Specialised Services Commission
Wednesday, 3 February, 2016

The Specialised Services Commission sought written submissions from any stakeholders who wished to contribute to expert assessment of the future for NHS specialised care. This paper sets out the key topics under consideration by the Commission to inform written input.

What is the Specialised Services Commission?

The Specialised Services Commission is an expert working group convened by former Health Minister Lord Warner to examine the current challenges and opportunities facing NHS specialised care. As an independent short-life working group, the Commission will make recommendations to the Government, NHS England and others about the future direction of travel for over £15billion of specialised services.

Topics for written submissions: Stakeholders are invited to submit materials to inform the Commission’s recommendations on the future direction of travel for specialised services. The below topics cover the areas of greatest interest to the Commission, with the accompanying questions intended as prompts.

Safety, Quality and Money

  • How should specialised services be defined?
  • Is growth in expenditure on specialised services necessarily faster than the general rate of NHS growth? If so, by how should this be accommodated?
  • How can quality best be embedded in specialised services? Should national standards remain in place and how should quality be assured?
  • How and at what level should clinical leadership and patient involvement be embedded for specialised service planning?
  • Provision and integration
  • What role should providers play in the management of specialised care in future?
  • How should the provider landscape change? What role will New Care Models play?
  • How should payment systems adapt to support better specialised care in future?
  • What measures would best support an integrated experience of specialised care for patients?

Accountability and engagement

  • How will accountability for patients and the public be assured in a more plural world?
  • How should devolution affect specialised services and what safeguards will be required?
  • Where should the buck stop and how will patients and the public know who to engage with?
  • How should the Commission consider innovation within the above programme, without duplicating the work of the Accelerated Access Review?

Specialised Services Commission – call for written submissions

Safety, Quality and Money

  • How should specialised services be defined?

Specialised services are either those developed to assess and treat rare conditions, or those that require specific skills and experience provided by a multiprofessional and multidisciplinary team in a coordinating centre, where a critical mass of case experience is crucial to realise high quality care.

There is a clear definition from the NHS Commissioning Board already in place which is appropriate. This definition may change as the NHS explores new models of care and the devolution of budgets and responsibilities.

  • Is growth in expenditure on specialised services necessarily faster than the general rate of NHS growth? If so, by how should this be accommodated?

It is not unreasonable to assume that the cost of innovative research and novel therapies, with the aim of enhancing length and quality of life, will require additional expenditure at a proportionally faster rate than NHS growth.

There will need to be a regular process of decommissioning back to local Clinical Commissioning Groups.  As services are tariff based, control needs to be in place to restrict which providers would supply a service (to maintain quality, benefits of scale etc.) but many services could be local commissioner based.

  • How can quality best be embedded in specialised services? Should national standards remain in place and how should quality be assured?

Quality assurance is of critical importance in commissioning specialised services. National standards can provide a benchmark in defining minimum acceptable service standards and clinically relevant quality markers. These should reflect best available evidence, acknowledging that for rare conditions there may be a lack of trial evidence to support investigation and management algorithms. Without defined national standards, there is a risk of fragmentation of services and increased variability in quality and scope of specialist services by geographical provision. There are also international standards for some rare conditions and treatments in addition to our national standards, or when we do not have standards.

  • How and at what level should clinical leadership and patient involvement be embedded for specialised service planning?

Clinical leadership involvement is essential for the decision making process to be driven by justifiable clinical need and devoid from political influences. There is a balance to be struck between impartial external objectivity in commissioning specialist services, and the crucial role of specialist expertise in defining the scope and function of each specialist service. Clinical leadership should be derived from acknowledged experts in each specialist field based on evidence of improved patient outcomes arising from service models or innovative management approaches.

Patient involvement is vital in helping shape what patients can reasonably expect from each specialist service with the role of the expert patient to support the service model components. It is particularly important, however, that external oversight mechanisms are embedded to provide proportionate distribution of expenditure and prioritisation based on a model that incorporates all aspects of health care. There is a risk that articulate, effective and passionate individuals are successful in championing a single area of patient care at the expense of other areas of clinical need where patients lack the mechanisms or abilities to effectively influence service development. Patients could be drawn from a general patients' pool to minimise the emotive influences of one's own involvement in a specific disease process.

Clinical leadership and patient involvement need to be embedded at all stages, thus they need representation on Clinical Reference Groups, the Clinical Priority advisory group and NHS England’s specialist commissioning oversight committee. Allied to this there needs to be transparency for the public and profession concerning the process and decisions made.

Provision and integration

  • What role should providers play in the management of specialised care in future?

The establishment of high quality effective specialised services is frequently a progressive and evolving model, established over many years in order to recruit, retain and develop a service with expertise and skills in both breadth and depth. Existing specialist service providers have invested time and effort to reach a stage where meaningful outcomes for patients can be consistently determined. Instability or uncertainty about specialist commissioning of services carries the risk that expert teams lose functionality as clinical expertise is lost. Providers with evidence of innovative practice supported by robust data demonstrating excellent clinical outcomes and meeting service specifications should continue to be key stakeholders in specialised care management.

Regional NHS England reviews will set the geographical model which will determine how many providers are required in any area for each service. There is a need for strong local CCG input and there are growing collaborative arrangements for CCGs to achieve scale and allow more regional focus.

  • How should the provider landscape change? What role will New Care Models play?

A regionalisation of services is developing both from the provider and CCG side. This may lead to more hub and spoke models of care. This could impact on specialist services, for example in renal transplant services – there may be one transplant centre in a region with other hospitals providing work up and post-transplant care. At present each hospital will attract tariff for their particular contribution. In future there may be a central NHS England budget with sub-division of payments. As units of care become larger there is an argument for specialist services tariffs to come under CCGs who have a more global and integrated outlook.

Specialised Service models are more effective if collaborative, integrated working between providers is encouraged and supported both clinically and financially. Under a competition based system, duplication of services has been encouraged with differences in clinical performance used as a mechanism to determine which service expands at the expense of another. This model does not benefit patients as services are more likely to be fragmented, duplication of service development is inefficient, and expert teams are more difficult to recruit and retain. Specialised service commissioning should support providers in developing the clinical capacity to effectively manage the defined patient population for a geographical area. Nationally defined standards should be used to determine if the provider has the capability to achieve these standards based on past clinical performance outcomes and critical assessment of business plans to address any gaps identified.  Specialised services could be given special status in terms of management structure and funding that is suitable to cope with their regional or central delivery nature; without giving them a status that allows them to operate as a separate or superior NHS tier.

New Care Models has the potential to improve efficiency and clinical effectiveness. A model which is based on reducing duplication of assessment and appointments, improving communication between health and social care professionals and which integrates care records and IT systems would maximise resource efficiency. However, such services must be truly clinically effective, assessed against robust clinical outcome data, incorporating patient input on accessibility and acceptability. External oversight will be necessary to ensure that resources are not taken from one aspect of the service to support another area of care based solely on cost reduction at the expense of clinical effectiveness.

  • How should payment systems adapt to support better specialised care in future?

For many clinical conditions it should be possible to determine the costs associated with a pathway of care linked to the achievement of defined clinical parameters. Models such as best practice tariff for hip fracture have demonstrated improvements in clinical outcomes for patients and service responsiveness through such models.

There needs to be clarity and transparency about service specifications and long term conditions and their likely costs should be factored in.

  • What measures would best support an integrated experience of specialised care for patients?

Patient experience will need to be determined against a range of other quality parameters, including accessibility to service (geographical and delays to care), evidence of equity of access, responsiveness to need and measures of patient experience through both condition-specific and generic quality of life measures.

Accountability and engagement

  • How will accountability for patients and the public be assured in a more plural world?

Accountability is reliant on robust and effective systems and processes of governance, both clinically and financially. Transparency is required in defining service standards, the scope of service provision, accessibility and equity. Similar transparent mechanisms will also be required in the selection process for providers determined against defined standards. Public consultation and public / patient representation will be necessary within the standard setting and commissioning bodies.

There are established vehicles such as the Overview and Scrutiny committees of the local councils, the national patient associations etc. NHS England can be transparent by publishing key documents and minutes of meetings and being open to FOI requests.

  • How should devolution affect specialised services and what safeguards will be required?

Devolution in this sense means setting up combined social, mental health and medical arrangements for geographical areas such as Manchester. NHS England must maintain a position of scrutiny through service specifications and contracts, backed by quality outcome metrics that protect specialised services and safeguard equity across the country – this being a key tenet of the specialised services programme.

  • Where should the buck stop and how will patients and the public know who to engage with?

Accountability lies with both the clinicians in terms of clinical decision making and clinical outcomes shared with the management responsibility for the delivery of the care at the nationally agreed standards.  It is important that there are clear steps for challenge and a final arbiter which might be NHS England. At present their power would be in removing a service if the specification was not achieved, but in fact there would need to be powers to force a shared care provider to provide a certain service to maintain equity of access.

The NHS remains a national organisation and patients will expect that the ultimate responsibility for well governed, high quality, universally accessible specialist services rests with the Department of Health rather than with local government, NHS England or devolved NHS bodies.

  • How should the Commission consider innovation within the above programme, without duplicating the work of the Accelerated Access Review?

Placing patients at the centre of innovation is one of the key driving forces within the Accelerated Access Review. Specialist services have consistently pioneered innovative approaches to patient assessment and therapies with many centres of excellence hosting a duality of function with research driving changes in clinical care.

The role of the Academic Health Science Networks in supporting the translation of research into the clinical arena will become more prominent. The Commission could establish strong links with these established networks and work in partnership with the proposed Innovation Partnerships.

It is important that the Commission recognises that efficiencies can be achieved and quality improved through effective governance structures, benchmarking of services against standards in a consistent and transparent fashion in order to create a sustainable environment in which innovation can flourish. The role of pharmaceuticals within the innovation structures should be supported in its contributory role to future healthcare, whilst ensuring that business agendas and drive for profit from commercial organisations do not lead the agenda for specialist service provision.

We would warn against the ready adoption of technology with very little evidence base to support its use. There are a number of examples where expensive technology and IT developments delivered far less improvement than expected. The impact of the apparent rush to accept these developments should be treated with the same scrutiny applied to new pharmaceutical agents.

Other comments

There was a large public consultation on specialist commissioning in 2015 which looked at policies and procedures and a mechanism for prioritisation. Much in the outcome of that consultation is relevant to this work.