Commissioning Renal Services
The White Paper, ‘Equity and Excellence: Liberating the NHS’ (2010) and the subsequent Health and Social Care Act (2012) signalled a significant change in the commissioning landscape in the NHS in England. The establishment of the NHS England (NHSE; previously known as the NHS Commissioning Board, NHSCB) in April 2103, as an independent body from the Department of Health, was one of the key developments that came out of the aforementioned Health and Social Care Act. The NHSE has responsibility for the direct commissioning of a range of healthcare services including specialised services, military and offender health and primary care. It also has responsibility for overseeing the establishment and governance of around 211 newly formed Clinical Commissioning Groups (CCGs).
The NHSE is a single organisation with one operating model that is delivered in a number of localities. There are 4 regions:
- NHS North of England
- NHS Midlands and East
- NHS South of England
- NHS London
Within these 4 regions, there are 27 Area Teams (ATs; previously known as Local Area Teams, LATs) who have responsibility for the direct commissioning of a number of services. 10 of the 27 ATs have specific responsibility for commissioning specialised services like kidney care.
Clinical Commissioning Groups
CCGs have responsibility for commissioning a range of hospital and community health services to meet the needs of their local populations. These CCGs are more clinically led organisations with the Chair and/or the Accountable Officers being General Practitioners (GPs). All GP practices within a given area are included within a CCG. The establishment of CCGs aims to bring decision making on how NHS resources are utilised closer to the clinicians who make referrals.
Commissioning Specialised Services
The commissioning arrangements for specialised services have, for many years, been different to those for services provided within most local hospitals. Primary Care Trusts (PCTs) were previously the only statutory commissioning body in the NHS, and they delegated the commissioning responsibility and budget for specialised services to 10 specialised commissioning teams who acted on their behalf. With the Health and Social Care Act has come the abolition of Strategic Health Authorities and PCTs, which have been replaced by the Area Teams (ATs) and CCGs. Within the single operating model of the NHSE, there will be a much greater emphasis on national consistency and equity in access to services and clinical outcomes of specialised care.
The portfolio of specialised services to be commissioned by the NHSE was determined by a clinically led group - the Clinical Advisory Group (CAG) - which comprised both GPs and hospital clinicians. This group reviewed the National Definition Set of Specialised Services and identified, for each of the 34 specialised definitions, which elements were considered to be ‘prescribed’ specialised services and therefore not to be commissioned by CCGs. The final report of the CAG is located on the DH website
The transition of funding and commissioning responsibility for all these ‘prescribed’ specialised services to NHSE has now taken place - in time for the formal establishment of the NHSE in April 2013.
In order to support the drive for national consistency and equity in specialised services, 60 Clinical Reference Groups (CRGs) have been established. These CRGs all have a clinical lead and their membership comprises clinicians from around the country, public health representatives, patients, carers and commissioners. Their role is to produce nationally consistent documentation for inclusion within provider contracts. These documents include service specifications, CQUINS, QIPP plans, service policies and quality dashboards. Once signed off, these documents will be incorporated into all contracts and local actions plans will be prepared to address any variances. There are 2 renal specific CRGs:
- Renal Dialysis CRG – this is chaired by Dr Chas Newstead, Clinical Director of Renal Medicine at Leeds Teaching Hospital
- Renal Transplant CRG – this is chaired by Mr Keith Rigg, Consultant Transplant Surgeon, Nottingham University Hospital
Kidney Care Commissioning
The specific kidney care services that are included within the NHSE portfolio can be found in the CAG report . Kidney care is one of a number of specialised services that span the patient pathway. It is therefore fundamental that commissioners within the NHSE and CCGs work closely together - and in partnership with the cardiovascular Strategic Clinical Networks - to ensure a joined up approach is taken to service improvement initiatives and contracting with providers.
The commissioning process continues to evolve and there is now a much stronger emphasis on quality, clinical outcomes and patient experience rather than just activity outputs. Implementation of the NHS Outcomes Framework is central to this and will be used as the framework that binds different commissioners together in common goals of health improvement. The strengthening of clinical networks into Strategic Clinical Networks (SCNs) is also an important step forward. Kidney care will be included within the Cardiovascular SCN and as such will receive national funding and will have stronger accountability processes. Clinical Senates and local Health and Well-being Boards will also provide a forum to address gaps in services.
Finally, fundamental to all of the changes in the NHS is placing the patient and their carers at the centre of the planning and decision making process – ‘no decision about me, without me’. This will require commitment, time and resources to ensure it is not a tokenistic approach. For kidney care services, the invaluable experience and knowledge to be gained from patients, carers and support groups such as the National Kidney Federation and Kidney Patient Associations must be harnessed.