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Howe: Specialised health commissioning is in a precarious state

Speech in the House of Lords on Specialised Health Services

No one should conclude from the short list of speakers in this debate that its subject matter is of little importance. Quite the opposite is true. The noble Lord, Lord Clement-Jones, is to be congratulated on having tabled this Question on a day which could hardly be bettered in terms of relevance and topicality. Those of us here who are veterans of the NHS Reform and Health Care Professions Bill a year ago need no reminding of the debates that we had on specialised commissioning during both Committee and Report stages. Those debates underscored the doubts felt by many, both inside and outside this Chamber, that the model being proposed by the Government for commissioning specialised services was badly flawed. In the end, of course, no amendment to the Bill was pressed; but I venture to say that that was no reflection of the government response, which did very little to allay the concerns that we all had.

As if to acknowledge those concerns, Mr Hutton announced in March of last year that there was to be a review of the whole issue, which indeed there duly was. One must not be too churlish about this. Unlike some consultations I can think of, this one had all the signs of being a genuine listening exercise. The only trouble is that for an inordinately long time after that it was we who found ourselves listening. Until the end of last week, we were still listening for a statement of what exactly is going to happen and how the new system is going to function. Ever since the end of last year, we have been told that an announcement on this critical issue would be made "shortly". So it was a great relief to learn, on the cusp of the new financial year, that definitive guidance had actually been published by the department.

I should say straight away that our recent concerns about delay and uncertainty were not abstract worries about the process. What matters in all of this is of course the patient. The Minister will know that there has been great concern among patient organisations that gaps are appearing in the provision of services. We have just had a supposedly transitional period in which the regional specialised commissioning groups have continued to oversee the setting up of PCT consortia. That was undoubtedly the right decision. It was the absolute minimum needed to try to ensure some degree of stability and continuity as the new commissioning arrangements were being assimilated and put in place. But the Minister will also know that there is widespread agreement out there that the RSCGs have by no means outlived their usefulness. Many believe that they have a permanent role to play in commissioning services which are best planned across several strategic health authorities, with a population of perhaps three million to six million people.

It is pleasing to see in the new guidance that the Government have heeded those concerns by saying, in effect, "If it ain't broke, don't fix it". RSCGs, where the arrangements are currently working well, are not now to be disturbed. As I said just now, I do not want to be churlish. But really what we have just witnessed is a giant chasing-around exercise which has ended up more or less at the point where we started. At the heart of the argument is the fundamental concern that we voiced last year during the passage of the Bill, which is that to devolve the purchasing of high-cost, low-volume treatments to PCTs is to devolve down to the wrong level in the system. PCTs suffer from something that they cannot help. Most of them will have no in-house expertise for commissioning this type of service. That expertise was thinly spread in the first place when we had regional health authorities, but it will be even more thinly spread now, and much of it would have been dispersed altogether if the RSCGs had been allowed to disappear.

It is also felt by many that small PCT consortia are not good mechanisms for encouraging innovation into the NHS and for driving forward those innovations in a timely way. To do that, one needs some kind of central mechanism to operate across a broader base—not, I hasten to say, a central means of control but rather some way of overseeing and guiding commissioners and facilitating improvements.

A considerable weight of opinion in the response to the consultation favoured a national group, as mentioned by the noble Lord, Lord Clement-Jones, consisting of representatives from the various commissioning consortia, whose job it would be to take a bird's eye view of specialised services across the country and to play a role as a facilitator in introducing and monitoring them. The guidance is silent on that idea, but perhaps I could ask the Minister whether she could be a little more forthcoming on it.

In that general context, I have a query about strategic health authorities. When it comes to making a new investment through either of the two tiers of commissioning consortia, I am not quite clear what role SHAs will have in the decision-making process. Will they be able to influence or second-guess decisions taken by the collaborative commissioning groups and, if so, in what way?

The consultation also threw up the real worry that at PCT level some specialised services will be squeezed out in the annual budgeting process. A PCT board, faced with cost pressures as all boards are, could decide that low-cost, high-volume services were a greater priority for them than signing up for a slice of a service level agreement of which only a small handful of their patients might in the end avail themselves.

Some PCTs might decline to join a consortium altogether. There are already examples of that happening around the country. A prime example is enzyme replacement therapy in Croydon PCT. Another is renal services in London. Two years ago, there was agreement in the RSCG that a fourth renal transplant surgeon should be funded in south-west London at a cost of £340,000. That money would be contributed by the PCTs in each of the five London sectors, plus Kent, Surrey, Sussex and Thames Valley. But what has happened? We find that the PCTs in four of the five London sectors have refused to put any money on the table, and that could put the proposal at risk.

So, again, it was a huge relief to find in the guidance that the Government have woken up to that damaging possibility. Henceforward, it appears that all PCTs will be required to join collaborative commissioning groups and that the decisions of those groups will be binding on all members. It would, however, be very helpful if the Minister could make clear exactly what degree of compulsion is involved here. The guidance seems to be worded in a way that could be interpreted as being precisely that—in other words, guidance rather than anything stronger. If a PCT refuses to contribute to a particular service which other members of the collaborative group are funding, what action can be taken? Are there sanctions against that PCT which can be enforced?

The noble Lord, Lord Clement-Jones, referred to the unanswered questions in the guidance. That is certainly one. I agree with him completely on his observation. But, in particular, I believe that there was a lack of clarity about the interface between the commissioning consortia and managed clinical networks. The guidance states that the collaborative commissioning groups will ensure—that is the word used—support for managed clinical networks without explaining how or through what governance mechanisms that support will be forthcoming. Managed clinical networks cover cancer and renal dialysis and transplant, among other services, and are extremely important. Clinical and managerial accountability is essential for those services. The example in the appendix to the guidance of NorCom states that it will monitor and support managed clinical networks. One has to ask how quality standards can be guaranteed if this model is not followed.

What is needed, of course, in the procurement of specialised services are two things: stability and certainty. But if there is no guaranteed, committed funding by PCTs for a service, we shall have the very opposite of that. There must be a way of achieving 100 per cent involvement and compliance among PCTs. The obvious means of doing that is to have a levy, rather as the NorCom model does in the appendix to the guidance. Is that what the Government envisage and, if so, why is it not mentioned explicitly in the body of the guidance? For the year just beginning, it may be rather late in the day to ensure that the funding of some services is safeguarded in real terms, especially where service agreements have run out. It would be helpful to know whether the department is examining ways of addressing that.

But there is, in any case, an in-built tension here. Priorities are never set in stone; they change over time. Deciding on priorities depends on a number of things. To start with, there must be input from patients and the public. Only with that voice from outside is there likely to be an objective view about what services are needed where. Secondly, there must be some clinical input to ensure that proposals emanating from providers of services can be evaluated properly. I do not know how either of those will be achieved, and perhaps the Minister could make that clear in her reply.

The third ingredient in setting priorities is surely the freedom to move commissioning money from one provider to another. I have a particular worry here in relation to foundation trusts. Specialist providers which become foundation trusts in the future will depend on the income they receive from commissioning consortia in order to service their capital commitments. We understand that those service agreements will be legally binding. I should be very glad to hear from the Minister how this apparent rigidity in the way that funding is to be directed is consistent with the need to switch money between different services in response to changing priorities.

Notwithstanding the publication of the guidance, we should not delude ourselves that some areas of specialised commissioning are in anything other than a precarious state. In a number of regions, the commissioning consortia have barely got off the ground. Dermatology, foetal medicine, epilepsy surgery, rheumatology and specialised women's health services have very low coverage and can be seen only as being at risk. Cleft lip and palate, neonatal care and spinal injury services have very patchy provision. Those gaps must be addressed.

The government guidance, although late, is welcome. We shall need to continue digesting its implications. There are still many unresolved and serious concerns about access to services. It is helpful that the Minister now has an opportunity to shed a little light on some of the darker corners.

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