08/11/12 - NHS CB Board Meeting - Part 5 -- Specifications for Specialised Services

Uploaded by NHSCommissBoardAuth on 11.11.2012

Let us move on, please to agenda item ten: the specifications for specialised services.
Ian? Ian Dalton: Thank you. Our business is to
ensure patients get high quality care and we have a particular set of responsibilities
around those patients using specialised services which we, ourselves, will be commissioning
on behalf of the population of England. This is really core business for us: delivering
for our patients. What I want to do in this paper is give a little bit of context on our
role in relation to specialised services and then talk a bit about the process of engagement
and consultation in relation to some clinical policies and some specifications. I shall
discuss those in a minute. Firstly, let us take a step back and look
at what specialised services are. Specialised services, by definition, tend to relate to
either small numbers of people who have relatively rare conditions; and/or conditions which can
only be treated by a relatively small number of expert sets of clinicians in the country.
That is the kind of working hypothesis on which they are based. More specifically, they
cover a fairly broad range of health conditions and diseases, which can be broken down into:
some long term conditions and the response to them, such as kidney disease and some serious
mental health related issues and cardiac care; they relate to some particular episode of
specialist care, such as intensive care for neonates and children and the care for patients
who have severe burns; they also relate to conditions which are rare, such as uncommon
cancers, medical genetics and the clinical response to morbid obesity. There is a fairly
broad range of conditions. Taken together, they related to about 10% of the NHS budget,
around £11.8 billion. This is really important for the patients concerned. It is also a big
responsibility for this Board and we need to get it right for our sake, as an organisation;
but frankly, more importantly, for the patients we serve here.
The situation we are inheriting has developed a lot over the last few years since the publication
of a really important report in 2006, the Carter Report, which talked about the need
for improved consistency in the commissioning of these services across the whole of the
country. Nonetheless, I think we have a significant opportunity to move things forward and in
particular, to address the consequences of the way services were previously commissioned
by ten separate regionally based specialised commissioning team and an eleventh team, which
did the very rare conditions and which had an England reach.
The consequence of that was inevitable variation between the teams commissioning across the
country. One of our objectives as an organisation is the promotion of equality, and rightly
so; and we have, I think, a real opportunity as we move into this field and build our arrangements
to ensure that there is a consistent approach to the commissioning of services for these
patients across the whole of the country. From April 2013 this Board will be the sole
national commissioner of this defined range of services – about which I will say a little
bit more in a minute – for England. We discharge that responsibility – as I think we discussed
several meetings ago when we first talked about the structure we have in the NHS – through
ten of our local area teams. There were ten specialised commissioning groups before, which
were regionally based, and we have ten local area teams; that creates a superficial similarity.
I think it is really quite important to understand, however, that there is a distinct difference
of approach. Previously, the ten specialised teams had
a budget on behalf of the population served by those by their boundaries and they would
contract with every provider in England on behalf of those patients, to local standards,
as required. Our arrangement turns that on its head: each of these ten teams commission
on behalf of England for every English patient who uses the services, which are provided
by hospitals in that geographical area. Our aspiration, here, is to offer the highest
quality care against a single national set of service specifications, standards, policies
and quality measures. That, I think, is an important and significant aspiration for this
Board. To get to where we are now, the Department
of Health, as part of its overall approach to the transition, commissioned a significant
review of specialist services and set up a clinical advisory group made up of both GPs
and hospital doctors to look at exactly which services we should be commissioning from 2013.
That has now reported and defined the services; and that is why I am able to talk to you about
the magnitude of what we are trying to do today.
Since then, there has been significant work looking at what needs to be done in relation
to those services; and there have been 60 clinically led reference groups looking at
the range of conditions as part of the process of moving towards transition. Those groups
have produced 132 service specifications so far and 51 clinical commissioning policies,
which we need to deal with now. A ‘Service specification’ is a clear description
of what a service is and the acceptable standards which need to be in place for their delivery.
They will include outcome measures and quality standards. A ‘Commissioning policy’ describes
the eligibility and access criteria for a service, a drug, a device or an intervention.
All of these need to be based on evidence, engagement with patients, and the best possible
professional clinical advice. We have now received these 132 service specifications
and 51 clinical commissioning policies and we need to manage them in a proper process.
The processes so far have been subject to three separate assurance processes: they have
been looked at by a clinical assurance group; they have been assessed financially; and equally
importantly, if not more importantly, there has been a degree of patient engagement, through
working with the Patient and Public Engagement Steering Group. That is not the end of the
business, however. That is the first stage. What I am coming you today to seek your approval
on is moving through a phased process of further engagement with patients and stakeholders
to get to the right place for us, so we can be confident we are in the right place for
patients by the time we have to go live with these. The first stage in that process is
a request today from me to you that, hearing what you have heard, you are happy for us
to go out to an engagement process: a consultation process with stakeholders over the next few
weeks, which will enable us to listen to their comments and, as required, respond to those
in relation to the work we have done so far. We then need to go through a clinical prioritisation
process and bring it back for the consideration of the Board. In paragraph 19 we had hoped
– and potentially might still do, although I think it is unlikely – to bring that to
the December Board meeting. What I need to ask you to note is that if we do – as I
suspect we might – get a lot of response, we need to have the time to consider those
responses properly. Consequently, I think I will need to take away, Chairman, looking
at our meeting structure, how we might bring that back; I do not want to curtail the amount
of time that we can have to listen to people’s responses.
Having done that, and the Board having considered that, we will then go into a final, significant
consultation on the whole package so that we can make a final response to comments;
make any revision, as required; and ultimately make a decision on what we do for next year.
There is a long, bitter process which has led us to this place; there is process that
we have to go through; and then there is a decision to be taken. We are in the middle
of that process now. I hope what I have been able to do is give you a sense of why this
is really important for patients and why it is really important for us; secondly, to give
you some assurance of the amount of work which has been put in to get us to where we are;
and thirdly and importantly, to talk about the forward process and to seek your permission
to proceed with it. Malcolm Grant: Thank you, Ian. Are there any
comments? Thank you, Barbara. Barbara Hakin: I am simply seeking a bit of
clarification, Ian. As I understand it, the review which was done by the Clinical Advisory
Group and its recommendations to the department has resulted in an increase in the volume
of services which are truly defined as ‘specialised commissioning’. In addition to that, I understand
that your work has shown that there were some areas which should have been defined as specialised
commissioning which were not being commissioned by specialised commissioning groups; further,
that those two things put together results in an increase in the volume of specialised
commissioning which will be undertaken by the Board. Alongside that, however, there
has been a careful and commensurate transfer of the funding; because there is an inevitable
reduction in the services – a small reduction, albeit, compared to the other things they
do – CCGs will have to commission and therefore, a small reduction in their resource.
Ian Dalton: You are right to raise that. This has been a clinically led process which is
important, I think. This is a process which has been run against four criteria: looking
at the number of people who need the services, i.e. rarity; considering the number of clinical
teams in England which are capable of responding, looking at those services which have relatively
small numbers of providers; importantly, in terms of the financial cost of commissioning
the service, looking for high cost, low volume services; and specifically, considering the
financial implications, particularly for CCGs if CCGs were to commission those.
I think, particularly where you have the really important services which happen to be high
cost and low volume, there is a need for a process – a clinical led process, but a
process nonetheless – that looks to insulate CCGs from the unpredictable risk of having
a small number of very expensive patients whom, when we look across the whole of England,
we are providing a kind of collective risk pool for and that. If it was taken within
a CCG, it could potentially be a very significant hit on their budget. Those are therefore the
criteria which have been gone through. That has resulted, as you say, in some expansion
of the basket of clinical procedures which we need to commission.
The second point is also right. As part of the previous inconsistency, different baskets
of services were purchased by the ten specialised commissioning groups. By definition, if we
put those together some, I think, in some cases, have actually gone back to CCGs, which
is appropriate and where we should [inaudible] if we can, because they are not within that
nationally defined, clinically driven set of procedures. As you say, however, where
that has not been handled at the right level, we need to bring it into the consistent England
wide approach in order to deliver our objectives as I have outlined. I think you have raised
an important point. It is quite complex methodologically but I look forward to a conversation with
Clinical Commissioning Groups and others about that process and how we have arrived here.
Malcolm Grant: Ian, thank you very much. This is immensely important work for us. It is
a huge part of our budget, especially now, given the further resources being put in and
the further range of specialised services defined. It is also an area, however, in which
we want to be an exemplar, both in the way in which we design this process – and thank
you for the painstaking work that has been going into it – and also, of course, in
launching it and developing it in the future so that this becomes the star ship for our
clinical commissioning across the sector. Ian Dalton: Thank you.
Malcolm Grant: Thank you for that. I take it that the Board are happy to endorse the
proposed consultation process? Thank you very much.