Policy responses and statements

Name of organisation:

Department of Health

Name of policy document:

Commissioning framework for health and well-being

Deadline for response:

28 May 2007

Background: The Commissioning framework for health and well-being was published for consultation.  It is aimed at commissioners and providers of services in health, social care and local authorities.  It is part of the White Paper 'Our health our care our say' implementation and the Department of Health was consulting as part of the development of a final document to be published in Summer 2007.

The key issues in the consultation include:

• Giving individuals more choice and control over their own care. For example, by increasing choice for patients to all services, not just elective care, and giving patients a louder voice in determining the type of care available.

• The new duty for NHS and local government to provide a strategic needs assessment - requiring those who plan services to deliver care that reflect the needs of their local communities.

• Wider use of flexibilities of practice based commissioning - so that GPs, for example, can spend NHS money on non-NHS services that have a preventative benefit for the NHS.

• Redesigning local health services based on people's needs, and convenience. For example - co-locating relevant health services for children and young people on sites that are used already, such as children's centres and schools.

COMMENTS ON
DEPARTMENT OF HEALTH
COMMISSIONING FRAMEWORK
FOR HEALTH AND WELL-BEING

The Royal College of Physicians of Edinburgh is pleased to respond to the Department of Health on the Commissioning framework for health and well-being.

This consultation document discusses commissioning for health and well-being, with the aim of involving the local community in order to provide services that meet their needs.  Eight key steps to more effective commissioning are identified:

1. Putting people at the centre of commissioning, giving service users greater choice and control over services and treatments, and where necessary providing advocacy to groups who need it.

2. Understanding the needs of populations and individuals via joint strategic needs assessment by councils, PCTs and practice based commissioners.

3. Sharing and using information more effectively, linking IT systems.

4. Assuring high quality providers for all services; focussing on outcomes.

5. Recognising the interdependence between work, health and well-being and encouraging businesses and NHS providers to promote and support health and well- being of employees.

6. Developing incentives for commissioning health and well-being and improving local cooperation.

7. Making it happen - local accountability with a single national outcomes framework.

8. Making it happen - capability and leadership; the Department of Health will provide support to fill any capability gaps for local commissioners.

The main idea of the Framework is to encourage local Commissioners of Health Services to work with community services and providers, to improve the quality of health and care for people; the focus is on preventive healthcare and giving individuals the power to shape their own personal community services as they want them.  There is emphasis on matching services to what people want and need, rather than what is available, and focussing on quality and outcomes, rather than numbers.

The College finds this Commissioning Framework a lengthy document which is not an easy read.  We fully support the laudable objectives, but find the document to be lacking in practical details of how these objectives will be achieved.

However, we recognise that current services may have poor or even hostile contacts between primary and secondary care and health and social services.  Anything leading to improvement in joint working is desirable, so overall we support this framework.

We do not feel qualified to address the specific questions in Annex E, but wish to make the following points:

1. Increased patient choice and control

We support the aim of giving people increased choice and control over their own care, but few people express views on health provision unless directly or indirectly affected. Special interest groups may be voluble and persuasive, but may be single agenda organisations.  PCTs must actively seek out the views of the disadvantaged to ensure their needs are not overlooked.  For example, contribution to consumer health surveys could be required of individuals seeking help, such as unemployment benefit.

We feel it is important to recognise that choice in many areas of care is inevitably limited, and care must be taken so that popular views do not result in deviation from key public health issues.  Patient satisfaction may not be a good surrogate marker for benefit.  We are concerned that the proposed changes in process are not accompanied by systems to test whether outcomes are improved.

2. Commissioning

We agree that the commissioning process has not always been satisfactory, and would be improved by ensuring members of commissioning teams are fit for purpose. However, the document does not specify how commissioners, leaders and group members will be recruited.  There is no mention of penalties in the event of failure to deliver by these groups.

National guidance will be helpful to PCTs, and a standard template plus audit will encourage consistency of quality in individual approaches.  Many examples of local initiative and strategies are quoted in the document; we hope the Department of Health would plan to analyse the quality of these strategies and advocate the most effective of them in different parts of the country to reduce inefficiency, duplication and avoid “reinventing the wheel”.

3. Resource implications

The Impact Assessment document reviews possible costs and benefits.  There seems to be no new allocation of resources for strategic needs assessment, improved IT and information gathering and sharing, or increased public health input.  Redesigning local health services for greater choice and patient/user convenience is, we feel, likely to increase costs, and the costings provided seem overly optimistic.

National resource allocation is key to improving health and well-being, especially as need will vary between different communities, given the known inequality in health outcomes and standards between poor and affluent communities.  Identified and ring-fenced funding will be required to prevent resources being diverted to achieve targets or into secondary care.

4. IT

Appropriate and accurate information about the health needs of local communities and adequate IT support are critical to good decision making.

We have concerns over security of personal information being shared more widely - as exemplified by recent NHS IT problems with the MTAS.  Pilot studies are essential.

5. Input by professional bodies

We note there is hardly any mention of input by professional bodies such as the Royal Colleges, or voluntary bodies.  The NHS currently benefits from input from such groups, which provide advice, support and help in monitoring standards.  Using alternative providers, locations and services is entirely appropriate, but must follow evidence as to their benefit and safety.  We also caution that changes in service provision could potentially destabilise acute hospital care and local health delivery.

Furthermore, the large number of agencies to be involved in the functions relevant to this document does increase the capacity for generating additional confusion and uncertainty for those asked to deliver the visions and service improvements envisioned in the document.

In conclusion, we support the Framework’s aims of freeing up commissioning rules and empowering an individual patient/user to allow them to develop the services they feel they need and want.  We suggest that General Practitioners have traditionally been the patient’s advocate, both to hospitals and local government provision, and GPs might be better placed than this College to comment more specifically on implementation of measures to increase care in the community.  We reiterate that it is essential to demonstrate that choices are evidence-based in order to withstand pressures from the short-term, target-based culture and special interest groups, including within the medical profession.

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

[28 May 2007]