NHS Specialised Services

Debate between Stephen Gilbert and Anne Begg

Thursday 15th January 2015 Westminster Hall

[Stephen Gilbert (St Austell and Newquay) (LD)]

It is a pleasure to open this debate and to serve under your chairmanship, Sir David. May I be one of the first to congratulate you on your recent knighthood? “Sir David Amess” looks very good on the name plate. I welcome the many hon. and right hon. Members who have made the time today to come and discuss this important issue. I know that there are many Members who would have been here today, but have other commitments, including my hon. Friend the Member for Meon Valley (George Hollingbery) and my right hon. Friend the Member for North West Hampshire (Sir George Young). They have both contacted me about particular cases and share the general concerns that we will be expressing this afternoon, and I am sure they are not the only ones.

I want to speak up for patients and reflect the concerns of those with rare and complex conditions, whose voice is often not heard. There are two principal issues here: concern over changes to commissioning arrangements for specialised health care and whether it is right that morbid obesity and renal dialysis are no longer considered to be specialised services. The debate comes at a vital time. We are in the middle of a six-month period during which NHS England is developing plans to change radically the way specialised services are planned and funded. NHS England is doing that with remarkable secrecy, militating against external scrutiny. Today is an opportunity to discuss what we know and to test its fitness for purpose.

[Dame Anne Begg (Aberdeen South) (Lab)]

I have to declare an interest as someone with a rare condition. Although I live in Scotland, I benefit from a specialised service delivered by NHS England in Cambridge. Does the hon. Gentleman agree that the importance of specialised services means that they should be managed nationally so that they are not competing against local priorities? That is particularly important for cross-border matters. National management builds expertise—few people know a great deal about my condition—and ensures that there are national standards across the whole of the United Kingdom, and not just in one part.

--- Later in debate ---

[Stephen Gilbert]

There is a huge danger that we will move away from the improved patient experience that we have seen during the past year while national commissioning has been in place for specialised services towards more of a patchwork quilt approach in which patients may not get the same care in different parts of the country or the same pathways to care.

[Dame Anne Begg]

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.

[Stephen Gilbert]

The hon. Lady is entirely right. I will continue to set out the case that she so powerfully makes from personal experience.

In a board paper last November, NHS England published its next steps on specialised commissioning. Frankly, that was to the dismay of patient organisations, some of whom have been involved with specialised services for more than a decade, yet none was contacted or engaged with about the paper’s contents. It set out several principles for co-commissioning, perhaps the most alarming of which was the intention to move towards population accountability and lay the groundwork for place-based population budgets. That would essentially represent a return to the status quo ante under primary care trusts and, therefore, contravene Parliament’s wishes as embodied in the Health and Social Care Act 2012.

In particular, budgets allocated to local populations will usher in that patchwork quilt of provision for patients throughout England that hon. Members have referred to, with varying standards of care to match. NHS England suggests that its national standards would continue to apply, but experience shows that that would be untenable. The history of the PCTs is likely to be repeated, with the clinical commissioning groups going their own ways.

Despite opposition from key stakeholders, which I will touch on shortly, NHS England seems determined to implement its proposals. In December it took the unprecedented step of publishing notional local allocations of its own specialised commissioning budget. The sums have already been done and NHS England is now showing local CCGs the sheer scale of the budget that it expects to make accessible to them. Remarkably, only £1 billion of the £14.6 billion of allocated expenditure for 2015-16 is exclusively for national commissioning. Therefore, more than £13 billion of services that are currently commissioned nationally will be subject to co-commissioning. That is a huge transfer of resources and responsibility in the making, which surely requires prior, not retrospective, parliamentary and public scrutiny. Remember: that is funding for complex heart surgery, teenage cancers and chronic liver and blood diseases that affect some of the most vulnerable people in our community.

Why is this move so risky? First, we can say with certainty that local commissioning of such services does not work. As I alluded to already, before April 2013 responsibility for those services was with local commissioners. The 2006 Carter report brought about significant improvements, but the results remained mixed at best. The Select Committee on Health produced a report on commissioning in March 2010 that reviewed local primary care trusts’ performance in funding specialised services. It found that

“many PCTs are still disengaged from specialised commissioning…In addition, specialised commissioning is weakened by the fact that as a pooled responsibility between PCTs, it sits in a ‘limbo’, where it is not properly regulated, performance managed, scrutinised or held to account.”

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. Last year, the Specialised Healthcare Alliance, a coalition of more than 100 patient-related organisations and 15 corporate members that has campaigned on behalf of people who use specialised services for more than a decade, ran a survey of more than 100 representatives of patient groups, companies and expert clinicians that sought views on potential changes to commissioning arrangements for specialised services. It found that 90% of respondents preferred their service to remain part of specialised commissioning at a national level and none favoured leaving specialised commissioning arrangements. It also found that 82% favoured either no change to commissioning responsibilities for their service or for more of their service to be incorporated within specialised commissioning. Only 9% opted for more commissioning responsibilities to fall to CCGs. On co-commissioning, while respondents were open to collaboration between NHS England and local commissioners, only 15% would be happy to see that include pooling of budgets with CCGs.

I am grateful to the Muscular Dystrophy Campaign, the British Kidney Patient Association, the Cystic Fibrosis Trust, the Motor Neurone Disease Association, the Association of British Pharmaceutical Industry, the Royal College of Physicians, the NHS Clinical Commissioners, NHS Providers, the Medical Technology Group, AbbVie and Novartis for engaging with the debate. Uniquely, all the groups that have been in discussion with me share my concerns about the timing and content of these proposals.

Despite the clear views being expressed by the patient community and others, neither NHS England nor the Department of Health has opened any consultation on the developments. No stakeholder events have been held and NHS England has not even published full and explicit details of its plans for co-commissioning.

Given the magnitude of the plans, I hope that my right hon. Friend the Minister will give us assurances today. I ask for specific guarantees to satisfy the concerns that have been raised with me. First, will he commit to ensuring that NHS England will remain the sole budget holder for specialised services? Specifically, will he commit to that not just for 2015-16, but for the years that follow? That is crucial to clear accountability and consistency in those specialised services.

Secondly, will the Minister guarantee that national service standards and clinical access policies will remain in force throughout England, with no variation from the core standards permitted? Again, will he specifically give these assurances not just for 2015-16, but for future years?