16.01.15
MPs attack ‘risky and secretive’ specialised commissioning plan
NHS England plans for co-commissioning of specialised services will usher in a “patchwork quilt of provision” and have greatly dismayed patient groups and rare disease charities, according to MPs.
In a Westminster Hall debate in Parliament yesterday, Lib Dem MP Stephen Gilbert said: “We can say with certainty that local commissioning of such services does not work.”
He said that NHS England plans to transfer £13bn of the £14.6bn allocated for the commissioning of the 147 specialised services in 2015-16 to the co-commissioning pot, undoing the centralisation of those services ushered in by the NHS reforms, despite them being widely welcomed by MPs and patients.
Such a move would return us to the situation under primary care trusts (PCTs), he said, which were found by the health select committee to often be “disengaged” from specialised commissioning, which – because it was a pooled responsibility between various PCTs – was not properly regulated, performance managed, scrutinised or held to account.
Gilbert said: “In view of NHS England’s intention to move towards place-based budgets, it is also worth quoting the Committee’s remarks on the ‘danger that the low priority’ given to specialised services by local commissioners ‘will mean that funding for specialised commissioning will be disproportionately cut in the coming period of financial restraint’. Perhaps because of that, patients’ groups and others have been emphatic in their opposition to local control of the specialised budget.”
He quoted a survey of more than 100 patient groups, clinicians and health businesses involved with rare diseases, which found that 90% wanted their service to remain part of national specialised commissioning.
Gilbert also raised the issue of morbid obesity and renal dialysis, which may no longer be considered to be specialised services.
Dame Anne Begg said: “A number of rare diseases are genetic and, therefore, they often come in pockets, which means that some local health commissioners may face a heavy burden while others face none. The beauty of the specialist commissioning is that the cost is spread across the whole country, rather than falling on individual commissioning bodies.”
This is also the position of the Specialised Healthcare Alliance, which says: “Specialised services are best planned on a national level – in the past patients experienced very different levels of access to specialised care.”
It also says that “given the highly variable incidence of rare and complex conditions, individual CCG allocations will not be aligned with actual need in-year”. It accuses NHS England of seeking to “abdicate its responsibilities”.
It argues: “NHS England is planning to introduce a ‘50/50 gain share’ with local CCGs to incentivise them to reduce spending on specialised services in order to release funding from their population budgets for local services. Under this arrangement, CCGs would have the discretion to redirect any underspend in a locality’s specialised commissioning budget to funding other local priorities. This would run the risk of seeing patients with rarer and more complex conditions being overlooked in the context of local planning.”
Mitcham and Morden MP Siobhain McDonagh said it is “imperative” that CCGs, “if they are to become more involved in the commissioning of specialist services, are supported to increase their expertise in these areas of health, so that they are able to make effective and well-informed decisions”.
Bristol East MP Kerry McCarthy asked: “Just how will co-commissioning work for a condition such as cystic fibrosis without undermining the key principles of the existing nationally commissioned service – avoidance of duplication, the consistent standard of care and facilities across the country, and a joined-up approach to future treatment?”
Copeland MP Jamie Reed said: “Many CCGs are already overwhelmed; are they truly capable of doing what is being proposed? The ability to commission effectively will inevitably differ from CCG to CCG, which runs contrary to the initial intentions behind specialised commissioning.”
Health minister Norman Lamb MP said he hoped to “reassure” the speakers, saying: “We should not do things that damage care, simply to cut cost.”
He called equity of access “incredibly important” and said: “We do not want to return to the postcode lottery that existed in the past.”
Lamb said the proposals are for “a more collaborative approach”, saying: “That is not a transfer to CCGs – it is joint commissioning. While some highly specialised services will continue to be commissioned entirely nationally, CCGs will be invited to have a greater say over the commissioning of the majority of specialised services.
“A number of services on the current list could potentially benefit from being commissioned on a smaller footprint with greater local involvement, to make joined-up services possible across the care pathway, while maintaining national standards.
“One faces a danger when separating off some procedures for national commissioning if other parts of the pathway are commissioned at a local level; that is the case with obesity services, because preventive services are commissioned locally whereas bariatric surgery is commissioned nationally. The danger is that one creates false or artificial divides in the patient pathway, which can damage patient care and create perverse incentives. We have to be cognisant of that and see whether there are better ways of doing things.”
“NHS England is aware of several CCGs that would welcome the opportunity to become involved in specialised commissioning, but it is equally aware that many CCGs will not be in a position to take on such increased commitments from 2015-16. There is therefore no question of a return to the previous arrangements.”
He also promised to address the “anomaly” of people with cystic fibrosis having to pay prescription charges, when people with both diabetes and cystic fibrosis would not.
The Specialised Healthcare Alliance said today that, despite Lamb’s assurances, “crucial questions remain”, which it lists here.
Tell us what you think – have your say below or email [email protected]