Policy responses and statements

Name of organisation:

Department of Health

Name of policy document:

Health reform in England: update and commissioning framework

Deadline for response:

6 October 2006

Background: This document provides an update about health reform. It then focuses on commissioning NHS services, and in particular hospital services. It sets out a framework detailing key changes designed to strengthen commissioning and ensure commissioning drives health reform, improved health and healthcare, and improved financial health for the NHS.

The document builds upon Health reform in 'England: update and next steps', published in December 2005. It focuses upon the development of first-rate commissioning to create an NHS where patients have more choice as well as a real voice in the design of their services. Commissioners need to work with providers to secure the best health outcomes and the best services with the best value for the public's money.

Drawing on best practice already operating in many parts of the NHS, it outlines how practice-based commissioning will empower GPs to develop new services, flexible to reflect patients' needs and delivered closer to people's homes. This will also unnecessary hospital admissions, particularly for those with long-term conditions. It describes the role of Primary Care Trusts and Strategic Health Authorities and their relationship with GP practices, and it emphasises the central importance of clinicians and other health professionals, in their relationship with their patients.

Finally, it reaffirms the Government's commitment to a diverse provider base, including strong NHS Foundation Trusts, within a regulated framework, supported by the tariff system and good information.

COMMENTS ON
DEPARTMENT OF HEALTH
HEALTH REFORM IN ENGLAND: UPDATE AND COMMISSIONING FRAMEWORK

The Royal College of Physicians of Edinburgh is pleased to respond to the Department of Health on its consultation document Health reform in England: update and commissioning framework.  There are a host of principles in this document that influence policy, whilst the overall theme continues to be the challenge of narrowing the gap between policy and practice.  A detailed response follows, but the College would also like to make the following two key points:

1     The contribution of evidence as a foundation for clinical decision making and resource allocation appears to have dropped out of the framework for commissioners and policy makers.  Evidence for action is one key element of the foundation on which withdrawal from resource use, as well as re-investment, can command public and professional support.  The College regrets this trend as it has spearheaded clinical guideline development and witnessed the rise of NICE with its satellites as a very welcome keystone for NHS development in England.

2     The College has particular concern over the changing balance of care for long-term conditions, a prominent consideration in the current consultation paper.  Specialist physicians are very willing to engage with primary care colleagues and those from several disciplines to agree best practice that is based on evidence of good quality care relating to people who belong to these groups.  We believe that the current rule-based intentions and instructions on out-patient care and follow-up from hospital management will constrain choice, drive ill-informed decision and harm patients.  There will be people with less common and important conditions for whom specialist monitoring is very important in most cases.  More common conditions come in many severities and can be unpredictable - not least people who have impaired mobility, heart or lung conditions etc.  Guidelines for care, where they exist, should be evidence-based.  This College has contributed in this area, on a multi-disciplinary basis, with widespread political, professional and public support.  However, there must be the capability to make decisions based on informed choice and individual circumstances.  This discretion is essential for good patient care, in primary and secondary settings alike, and is under threat.  This threat is, perhaps, inadvertent as a by-product of forging changes for reasons that are neither clinical nor based on evidence, and sit uneasily beside an overriding commitment to patient safety.  This College will take up the matter with GP and Nurse College colleagues in order to build the evidence-based clinical guideline library where this is appropriate.

The following detailed comments relate to specific parts of the text:

The Royal College of Physicians of Edinburgh has a vigorous constituency across England, as well as Scotland.  In both countries, members of the College are involved in and witnessing, changes in the NHS as clinicians, managers and policy participants.  This contribution reflects these perspectives.

First, we share the aspiration of the policy paper in that we should put the patient at the heart of all that we do.  This is right, and wise, but it has consequences in conflicting policy levers.

Second, we have already set out two key challenges that, we believe, must be more central to the thinking of this consultation, and the development of the NHS - that is evidence-based clinical decision-making that influences the balance between secondary and primary care; and the importance that policy makers attach to clinical evidence.

Third, we have a general feeling that the challenge of health service reform has changed little since 1988.  There are stronger patient involvement themes, and information systems are welcome.  But full involvement of patients, valid information that records events, interventions and costs accurately; and intelligent transaction are still some way off.

Fourth, the consultation paper produces a valid diagnosis of the problems that confront the NHS, and the proposed treatment, but these are not well aligned.  Similarly, incentives for reform are not aligned.  For the consumer - the patient - they are persuaded of choice of venue but not of the person looking after them, which is perhaps not what they were seeking in hospital care.  They also are aware that resources are constrained but only marginally involved in making decisions with this influence.  In all but the largest conurbations, choice is likely to include time and travel, and it is important to recognise differences in the equation of informed choice when markets do not operate in the urban sense.

Choice, then, has been restricted to planning waiting list procedures until now.  Moving out of this area is bold and correct, and we welcome this move.  We recommend that it is incremental, and not radical, and there is quality assurance of appropriate referral channels.  We should take particular care in emergency and unplanned care areas.

Finally, on the theme of choice, the consultation addresses the patient side of the equation, in the charter rights, but the mention of constraints or responsibilities is largely absent.

To specific matters in the text, we particularly welcome commitment to:

• work in partnership with local authorities and local services;
• partnerships to agree clinical protocols and pathways, with particular attention to process that delivers good care;
• patient navigators;
• clinical protocols; and
• financial frameworks and tariffs that incentivise improvements that lead to a sustained balance between valuable specialist care and primary care.  Once again, thought and care is required to match choice with clinical evidence, and guard against variability and the quality of care.

To the consultation questions:

3.7

1. The College members support principles as set out.  Implicit in the principles are that choices are fully informed, that information includes intelligent analysis and advice, and that a consumer of information will take an unweighted but wise judgement with all the available expertise.  Additionally, an individual's beliefs are appropriate where they are reasonable.  Referral from primary care is welcome, within acceptable timescales.

   At some point, the health service will wish to flag high quality from low quality information sources and give an opinion as to the relative emphasis to be placed on access to services, experience and outcomes as a guide to making decisions and adding advice to consumers about how they wish to engage with the service - in an empowering way.

2. There are other points, including choice and decision points of access to primary care, building in lifestyle elements to a package of measures that will maximise the effectiveness of elective care.  Rights and choice come with constraint, particularly money and resource.  That should be transparent to the consumer/patient, and integral with ways in which the patient can contribute to their own wellbeing.  Choice should continue past the point of entry to planned care, to include further investigation and follow-through.

3. Maternity and "end of life" are areas of care where people are well informed; they can, for the most part, contemplate their choice before they embark on that course.  Also, choices of good provider and setting probably exist for many.

4. Sources of information that are quality assured.

   Access to more than one discipline in primary care, and one source of trusted advice.

   Health professional adviser capable of levelling with them on the basis of the extent of their understanding.

   Times of the day when they might wish to consult.

   More strategically, the style of primary care.

   Strategically again, lay involvement in practice-based commissioning which completes the accountability circuit.

5. Choice is welcome, if couched within a framework of rights and responsibilities, with governance of these consumer rights.

6. Information to support management of long-term conditions is a vital and high priority development.  Partnering information with intelligence, multiple sources of advice, impartial interpretation that is both available, individually centred and web-based, with lay involvement in the development of these materials.  Finally, the patient should have time to consider the advice available to them before coming to a decision.  It should not be rushed if the patient does not wish it.

3.19

1. There should be more transparent and rational explanation of actions taken on behalf of the population - why they are where they are, and what they comprise.  Swinging the balance into primary care is welcome, but should be based on evidence and guidelines, and less on rule-based or opaque criteria.

2. Means local democratic involvement, transparent processes, clear criteria for decision-making and truly informed by population needs and a range of conditions and treatments, rather than dealing in isolation with single issues - see next question.

3. There should be a "rule" or principle to avoid single issue decision-making.  Choices are about one thing or another, not just one thing in the ignorance of another.  Involvement in "community petitions" will have to be balanced with the consequences of constrained and shared resources.

Section 4: Provider Reform

Although there are no questions in this section, we strongly support the proposal for patient navigators.  We are concerned to ensure the evidence-base to fast-track access assures quality of the consultation and the trouble saved by specialist expertise in offering to deflect inappropriate care or offer re-assurance that ends the treatment episode in an appropriate way.

6.15

1. On commissioning, it should expand to create rounded systems of commissioning with a population-wide viewpoint, agreed priorities, and local lay involvement that brings everybody through the decision-making process and sees the implications of particular actions.

   Although tariff stability is attractive in the medium term, commitment to managed change should include acceptance that tariffs must be part of that change.  This is particularly important when tariffs more accurately reflect resource use and price of the intervention.  Current anecdotal evidence is that the current arrangements are not working.

2. Individual choice cannot be seen in isolation from constraints, population choices and professional influence.  These incentives and systems are not aligned at the moment.  There are consumer rights and professional opportunities and responsibilities, and neither really has the whole picture on the management of resources.  Until there is some way of "bottom up" determination of a given set of resources, these market reforms are bound to perpetuate tension between illusory choice and illusory values on expertise, knowledge and resources deployed at a micro-level by professional individuals and teams.  Relating to the involvement of specialists, there would be merit in membership of such groups by an experienced and respected clinician, in a manner fully integrated with regular processes.

We hope these comments are helpful.

Copies of this response are available from:

Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.

Tel: 0131 225 7324    ext 608
Fax: 0131 220 3939

[5 October 2006]