What is commissioning?
Commissioning is the process of planning and purchasing the services required for a given area or population. This can involve:
- understanding the health-needs of a population
- deciding what services are needed to meet those needs
- designing the routes people with follow through the different services
- purchasing services and negotiating contracts with provides
- undertaking quality assessment
Commissioning is a key process in the health and care system as it determines which services will be available and how they will be provided. It has been an area of concern for the Neurological Alliance as services for people with neurological conditions have a long history of being under-prioritised and overlooked by commissioners. This has often resulted in low-quality, fragmented services.
Local Clinical Commissioning Groups (CCGs) commission most of the hospital and community NHS services in the local areas for which they are responsible. This includes mental health and learning disability services, urgent and emergency care, planned hospital services, and community care.
There are 195 CCGs in England. They are independent but are accountable to the Secretary of State for Health through NHS England. CCGs are membership bodies, with local GP practices as the members. They are led by an elected governing body made up of GPs and other clinicians, as well as lay members.
In 2014 The Neurological Alliance audited every CCG in England, to find out whether they had assessed the needs of their neurology population, and were adequately prioritising neurological services. Our findings are published in our report: The Invisible Patients: Revealing the State of Neurology Services.
NHS England is responsible for commissioning primary care services directly. This includes GP and dental services, as well as some specialised hospital services. In some areas GP services are co-commissioned with CCGs.
In recent years there has been a moves towards place and population based commissioning in the NHS. This means focusing more on population needs, bringing together commissioners and providers involved in serving that population, to improve integration. There is also a move towards better integration across health and social care services. As well as NHS providers place based commissioning includes local authorities, the third sector and other partners. There are different levels/types of place-based commissioning across England. These include sustainability and transformation partnerships, integrated care systems, devolution, and co-commissioning.
In 2016 The Neurological Alliance worked with Sue Ryder to audit Sustainability and Transformation Partnerships to discover whether their five year plans engaged with neurology. The results are published in our joint report, Going the Distance 2: National calls to action to improve neurology services in England.
Following the October 2018 announcement that Sustainability and Transformation Partnerships will be drawing up new five year plans in 2019/20, we our considering our future influencing work in this area.
While most healthcare is planned and arranged locally, specialised services are planned nationally and regionally by NHS England. This is because specialised services provide treatment for people with rare and complex conditions. Economies of scale mean that these services are not available at every hospital. Factors which determine whether NHS England commissions a service as a specialised service include:
- The number of individuals who require the service
- The cost of providing the service or facility
- The number of people able to provide the service or facility, and
- The financial implications for CCG if they were required to arrange for provision of the service.
At present specialised commissioning is undertaken by ten NHS England Hub Commissioning Teams which sit under four regional teams (the South, London, Midlands and East, and North). However, moves to transition to place and population based commissioning are ongoing, with the intention that all Sustainability and Transformation Partnerships/Integrated Care Systems are engaged in specialised commissioning from 2018/19, to better join up care pathways for patients.
Specialised commissioning for neurology suffers from a degree of confusion over the boundary between specialised and non-specialised services. This has led to situations where neither NHS England nor CCGs are willing to take on responsibility for certain services, leaving patients under-served. The Alliance is working alongside other members of the Neuroscience Clinical Reference Group to improve the neurology service specification to resolve this issue (see below for further detail).
National Services Review of Neurosciences
The specialised commissioning term at NHS England have initiated a national service review of neurosciences. They have identified that neurology and neurosurgery are a specialised commissioning priority area for national improvement work due to the high level of spending without good outcomes for patients. The programme is still in its scoping phase. However it is likely that it will focus on improving productivity through getting better value out of existing configurations of care such as length of stay, delayed transfers of care, clinical practice, and making sure the right care is delivered in the right setting. This could include looking at improving delivery within district general hospitals, and improving access to rehabilitation.
The Neurological Alliance is actively engaging with NHS England on the review. We submitted a response to the notes circulated following an engagement event in September 2018, and met with the project lead. We also sit on the Programme Board which will be overseeing the project.
Clinical reference groups
Clinical Reference Groups (CRGs) use their specific knowledge and expertise to advise NHS England on the best ways that specialised services should be provided. Several CRGs are relevant to neurology, most particularly the Neurosciences CRG and the Paediatric Neurosciences CRG.
CRGs have responsibility for the delivery of the ‘products’ of commissioning – the tools used by the ten Hub Commissioning Teams – which sit under four regional teams (the South, London, Midlands and East, and North Regional Service Programmes) – to contract services on an annual basis. These include service specifications, which are important in clearly defining the standards of care expected from organisations funded by NHS England to provide specialised care, and commissioning policies which define access to a service for a particular group of patients.
The Neurological Alliance sits on the Neurosciences CRG as one of three patient and public voice members. We are keen to hear members’ views on items the CRG is considering. If you would like to input, please get in touch.
Neuroscience service specifications
At present the neurosciences CRG is in the process or re-writing three important service specifications: the neurology service spec, the neuropsychiatry and neuropsychology service spec, and the neurosurgery service spec. Some details of progress and the expected publication date for all service specs in development are available here.
Neuroscience commissioning policies
A commissioning policy is a document that defines access to a service for a particular group of patients nationwide. A NICE Technology Appraisal Guideline on the same topic will either replace, or be incorporated into, a commissioning policy. Details of commissioning policies currently being developed across all CRGs, including neuroscience commissioning policies, are available here.