear what, if any mechanisms will assure the process of matching consortia size to the services they commission. Also, it may be that smaller consortia are able to commission appropriately for some services, but they will need to find mechanisms to work together to commission other services across a larger population base. — Research shows that adequate levels of management support are vital, and schemes with higher levels of support tend to be more effective in terms of outcomes. In the context of a significant decrease in the level of overall NHS management capacity it will be particularly important to ensure that GP consortia have access to sufficient levels of support. — In an environment where competition in healthcare is being encouraged commissioners will need to employ methods such as those developed in the Isle of Wight and Sheffield to balance the tension between ensuring clinical engagement and assuring appropriate public and management accountability. Accountability for commissioning decisions How will patients make their voice heard or their choice effective? 4.7 The Health Foundation’s work in the Isle of Wight and Sheffield, as set out in paragraphs 3.5 to 3.11 above, shows how the full spectrum of community partners can be engaged effectively in making decisions about local commissioning priorities and disinvestment. 4.8. The Health Foundation’s Co-creating Health initiative5 shows that significant improvements in health outcomes can be achieved if patients become “activated”—ie they become active partners managing their health. This includes, but goes significantly beyond, simple choice of provider of care or commissioner. By engaging activated patients, GP commissioners will need to consider different forms of provision that support active self-management. This is a distinctly new and separate dimension of the choice/voice debate. Health Committee: Evidence Ev w201 What will be the role of the Commissioning Board? 4.9 It is particularly important during the period of transition and major structural change that there is clear leadership from the centre to encourage, inspire and communicate best practice on patient safety and continuous improvement. This includes building appropriate technical expertise on the new Commissioning Board and ensuring alignment of roles and action by the Commissioning Board, Monitor, the CQC and NICE. How will commissioning interface with the Public Health Service? 4.10 A potential unintended consequence of the creation of a national Public Health Service, should it be given responsibility for commissioning school nurses and health visiting services, would be to add to the number of bodies responsible for different elements of health services for a given population. In an context where the Public Health Service, a GP consortium and the NCB will all have a commissioning role to play, and at a time when there will be tough spending decisions to be made, it is vital that one player—in our view the GP consortium—should be given an overall, formal co-ordinating function. Where will the “buck stop” when commissioners face hard choices? 4.11 The Health Foundation strongly believes that the GP consortia should take responsibility for their decisions. Clear lines of accountability are essential prerequisites for successful commissioning. Consortia must develop the resilience to justify often controversial decisions to reconfigure services based on the best available evidence, local community and clinical need. This includes confidence that the NCB will not second-guess local decision making as a result of political considerations or media pressure. Integration of health and social care 4.12 Forthcoming Health Foundation research, Does Care Coordination Improve Quality and Save or Make Money? By Dr John Øvretveit, indicates that poor coordination absorbs approximately 5% of healthcare costs. The NHS must be able to achieve these savings under the new arrangements and during the transition period. How will the new arrangements strengthen commissioners against provider interests? How will vulnerable groups of patients be provided for under this system? How will the proposed system facilitate service reconfiguration? 4.13 The Isle of Wight/Sheffield evidence detailed in paragraphs 3.5 to 3.11 above demonstrates the importance of consortia-led systematic engagement to set priorities and facilitate service reconfiguration. By engaging all stakeholder groups and focusing on evidence and overall public health outcomes, fair decisions become possible that transcend provider interests and protect vulnerable groups of patients whose voice might otherwise not be heard. 4.14 Preliminary statistical analysis by the Health Foundation earlier this year5 showed that PCTs with higher levels of deprivation tend to be less efficient. The new arrangements need to take this into account to avoid replicating structural weaknesses. Endnotes 1 The Health Foundation submitted written evidence to the Committee in September 2009. The submission can be found in full at: http://www.health.org.uk/publications/consultation responses/evidence to inquiry.html 2 Smith J, Mays N, Dixon J et al (October 2004). A review of the effectiveness of primary care-led commissioning and its place in the NHS. Health Foundation. 3 The Health Foundation (2010). Improvement in practice: Commissioning with the community. 4 Martin S and Smith P (2010). Commissioning health. A comparison of English PCTs: preliminary statistical analysis. London: Health Foundation. 5 Co-creating Health is a self-management scheme that aims to transform healthcare for people with longterm conditions. Weblink: http://www.health.org.uk/current work/programmes/cocreating health.html October 2010 Written evidence from British Association for Adoption and Fostering (COM 79) Introduction In 2010 British Association for Adoption and Fostering (BAAF) will be celebrating 30 years of supporting, advising and campaigning for better outcomes for children in care. (BAAF) is the leading charity and membership organisation for fostering and adoption in the UK. We: — promote the highest standards of child-centred policies and services; Ev w202 Health Committee: Evidence — speak out on behalf of looked after children; — influence UK-wide policy and legislation; — provide much-needed information and advice; — promote greater public understanding of adoption and fostering; and — support our members in their work. BAAF’s main activities are the development, promotion and advocacy of best policy and practice; the provision of advice and information to our members and to the general public; training, consultancy and seminars; child placement services including Be My Parent online. We also publish a quarterly professional journal, Adoption and Fostering, books and guides for professionals, academics, parents and carers and research studies. The main users of our services are our members comprising local authorities across the UK, voluntary adoption agencies, independent fostering agencies and also individual social care, legal and health professionals, and carers. This response is being submitted on behalf of the BAAF Health Group, which is also a special interest group of the Royal College of Paediatrics and Child Health (RCPCH), in consultation with social care professionals. The Health Group was formed to support health professionals working with children in the care system, through training, the provision of practice guidance and lobbying to promote the health of these children. With over 500 members UK-wide, an elected Health Group Advisory Committee with representation from community paediatricians working as medical advisers for looked after children and adoption panels, specialist nurses for looked after children, psychologists and psychiatrists, the Health Group has considerable expertise and a wide sphere of influence. General Comments We very much welcome the opportunity to submit written evidence. Our comments relate primarily to the very vulnerable group of children who are looked after, including those with a care plan for adoption, and unaccompanied asylum seeking refugee children and young people. We will be making reference to the revised statutory guidance Promoting the Health and Wellbeing of Looked after Children published in 2009 by the previous government, and will take into consideration the current government’s white paper Equity and Excellence: Liberating the NHS. Prior to any consideration of commissioning health services for looked after children (LAC), it is essential to appreciate that looked after children are significantly different from other children in a variety of ways. Greater Health Need As acknowledged in Promoting the Health and Wellbeing of Looked after Children, they have significantly greater prevalence of health problems as well as more complex health needs, particularly mental, emotional and behavioural, arising from the following factors: — health inequalities on entry to care; — experience of early trauma and loss; — physical, emotional and sexual abuse; — neglect; — attachment insecurity or disorganisation; — learning difficulties; — disability; — parental misuse of substances; — experience of domestic violence; and — multiple moves within the care system. Currently, PCTs provide a number of clinical sessions for looked after children’s health services. Most PCTs currently will have Designated Doctors and Designated Nurses for looked after children, carrying out strategic roles. In addition, community paediatricians engaged in clinical roles with looked after children and appointed as medical advisers to adoption and fostering panels, and specialist nurses for looked after children, will working together as a team undertaking statutory work. Lack of Parental Advocacy Parents undertake multiple functions which are often taken for granted, but none is more relevant to commissioning than the role of advocate. The philosophy of the current government’s white paper Equity and Excellence: Liberating the NHS, to put patients at the heart of the NHS, through involvement and shared decision-making is admirable but problematic for this population of children. Parents normally act as advocates in considering the best interests of their children, but looked after children do not have the Health Committee: Evidence Ev w203 benefit of committed, caring parent/s who know them well and are prepared to do whatever is needed on their behalf. Who will be effective in the role of advocate for looked after children, not just for commissioning, but concerning individual health needs of specific children? Corporate Parenting Ultimately, social care as the corporate parent, often in partnership with the birth family, becomes responsible for looked after children, and must work in partnership with health services to promote their health and wellbeing. The difficulties and poor outcomes of the care system are well documented. The difficulties with the issues noted above are that the child’s needs are intimately related to the stability and security of placements, usually in foster care, and other critical factors such as school. Both physical and mental health are located in the carer’s understanding of, and commitment to the child, both generally and specifically. Carers act as sources of information, monitor well being, act as advocates, coordinate the system around the child, and have intimate knowledge of the child including the sustaining qualities of relationships and commitment. These cannot be directly replicated by professionals or professional systems. Additionally, carers often change and it is only the best who will offer the same level of commitment and advocacy as dedicated parents. It is essential for commissioners to appreciate that meeting the physical and mental health needs of children looked after must primarily be located in the early resolution of the child’s permanence plan and that the services and expertise of health professionals must engage and support that plan and those carers. However good the professional system, in the absence of a secure, stable committed lifelong relationship for the child with people who they come to regard as parental figures, those systems will always struggle to be effective. Different Health Needs In practice, our members report widespread lack of understanding of the health needs of, and service provision for, looked after children, with the unfortunate effect that service provision is low on the priority list compared to, for instance, children requiring the child protection aspects of safeguarding. Even colleagues in acute paediatrics often fail to recognise that for the most part, these are the same children who became looked after following child protection concerns. So it is no surprise that social care managers and commissioners fail to recognise the health inequalities and resultant unique needs of looked after children, including the need for services structured in different ways than for most other children. And without a clear and in depth understanding of health needs, it is virtually impossible to make effective commissioning arrangements. Commissioners need to understand that a looked after child often has multiple inter-related and overlapping needs, which are different than a child with, for example, diabetes, who needs a series of consultant appointments in a diabetes clinic. While different in some very important ways, looked after children are children first, and they should have access to universal services which understand their issues. Much preventative and supportive work is already being carried out by the looked after children’s health team and in schools and pre-school provision, and this must be continued, acknowledged and supported. Need for Specialised Health Services Because of the statutory requirement to monitoring health of L looked after children as well as the increased prevalence of difficulties, particularly with mental, emotional and behavioural health, health services for LAC must be organised differently than either typical outpatient or acute hospital services. This is also a complex area of social paediatrics which requires specialised training and understanding of issues such as consent, confidentiality and information sharing, special needs of black and minority ethnic children, unaccompanied asylum seeking refugee children, and disabled children, as well as purely medical issues. BAAF Practice Note 53 Guidelines for the testing of looked after children who are at risk of a bloodborn infection, (attached for reference) provides an example of one specialised area of medicine where such complex issues need to be addressed. Need for Specialised Mental Health Services Given the high prevalence of mental, emotional and behavioural difficulties, specialised expertise is particularly needed in these areas For dedicated services, it is essential that all CAMHS professionals recognise that the mental health needs of looked after children are often quite different from other children in the general population. Looked after children often present with a range of interacting symptoms and disorders. CAMHS professionals must receive specialised training to ensure that they have a good understanding of, and ability to recognise and provide interventions for, the complex mental health needs of looked after children, which may arise from the factors noted above. CAMHS services must be flexible and develop ways of working to meet the particular needs of LAC. There also needs to be recognition that services may need to be continued over many years, with interventions appropriate to different developmental stages of the child’s life. In addition, it should be Ev w204 Health Committee: Evidence acknowledged that working with this disadvantaged group of children with complex needs requires a high level of skill. Concomitant commitment to development of greater numbers of highly skilled CAMHS professionals dedicated to looked after and adopted children and their families/carers is essential. Training Needs Commissioners must also have an excellent understanding of the various needs of looked after children to be effective. Specialised training is also needed for all health professionals and should be based on competencies and job descriptions for medical advisers, such as those published by BAAF in 2008 (attached) Similar competencies and job descriptions for specialist nurse roles would enhance the Guidance. This information would assist agencies in recruiting, training and evaluating health professionals, and would further assist commissioners in understanding the roles, as well as providing a standard for inspections. Responses to Questions Raised in the Call for Evidence The last substantive report of the Health Committee in the last Parliament, published on 30 March 2010, reviewed the progress of commissioning in the NHS. Among its conclusions were the following: — “Weaknesses remain 20 years after the introduction of the purchaser/provider split”. — “Weaknesses are due in large part to PCTs’ lack of skills, notably poor analysis of data, lack of clinical knowledge and the poor quality of much PCT management. The situation has been made worse by the constant re-organisations and high turnover of staff”. We must express serious reservations about the impact on looked after children of the proposal to place responsibility for commissioning in the hands of GPs consortia. As explained above, the health needs of this population are poorly understood even amongst paediatricians. Health professional teams for looked after children have had an ongoing challenge negotiating with PCTs for appropriate specialised health services for this population. The reality is that most GP surgeries will have at most a handful of looked after children registered in their practice, so it is understandable that most will have little understanding of their needs. A good understanding of the complex health issues of looked after children and their need for specialised services is essential to effective commissioning and we believe that GPs lack clinical knowledge, lack understanding of appropriate services and lack skill and opportunity to collect and analyse audit data to inform commissioning. We are very concerned that given the inevitable pressures of competing needs, this vulnerable group, lacking advocacy, will be overlooked completely. The Committee’s inquiry will focus in particular on the following themes: Clinical engagement in commissioning. — How will commissioners access the information and clinical expertise required to make high quality decisions about the shape of clinical services? It will be critically important to draw upon the expertise of specially trained and experienced health professionals involved in clinical work with looked after children. Typically these will be community paediatricians appointed as medical advisers to adoption and fostering panels, and engaged in clinical roles with looked after children, and specialist nurses for looked after children, working together as a team, and with appropriate support from dedicated CAMHS services. Most PCTs currently will have Designated Doctors and Designated Nurses for looked after children, and they will have either a direct or advisory role in commissioning. Most of our members think that the role of Designated Doctors and Nurses has been underutilised and undervalued within PCTs; it is hard to envision this role being strengthened within GP consortia. — How will commissioners address issues of clinical practice variation? We believe this will be much more difficult to address within GP commissioning consortia, as there will be even less of an overview. — How will GPs engage with their colleagues within a consortium and how will consortia engage with the wider clinical community? It seems inevitable that there will be even greater numbers of clinicians involved in a model of GP commissioning consortia. Even with the best of intentions, we are greatly concerned that looked after children will be even more marginalised than currently. Health Committee: Evidence Ev w205 How open will the system be to new entrants? — Will care providers be free to offer new solutions which offer higher clinical quality, better patient experience or better value? What arrangements will be made to encourage the Third Sector both as commissioners and providers? We note that there are a variety of services of relevance to looked after children already available, but underutilised because of lack of funding. . For example, the charity Action for Children offers a variety of innovative therapeutic interventions for children who have experienced sexual abuse. These currently exist as projects in areas scattered throughout the UK where funding has been procured, but should be available universally. Once again, given the small numbers of looked after children in GP surgeries, we must express great concern that provision of these types of services will not be seen as a priority by GPs. Accountability for commissioning decisions — How will patients make their voice heard or their choice effective? We are gravely concerned that due to lack of parental advocacy and reliance on advocacy from corporate parents, whose track record has largely been poor, the voices of looked after children will not be adequately heard and their needs will be given lowest priority, or may indeed be missed entirely from the list of priorities. Integration of health and social care — How will any new structures promote the integration of health and social care? — What arrangements are proposed for shared health and social care budgets? How will the new arrangements strengthen commissioners against provider interests? — How will vulnerable groups of patients be provided for under this system? Specialist Services — What arrangements are proposed for commissioning of specialist services? If the proposed model of GP commissioning consortia proceeds, consortia must accept responsibility for provision of health services for looked after children in the broadest sense. They must address some of the current barriers to high quality provision of health services which arise from corporate parenting, such as inadequate notification systems between health and social care and the difficulties of providing health care for children placed outside of local authority boundaries, which has not been resolved by previous guidance Who pays? Establishing the responsible commissioner. The need for good inter-agency working; support, advice and training for carers; intervention aimed at assisting carer and young person together, in addition to the more traditional services for the young person, all need to be emphasised. Resources need to take into account the additional need for time for liaison, interagency working, and provision of consultation and advice over and above the usual range of services for children and young people. Commissioners should receive advice from designated professionals who understand services, can identify gaps in services, and have a strategic overview. Commissioners must also understand that services and support for physical, emotional and mental health difficulties related to formerly being children in care, will often need to be commissioned for adopted children and their families. Commissioners must appreciate that arrangements for transition from looked after young person to adult services need to be improved. The complex needs of many young adults who are or have been in care are poorly understood by adult services. These services tend to be quite rigid, based on clinic appointments and brief interventions. Transitional young adult services are needed with more flexibility and an expanded range of brief and longer-term interventions provided by practitioners with a good understanding of the needs of young people who have lived “in care” and have experienced the trauma of neglect, abuse, loss and separation. Commissioners must recognise the extensive and multiple nature of the health issues and needs of looked after children. There needs to be an evaluation of what service delivery models are effective for looked after children, although we hope this will be an addressed in the forthcoming NICE guidelines for LAC. It would be extremely useful to have a debate concerning the development of innovative service models, to address common difficulties such as attachment insecurity or disorganisation, speech and language problems, autistic spectrum disorders, foetal alcohol spectrum disorders, and emotional and behavioural difficulties. We would recommend appropriate training for commissioners including an innovative model such as shadowing the foster carer of multiple children with a variety of health, emotional and behavioural needs for 24 hours. Commissioners must be knowledgeable about assessment and care pathways, and understand the needs of specific groups of children in care, such as disabled children, those from black and minority ethnic cultures, asylum seekers, children who have been sexually abused, or who abuse other children, trafficked children, and children affected by prenatal substance exposure. Commissioners should understand the issues concerning access and engagement of young people with disabilities, as well as young people from diverse cultural backgrounds, asylum seeking young people, and young people preparing to leave care and access adult services. More understanding is needed about engaging young people in services, including the importance of moving away from clinic based services with flexibility in place and time. Practitioners need to be prepared for long periods of building trust and Ev w206 Health Committee: Evidence engagement, with testing by the young people. They need to be prepared for non-attendance and committed to staying available to the young person. They also need to be prepared to be flexible and innovative in the interventions that they offer with more attention to bottom up interventions that provide stabilization and build affect regulation and less focus on cognitive interventions that do not address the underlying physiology. The importance of relationship within these interventions needs to be recognised. These suggestions will of course require development of innovative models of service. Summary Commissioning services for looked after children is a complex area and requires considerable understanding of a vulnerable group of children with above average health burden, and who lack advocacy, thus putting them at risk of occupying an unacceptable low position on the priority list. Specialised expertise is required and we are concerned this will be lacking in GP commissioning consortia. October 2010 Written evidence from Turning Point (COM 80) 1. About Turning Point 1.1 Turning Point is a leading health and social care organisation. We work in over 200 locations, providing specialist and integrated services that meet the needs of individuals, families and communities across England and Wales. We have also developed Connected Care, Turning Point’s model of communityled commissioning: currently working in 10 areas of England to integrate health, housing and social care. 1.2 We are a large social enterprise reinvesting its surplus to provide the best services in the right locations for people with a range of complex needs who need them the most. 1.3 With the biggest change to health policy since the formation of the NHS over 60 years ago, Turning Point welcomes the opportunity to respond to the committee’s inquiry specifically into commissioning on behalf of the 100,000 individuals accessing Turning Point services each year and our 2,000 members of staff. 2. Role of Organisations in Commissioning 2.1 Turning Point believes that there is an important role for non-statutory organisations to play in ensuring people have choice not only of treatment but also of provider. 2.2 Civil society organisations provide a unique link into communities, supporting statutory services to engage with people they may not otherwise reach because of their unique position within communities. Organisations like Turning Point provide services that cross the boundaries of health and social care and already deliver cost savings to the health service. Our Crisis model, for example, delivers a 70% reduction in admission to acute mental health wards while many social care interventions relate directly to ensuring improved health outcomes. 2.3 However recent survey data from 250 GPs commissioned by Turning Point and conducted by ICM found that: — Only 9% of respondents felt consortia would be very likely to commission services from social enterprises, compared to 46% thinking they would be very likely to commission services from Foundation Trusts. — 84% of respondents felt that consortia were likely or very likely to commission services from GP provider arms. 2.4 It is therefore important to recognise the role that social enterprises and charities can play not only as providers but as navigators between services. With the above results in mind “any willing provider” could become an open gate for either the private, for-profit sector or internalism of the health service, rather than allowing people to choose services from the not-for-profit sector where so much innovation stems from. 2.5 Turning Point would therefore be keen to work with partner organisations and the Department of Health to roll out a comprehensive training programme to ensure that all health professionals know what civil society has to offer; and want to ensure the role of the NHS Commissioning Board in encouraging cross sector working. 2.6 Currently there are large groups of people within society, namely those Turning Point supports, who do not feel able to access their local GP surgeries or are not registered for a number of reasons. For these reasons Turning Point is cautious as to whether the proposed plans for GP Commissioning can work. As this seems the inevitable way forward Turning Point advocates strongly for a better understanding of the not-for-profit sector so to ensure people are not left behind. 2.7 Turning Point has recently pulled together data from our clients, views of those at the sharp end that will feel the impact of these changes the most and we have included some of these figures in this response. 2.8 We have sent a questionnaire to over 100 clients accessing Turning Point substance misuse, mental health and learning disability services and asked them about their experience of GPs and GP surgeries. Health Committee: Evidence Ev w207 2.9 The results of the above can both be found in Appendix 1 and are detailed in this response. Turning Point’s clients state a number of reasons why they feel they cannot access GP surgeries which Turning Point think proves the case for non-statutory involvement: — “Doctors end up judging you by your prescription history”. — “I see a different GP every time and do not get to build a familiar relationship with a doctor who understands my situation”. — “My GP is too far away”. — “My GP doesn’t understand my needs”. — “I feel more comfortable accessing an organisation that specialises in issues which affect me”. 2.10 It appears that many people feel more comfortable accessing non-statutory services that are less imposing, more flexible, locally based and non-judgmental. To this end Turning Point welcomes the Government’s position on “any willing provider” and the increased role of social enterprise outlined in the proposals. 2.11 It is therefore essential that health professionals: — Understand social enterprises and charity organisations and the role they can play in delivering primary and integrated care; — Support smaller social enterprises and charities to work together with each other and/or health partners to offer locally led solutions to gaps in provision; and — Are encouraged to engage with the “any willing provider” and consider them on the same footing as existing health providers. 2.13 To ensure the role of civil society organisations is at the heart of commissioning and delivering future health services, Turning Point will continue with our role to educate health staff and commissioners around the role these organisations can play but will seek to work with the Department of Health and other partners to roll out a comprehensive programme of awareness training across the health service, particularly with GPs. 3. Commissioning Definition 3.1 As a national provider of health and social care services working across specialisms Turning Point knows from experience that the end product will only improve if there is a clear, consistent and agreed upon definition of commissioning. We believe that this definition should be routed in community engagement— leading to local services, built around local needs, meeting local outcomes. 3.2 Currently the quality of commissioning is not consistent and often resembles purchasing more than world class commissioning of person centred, locally driven services. Therefore Turning Point sees that it is of great importance that there is a Government supported definition of commissioning, to ensure consistency of services at a time when there is fast paced, all encompassing changes being made. Turning Point’s proposed definition is: “Commissioning: the means by which you understand the needs of an individual and/or a community such that you can build a platform for procurement.” 3.3 Turning Point proposes a model of commissioning services that is embedded in the community they serve. Any future model of commissioning must be embedded within the community and work across existing silos. 3.4 The introduction of GP commissioning will offer both benefits and potential risks for the people we support and there are mixed feelings as to whether it will improve access to services or even if GPs are the best placed professionals to know their local populations. 3.5 According to figures from people accessing Turning Point services, when asked whether GP commissioning would enable them to have a bigger say in their care 37% said yes, 48% said no and 15% were undecided. When asked if our clients thought their GP understood all of their care needs, not just physical health, they were divided 50/50. The reasons for people saying no included: — My GP does not spend enough time with me (27%). — My GP doesn’t listen to my needs (13%). — My GP is not aware of real problems—they are too removed from my life (27%). — My GP is not aware of services that can help me (18%). — My GP is not interested in my needs (15%). These concerns from a patient perspective are corroborated by the figures from our September 2010 survey of 250 GPs which found: — 38% of respondents stated they foresee consortia needing a lot of support in order to effectively commission mental health services. Overall 98% thought that some level of support would be needed. Ev w208 Health Committee: Evidence — 40% of respondents stated they foresee consortia needing a lot of support in order to effectively commission learning disability services. Overall 99% thought that some level of support would be needed. — 32% of respondents stated they foresee consortia needing a lot of support in order to effectively commission substance misuse services. Overall 99% thought that some level of support would be needed. 3.6 There are certainly opportunities for organisations like Turning Point in facilitating and providing some of this support that GP Consortia (GPCs) are going to need to effectively commission these services. However it is worrying that the people who are being positioned as knowing their local communities seemingly have little understanding of people with complex needs—many of which cost the health system the most and already feel disenfranchised by their GP surgery. For Turning Point this reiterates the need for commissioning to be routed in a good understanding of community and individual need. 4. Community Engagement Turning Point believes there should be a duty placed on GPC’s to engage with communities to ensure they know, and more importantly know how to meet, the needs of people not only accessing their services currently but those in the wider community they will be responsible for. Without a duty that can either be enforced or measured by the NHS Commissioning Board, there is no guarantee that this will take place or that GPs will effectively be able to commission these services. The case study of Turning Point’s Connected Care outlines one means of doing this and is detailed below. 4.1 Case study: Turning Point Connected Care The evidence base for Connected Care originated from research carried out by Turning Point, in conjunction with the IPPR in 2004. Meeting Complex Needs found that people with the most complex needs are often failed by the existing health and social care services. It brought to light the gaps in current health and social care services, finding: — They don’t provide joined-up, cost-efficient services. — They don’t address the whole person. — They don’t meet complex needs. The report called for the voice of the community to be central to the design and delivery of all connected services. 4.2 Connected Care provides a means to achieving integrated services by narrowing the gap between commissioner priorities and the needs of the local population through community engagement. By delivering a joined-up, user led approach to health, housing and social care, greater efficiencies can be achieved when: — Services are designed around people’s needs so therefore are more likely to meet them. — By listening to local people, services will be located in areas where they are most needed. 4.3 Connected Care follows a seven step path: Step One: Establish a steering group—This is made up of health, housing and social care service Commissioners, Connected Care staff and community researcher representatives to oversee the project. Step Two: Desk research of existing services. Step Three: Local Community Researchers are recruited and trained. They are people who live in the local area and often have had need for the local health and social care services. They conduct research by talking to local people to find out what people think of their local services. Step Four: The Connected Care audit. This determines the needs and aspirations of the local community, their perceptions about current services and the extent to which they meet, or do not meet, need. Step Five: The Audit Report. Step Six: A new Service Specification to deliver more integrated health and social care services based on the feedback from local people. Step Seven: Evaluation. Health Committee: Evidence Ev w209 5. Integration 5.1 Turning Point supports the greater emphasis on integration as an untapped resource to greater efficiency savings. Analysis by Turning Point Connected Care shows that integrated early intervention programmes can generate resource savings of between £1.20 and £2.65 for every £1 spent (POPPs, LINKAge Plus, Supporting People, self care schemes.147) 5.2 Turning Point has long since advocated the benefits of integrating health and social care and would like to see this not only “encouraged” between Local Authorities and GPCs but monitored in some way through both the NHS Commissioning Board and the Health and Wellbeing Boards if adopted. Turning Point will propose in our Consultation response Liberating the NHS: Commissioning for Patients that the most effective monitor would likely be through an outcomes framework and/or a National Indicator that the NHS Commissioning Board would report on periodically to ensure that integrated services are being commissioned, designed and delivered where these provide the most effective solution. 5.3 Integrated outcomes 5.3.1 The importance placed on delivering improved outcomes for individuals is clear throughout the White Paper and something Turning Point whole heartedly supports. In our response to Liberating the NHS: Transparency in Outcomes we clearly outline what is needed from an outcomes framework and call on the government to ensure that outcome measures are integrated so that colleagues in health, housing, social care and employment services are all supporting each individual to work towards their person centred outcomes. We have created bespoke outcome tools we have developed to support those with a learning disability (SPOT) and those with mental health conditions (ARROW) and have proposed that Government considers these before reinventing the wheel to ensure a standardised outcome measurement tool. 5.3.2 Turning Point understands the need for a consistent level of provision and focus but within the five core domains there must be nuisances for different client groups upon which providers will be, in the future, paid against. It is counter productive to have a system of measurement based on the mean when personal circumstance impacts so much on an individual’s ability to recover; work towards greater independence; or gain employment. 5.3.3 Therefore Turning Point calls for the development of bespoke outcome measuring tools that consider, for example, the different service drivers for BME committees; the unique health needs of people with a learning disability; and the health needs of carers who play such an important role in preventing readmissions. Indicators need to be disaggregated by geography and community to get a real grasp of outcomes for different groups over time. 5.3.4 To ensure outcomes are consistent and at the heart of every spoke of the wheel, they must be simple and they must be linked to the Commissioning Framework of both GPCs and Local Authorities, monitored by the NHS Commissioning Framework. To bring providers into the system outcomes should not be imposed but rather driven locally and linked to activity so to create incentives for providers to improve. The Framework should also focus on outcomes that are right for each individual—not just those easily measured. 5.3.5 In light of the tools Turning Point has developed we seek that the outcome measures used going forward are both person centred and individually driven within the key domains and work to integrate service delivery, along with the role of the NHS Commissioning Board. 6. Integration of Health and Social Care 6.1 Integrated health and social care support allows patient journeys to be simplified and prevents the need for individuals to repeat their story to several professionals. It also means that people are able to have an integrated package of care for their whole-person needs, rather than taking each individually. Integrating services can improve efficiency as well as help organisations meet the growing demand for health and social care services. 6.2 Turning Point has long since advocated the benefits of locally integrated services and would like to see this not only “encouraged” between Local Authorities and GPCs but monitored by both the NHS Commissioning Board and the Health and Wellbeing Boards if adopted. The measurement of integrated working should be through either an outcomes framework and/or a National Indicator that would be reported on periodically to ensure that integrated services are being commissioned, designed and delivered where these provide the most effective solution. 6.3 It is not simply a matter of partnership working but the integration of funding, working practice, back office functions and ethos that currently stand in the way of achieving the much talked about results integration can achieve. 6.4 LIS (Locally Integrated Services) seeks to rectify the current silo mentality by delivering a joined-up approach to the most complex and entrenched social problems. These problems, for instance long-term unemployment, crime reduction and health inequalities, are multi-faceted and are an insurmountable challenge for discrete agencies to resolve. 147 Assessing the evidence for the cost benefit and cost effectiveness of integrated health and social care“ (Turning Point, Feb 2010.) Ev w210 Health Committee: Evidence 6.5 LIS creates new relations between communities, individuals and service-providers by taking a grassroots approach to identify what the local area needs from their services. LIS will help services become more effective meaning resources go further by removing the confusion and duplication occurring within public service provision. 7. Joint Commissioning 7.1 Joint commissioning can deliver more for less by working alongside local communities to redesign services through a programme of change management and cost savings. Through co-production between the local authority, PCT and community greater efficiencies can be ensured by getting rid of duplication and encouraging the sharing resource. 7.2 Earlier this year Turning Point Connected Care published a benefits realisation report, “Assessing the evidence for the cost benefit and cost effectiveness of integrated health and social care” (Turning Point, Feb 2010.) The research in this report led to a number of conclusions: — Services that are designed to ensure that people can retain their independence and quality of life can deliver cost savings through the prevention of hospital admissions and residential placements. — There is a growing body of evidence to suggest that integrated health and well-being services can realise significant financial benefits. In particular, integrated early intervention programmes can generate resource savings of between £1.20 and £2.65 for every £1 spent (POPPs, LINKAge Plus, Supporting People, self care schemes.) — Early intervention through housing related support is also an important way in which to secure financial benefits and holds great potential for future programmes. The Supporting People programme provided net financial benefits of £3.41 Billion per annum. 8. Cost Benefit of Early Intervention 8.1 Research has consistently shown that investment in integrated solutions and early intervention, not only have societal benefits but economical ones too. For people with complex needs this is especially the case as they tend to cost the system more by being in receipt of multiple interventions while also being the most isolated from society and only reaching services when at a crisis point. 8.2 Turning Point particularly welcomes the increased role for Local Authorities, especially in integrating services and ensuring public health is at the centre of local accountability. The role of local Health Watch will help to monitor much of this activity as people try to navigate their way between the plethora of services on offer. The proposed Health and Wellbeing Boards will also be a positive platform to raise any concerns around the lack of integrated solutions and the possible sharing of best practice locally. 9. The Role of Citizen Advisors 9.1 As the results of our GP survey have indicated, GPCs are likely to need support to ensure navigation to and between services, particularly if they are to be outsourced. It is essential that people are not lost in transition or further distanced from the health service, therefore public services must start from a patient perspective. 9.2 Communities have a role in achieving good outcomes from public services. Turning Point also know that some communities need extra support to access services, and often don’t receive support they need because they find it difficult to navigate their way around the system. This is of particular concern if GP Commissioning is to add another layer to the service supply chain by outsourcing those services it does not understand, ie common mental health or learning disability services. 9.3 Turning Point Connected Care have written a report that recommends an approach provided through Citizen Advisors, to support people to interact and engage with services, and to build up their resilience and community capacity.148 9.4 The report brings together and appraises the international evidence-base of citizen advisor type functions. There are good examples of services performing different aspects of these roles: but most have struggled to meet the challenge of both having the confidence of the local community, and also providing a sufficiently strong and acceptable mechanism for working with other professionals across public services. Turning Point’s vision is for Citizen Advisors to help people access the variety of services they require to meet their needs. Citizen Advisors can help assess, signpost and support people into local programmes while enabling them to interact more effectively with services when they exercise their option for self directed support and personal budgets. 148 Further information can be found in Citizen Advisors: A Review of the Evidence Base, August 2010,. A full copy of the repart will be submitted along with Turning Point’s response to Liberating the NHS: Local democratic legitimacy in health. Health Committee: Evidence Ev w211 9.5 At the heart of Liberating the NHS is the aim of opening up services to patients in an unprecedented way. Its proposals focus on providing greater choice of providers, choice of treatment and more transparent information on the quality of local services. This “choice and information revolution” makes the role of Citizen Advisors essential if people are to navigate their way around the health service and truly experience the best it has to offer. 9.6 Citizen Advisors could play a critical role in brokering the new relationships the government is seeking to establish between health, social care services and communities. There are a number of approaches that would support this process. One solution would be for Citizen Advisors to support GP-led consortia so that both GPs and patients know more about the range of local services and community resources that might be available. A second approach would see Citizen Advisors linking health services to the wider community to help ensure more equal health and wellbeing outcomes are experienced across different social groups. 9.7 A third role would be in support of the integration of services with Citizen Advisors providing the much needed link between often fragmented services that many families currently find difficult to access as a joined up, coherent whole, available at the right time and in the right place. Finally, if the newly proposed Health Watch is to be the “Citizens Advice Bureau for health and social care” then Citizens Advisors can help makes this a reality by putting a community—based workforce behind it. In our communities, and particularly those that are the most deprived, there is huge benefit by having local experts by experience based at libraries or communities centres or on the end of the phone, guiding others to seek the advice and support they need. 10. Conclusion 10.1 With the wide spread nature of reforms there needs to be a consistent way of delivering Commissioning, Turning Point believes that this can be addressed in part by engaging with a definition of Commissioning which recognises the needs of the individual and the community, giving Commissioning a clear distance from procurement or purchasing. 10.2 Turning Point believes that here needs to be a duty placed on GPC Consortia to engage with the community to ensure that the needs of the communities are truly recognised and services are developed through such accountability. Community engagement activities aimed at building social capital, and changing behaviour, such as the Connected Care model, are a necessary pre-requisite to a truly patient centred health service and deliver true community led commissioning. 10.3 Turning Point would welcome giving evidence to the Committee in future evidence sessions. October 2010 APPENDIX 1 SERVICE USER SURVEY RESULTS Have Your Say: Changes to the NHS and GP’s 110 people who use Turning Point services were asked a series of questions relating to the future GP Commissioning proposals. These were to gauge how our service users felt about their GP being given more control over the direct commissioning of their services. 1. Do you have a GP? Yes I see him regularly Yes but I never go No 74% 25% 1% 2. Do you think your GP understands all of your care needs, not just physical health? For example issues relating to your mental health, employment, housing etc Yes No No answer 49% 49% 2% 3. If you have concerns around your GP understanding your needs (as in Q2) why do you have these concerns? Not enough time spent with me My GP doesn’t listen to my needs My GP is not aware of real problems—they are too removed from my life My GP is not aware of services that can help me My GP is not interested in my needs 27% 13% 27% 18% 15% GPs do not understand the roots of substance misuse and Ev w212 Health Committee: Evidence cannot understand my problems GPs are not usually knowledgeable in areas other than physical health My GP does not have enough knowledge of support available in my area I do not always see the same GP so it depends My GP does not take my concerns seriously My GP tries to palm me off with labels and it doesn’t feel like they’re listening I don’t feel comfortable speaking to my GP about my mental health issues GPs think they always know best and don’t always listen to patients concerns GPs do not generally have first hand experience and can’t relate to my problems Other comments 4. Are there any problems to accessing your GP or reasons why you don’t like accessing your GP? The staff at my GP surgery are unwelcoming (ie receptionists, nurses, doctors etc) They just prescribe medication which I’m not interested in My GP is too far away My GP doesn’t understand my needs N/A—I have no problem accessing my GP Other Other comments 17% 8% 5% 15% 50% 5% Doctors end up judging you by your prescription history I see a different GP every time and do not get to build a familiar relationship with a doctor who understands my situation GPs are just that—general practitioners and not specialises I feel more comfortable accessing an organisation that specialises in issues which affect me 5. If GPs were to take control of commissioning your services do you think you would have a bigger say in your care? Yes No Undecided Other comments 37% 48% 15% YES I will be able to inform my doctor of services available that sound helpful and he wasn’t aware of I have a good relationship with my GP and he is an easy point of contact There will be less paperwork Giving doctors more control to make decisions will give patients more control to influence doctors’ decisions NO I think the GP will decide what is “best” according to what saves most money in his budget GPs will want to save money for themselves GPs won’t have the time to deal with the added responsibility Too many issues for GPs to handle, need sector specific staff I don’t think my GP would be open to suggestions from me I don’t feel like my GP really cares My GP would consider cost before anything else and compromise the quality of services available, the same way it is now GPs are not equipped or trained to handle the added responsibility GPs have a big enough workload already GPs tend to have a tendency to be biased and ignorant towards users so I don’t trust my doctor to make well-informed decisions Could lead to preferential treatment Health Committee: Evidence Ev w213 Written evidence from the British In Vitro Diagnostics Association (COM 81) Accountability for Commissioning Decisions 1. The NHS Commissioning Board will be held to account by delivery against the NHS Outcomes Framework. The NHS Outcomes Framework should be developed to reflect outcomes focused on what matters to patients and healthcare professionals. This will mean an increased focus on accurate reporting of clinical outcomes, in which in vitro diagnostics have a significant role to play. 2. Commissioners should be offered guidance on areas where they may have less expertise in order to help them to improve outcomes. They can then be held accountable for commissioning according to such guidance. For example, the 2008 Carter review of pathology services recommends that all commissioners should be offered guidance on commissioning pathology services. 3. Commissioners will need to be accountable for the outcomes that are achieved in their health economy. A commissioning outcomes framework should include outcome measures at all stages of the care pathway, including at diagnosis. For example, commissioners should be held accountable for the stage at which patients under their purview are being diagnosed as a marker of the success of screening programmes. 4. The development of quality standards should also help to support efficient and effective local commissioning. As much as is possible, quality standards should be developed to cover all areas of the service that GPs may commission. Quality standards should include a focus on diagnosis to reflect the vital role that this plays in the pathway and in patient outcomes. 5. BIVDA believes that some part of GP practice income should be linked to the outcomes that the practice achieves as part of its wider commissioning consortium. The Quality and Outcomes Framework has shown that financial incentives can be effective. Linking these financial incentives to outcomes should drive up outcomes in the area. Linking a GP practice income to that of their wider commissioning consortium will ensure that GPs take an active interest in the outcomes being achieved by their partnering GP practices. Integration of Health and Social Care 6. Many health outcomes will depend on joint working between GP practices, GP consortia and local authorities. The link between GPs and local authorities will be particularly strong in relation to awareness and early diagnosis, and the services provided by these two groups will need to be integrated. It will be important to ensure that data are collected in a way that can be understood and used by both services, and that shared outcome indicators are developed in this area. 7. Outcome measures shared across GP consortia and local authorities will encourage a joint approach to public health issues. Specialist Services 8. GPs are unlikely to have the required expertise or purchasing power to commission all specialist services. It is not only low volume services where NHS Commissioning Board and GP consortia will have to work together. Some high volume, specialist services will need to be coordinated. 9. Pathology services provide an example of a high volume service, some of which may be better commissioned at an NHS Commissioning Board level. The 2008 Independent Review of NHS Pathology Services by Lord Carter of Coles recommended that pathology services be consolidated into reconfigured commissioning networks. 10. There is a role for both national and GP commissioning of diagnostic tests. Simple and routine tests can be commissioned at a GP consortium level, keeping the commissioning decisions as close to the patients as possible. However, national commissioning may be necessary for more complicated tests such as molecular diagnostics for use with personalised medicines. 11. It may also be necessary to commission some national screening initiatives at an NHS Commissioning Board level to ensure that there is equitable access across the country. 12. National commissioning will also be necessary where there is a clear link with the Quality, Innovation, Prevention and Productivity (QIPP) programme. There is a pathology work stream in the QIPP programme which will need to continue to consider the role of pathology networks as suggested by Lord Carter of Coles in his 2008 review of pathology services. 13. It will also be important for people responsible for both low and high volume service commissioning to work together to ensure that the experience of care for the patient along the pathway is joined up. Commissioning of Primary Care Services 14. Some clarity is needed regarding the commissioning of services from GPs, and to what extent GP consortia will be able to commission services from their constituent practices. It is unclear as to whether or not a GP commissioning diagnostics services from their own practice would be a conflict of interest. Where a GP can commission services from their own practice, it will be important to give patients a choice of service where it is available. Ev w214 Health Committee: Evidence Commissioning for Innovation 15. The NHS has traditionally been slow to invest in and adopt new and innovative technologies, many of which could go on to significantly improve patient outcomes for people with cancer and other diseases. BIVDA feels that more can and should be done to support the NHS in the uptake of new technologies that have been recognised as bringing benefits to patient experience, operational effectiveness and cost-saving. One area where new technologies could have an impact on patient outcomes is through the use of in vitro diagnostics to enable earlier diagnosis of cancer patients. Commissioning should be developed to ensure that these new technologies can be introduced. 16. Routes through which the uptake of assessed technologies might be encouraged are currently inadequate. While progress has been made in this area with the development of the Diagnostics Assessment Programme (DAP) by the National Institute for Health and Clinical Excellence (NICE), there is still some way to go to ensure that recommendations that will come from DAP are taken up by the NHS. NICE should consider what levers could be introduced to encourage the adoption of new and innovative tests. One way in which this could be done is through reference to diagnostics in the newly developed quality standards by which commissioning consortia could be held accountable. 17. The introduction of pilot centres for innovative diagnostics that can improve cancer outcomes could also help to stimulate uptake of those products and release their benefits into the NHS by allowing evidence to be gathered and demonstrating how a technology might be adopted. 18. The NHS Technology Adoption Centre (NTAC) offers a good example of a process for encouraging the adoption of technologies offering real benefit to patients (for example, an intra-operative breast lymph node assay) that have previously seen limited uptake in the UK. The NTAC process is a valuable template that could easily sit alongside NICE, to help encourage uptake of recommended technologies. October 2010 Written evidence from the National Spinal Cord Injury Board (COM 82) This response is submitted on behalf of the National Spinal Cord Injury Strategy Board (NSCISB) following a discussion at a meeting of the NSCISB in August 2010. The NSCISB was established in 2010 under the aegis of the National Specialised Commissioning Group, with representation from all 10 Specialised Commissioning Groups and all eight Spinal Cord Injury Centres in England. The purpose is: 1. To agree a co-ordinated and common approach across England to the delivery and commissioning of services for people with a spinal cord injury (SCI). 2. To ensure improved health outcomes for people with spinal cord injury in England by effective commissioning of appropriate high quality and cost effective services. There are two parts to this Response. Part 2 contains the responses in full. Part 1 is the summary requested. PART 1: Summary of NSCISB Response 1. Clinical Engagement The NSCISB structure fits well with the plan to transfer specialized commissioning to the NHS Commissioning Board and could be replicated for other specialized services. In planning the transfer of specialized commissioning to the NHS Commissioning Board, provision needs to be made for focused Public Health expertise to be provided and developed for each service. Ideally the public health expertise contained within SCGs would transfer directly to the NHS Commissioning Board and would not have to be contracted for from the proposed Public Health Service, which would have other important priorities such as health protection. 2. Information/Data As part of the forthcoming NHS Information Strategy that there needs to be a particular focus on the information needs of Specialised Commissioning to enable this area of commissioning to operate in a data rich environment in the future. A national information system is essential to enable consistent commissioning of the SSNDS and needs to be in place by April 2012. It is needed to support comparative analysis (including international benchmarking); needs assessment; contract management, service currencies and costs, and outcome-based commissioning. Health Committee: Evidence Ev w215 This could be provided by a single specialised services database, or a set of service-based databases, several of which exist or are in development. Arrangements need to be in place for the support, specification and development of national commissioning databases for specialised services. 3. How will patients make their voice heard or their choice effective? The NSCISB structure fits well with the plan to transfer specialized commissioning to the NHS Commissioning Board and it could be replicated for other specialized services. 4. What will be the role of the NHS Commissioning Board? Specialised Commissioning already has a national structure in place and there is considerable sharing of the work between the SCGs. It could therefore be transferred into the NHS Commissioning Board without too much disruption to work programmes. 5. Will the new arrangements safeguard current examples of good practice? There is a risk that that knowledge and expertise about rare services , and good work being implemented and planned, will be diluted or lost in the transition of Specialised Commissioning from SCGs to the NHS Commissioning Board, especially if reductions on staffing are imposed. Continuity in Specialised Commissioning is essential in the interests of efficiency and good outcomes. Consideration should be given as to how the learning and development needs of the next and future generations of commissioning staff can be provided for and assured in order to ensure the effectiveness of the reforms outlined in the White Paper. 6. How will resources be allocated between commissioners? When the NHS CB commissioning budgets are set, experienced specialised commissioners should be consulted about the most appropriate basis/methodology for each service. Clarity about the scope of funding is essential. Steps will be needed to prevent “cost-shunting”. Flexibility is needed to permit movement of funds between commissioners where there is evidence that this will improve services. 7. What arrangements are proposed for commissioning of specialist services? The transfer of Specialised Commissioning to the NHS Commissioning Board could work well for specialised spinal cord injury services, and fits well with the National Spinal Cord Injury Strategy Board structure and the planned change to national commissioning classifications (currencies). It provides the opportunity to solve some of the problems currently facing specialized commissioners in implementing QIPP and outcome-based commissioning, such as information flows and commissioning database. It was a particular concern that an experienced and dedicated team of commissioners for spinal cord injury—including commissioning, public health, finance, information and administrative staff—be in place to maintain the momentum of the substantial work programme. It was considered important to ensure that the special needs of Spinal Cord Injured people continue to be recognised as distinct, and they should not be grouped with other services under the general heading of “Specialised Spinal” as sometimes occurs. 8. How will these arrangements interface with the rest of the system? Perverse incentives and unforeseen consequences must be avoided when services are specified and budgets set. Ev w216 Health Committee: Evidence PART 2: Detailed Responses by the NSCISB to Specific Questions asked in the Consultation Clinical engagement in commissioning — How will commissioners access the information and clinical expertise required to make high quality decisions about the shape of clinical services? NSCISB response Clinical Engagement The National Spinal Cord Injury Strategy Board, established early in 2010, has a line of accountability to the National Specialised Commissioning Directors. It has seats for service users, commissioners and other stakeholders. Each specialized centre has a seat, and most are represented by a lead clinician. Additional there are sub-groups in which clinicians are involved. The Currencies Group, which has been running for several years, has been notable for the high level of clinical engagement throughout. The professional organization BASCIS has an e-mail clinical group which is useful when a view is required at short notice. The NSCISB structure fits well with the plan to transfer specialized commissioning to the NHS Commissioning Board and could be replicated for other specialized services. Public Health professionals are a scarce resource in Specialised Commissioning. Those supporting SCGs have found it difficult to provide an input to every service in the national definition set. In planning the transfer of specialized commissioning to the NHS Commissioning Board, provision needs to be made for focused Public Health expertise to be provided and developed for each service. Ideally the public health expertise contained within SCGs would transfer directly to the NHS Commissioning Board and would not have to be contracted for from the proposed Public Health Service, which would have other important priorities such as health protection. Information/Data The NSCISB supports the proposal to commission on the basis of outcomes. This has a real potential to improve the quality of healthcare, but if this is to be fully realised in specialised services the outcome measures need to be specific and tailored to the needs of the patients. Urgent work is needed to develop systems that allow the extraction of specialised services activity from standard information systems such as HES. The intent that the Government intends to bring about an NHS information revolution is to be welcomed. There are particular challenges facing commissioners of specialised services from an information perspective. The current classification systems used in the third edition are the International Classification of Diseases, version 10 and the OPCS Classification of Interventions and Procedures, version 4.5. Many areas of Specialised Commissioning are hampered by inadequate information, particularly Spinal Cord Injury Services. The problems result from the underlying coding (as a result of lack of specificity in terms of OPCS Surgical Codes and ICD-10 Medical Codes) and problems with the integration of necessary bespoke datasets to support specialised services with mainstream healthcare informatics systems (such as the Secondary Uses Service of the NHS Spine). Basing Specialised Commissioning Groups within a “host” PCT has hampered their ability to view data for the populations for which they commission, due to Information Governance restrictions. Example: The South of England Spinal Cord Board carries out strategic planning for five SCGs, and the South of England Consortium carries out procurement and risk sharing for four SCGs. Information sharing protocols are in place for only a small proportion of the PCTs in the Consortium. The Consortium is dependent on reports in the form of spreadsheets supplied by the specialised centres. In the case of long-term conditions, such as spinal cord injury, the need to view data for planning purposes extends to patients living with spinal cord injury who are being treated in non-specialised settings, where the activity is classed under the specialty treating the patient (eg urology). The National Spinal Cord Injury Strategy Board has highlighted this need in its information strategy. Many specialized services including Spinal Cord Injury are currently outside the scope of PbR because of the complexity of defining and measuring them. For spinal cord injury the DH has supported the development by commissioners and providers of National Commissioning Classifications (“currencies”) but has concluded that because of the complexity of the classifications they will have to remain outside formal PbR for the immediate future. There is therefore an urgent requirement for a national web-based database to provide a platform for spinal cord injury “grouper” software, to classify activity to the new currencies, which will be shadowed in 2011–12. To overcome these problems, there is a need for national commissioning databases in several specialized services, to record activity and support planning and procurement. These databases need to be adequately structured and supported, and capable of providing both commissioners and providers with information supporting the full range of commissioning activities, including outcome metrics. This need was recognized in the Carter Report. Health Committee: Evidence Ev w217 These problems will need to be addressed in order to deliver the information required to support the Governments intent to better care, better outcomes and reduced costs. We would suggest that as part of the forthcoming NHS Information Strategy that there needs to be a particular focus on the information needs of Specialised Commissioning to enable this area of commissioning to operate in a data rich environment in the future. A national information system is essential to enable consistent commissioning of the SSNDS and needs to be in place by April 2012. It is needed to support comparative analysis (including international benchmarking); needs assessment; contract management, service currencies and costs, and outcome-based commissioning. This could be provided by a single specialised servi
