Geraldine Hoban, deputy director of commissioning NHS
Max Kammerling, consultant in public health medicine. NHS
Penny Kinton, chairman, Social Enterprise Complementary Therapy (SECT) committee, representing about 140 CAM centres in the city.
John Kapp, secretary of SECT committee and LINk member for Sussex on National Association of LINk Members (NALM)
2 Purpose of the meeting
The purpose of the meeting was to discuss which CAM treatments would be included in the NHS Strategic Commissioning Plan (SCP) and Annual Operating Plan (AOP) for the city of Brighton and Hove (B&H). Hereafter, the views expressed by Geraldine and Max are styled ‘NHS:’ and those by Penny and John: ‘SECT:’.
3 Background to the meeting
The meeting arose out of a public question that John had asked on behalf of SECT at the NHS board meeting on 2.2.10: ‘Which and how many NICE-approved CAM therapies will be commissioned in the forthcoming AOP 1.4.10-11? Amanda Fadero, director of strategy and commissioning, and deputy chief executive of NHS B&H replied in writing on 8.3.10 saying that the following CAM treatments would be commissioned in the forthcoming year:
a) In palliative cancer care (Aromatherapy and reflexology presumed)
b) Chiropractic for lower back pain.
c) Meditation for carers.
4 What level of detail should SCPs and AOPs contain?
SECT welcomed the news that the above CAM treatments are to be publicly funded, and asked: ‘How many of those CAM treatments will you pay for, on what tariff, and how will you pay CAM therapists for them?
NHS said that they could not answer this question. They repeated what Amanda had written on 8.3.10: ‘The AOP is not a document which describes in detail every service we commission, rather it focuses on where there is likely to be significant service change or where there is a high priority for delivery in the coming year. Therefore it does not drill down on the level of detail with regards to service models or the NICE compliance of all services.’
SECT did not accept the policy expressed by Amanda’s statement. They asserted that the SCPs and AOPs should drill down to contain that level of detail to inform providers (and potential providers, such as SECT) what, and how many treatments will be publicly funded in future years.
SECT believe that the publication of this level of detail is the primary purpose of SCPs and AOPs, and is the basic function of commissioning. Moreover, doing so is the very reason why the government split the function of commissioning away from the function of providing 20 years ago. Since then you NHS commissioners have had the statutory duty to drill down to this level of detail as your public responsibility. You are paid from taxation to take this responsibility on behalf of providers, potential providers (such as SECT) patients and the taxpaying public. Your job is to ration treatments so that we all get the best health outcomes for limited public money spent.
SECT said that you (collectively) are failing to take this responsibility. You are also failing to implement the DoH reforms since April 2006, of making the ‘money follow the patient’, ‘Payment By Results’, ‘Practice Based Commissioning’ (PBS) World Class Commissioning’ and ‘making the GP the budget holder for each patient’.
SECT said that unless providers are informed about this level of detail, (how much public money you budget for each and every treatment in each year) they cannot plan to provide those treatments. The absence of this detail prevents existing providers from planning their provision of services. It also prevents alternative providers (such as CAM providers, whom SECT represents) from entering the market for publicly funded treatments. This is unfair discrimination against alternative providers, and is against the interests of the patients and the public who pay for the NHS.
NHS argued that no PCTs specify this level of detail in their SCPs and AOPs, and Brighton and Hove cannot break rank with other PCTs.
SECT said that the government have created 152 separate and autonomous PCTs and given them the local autonomy needed for them to act on behalf of their local constituents, whom they are failing in this regard. They likened NHS commissioners to railway companies who publish strategic plans stating: ‘ the trains will run on time’, but without publishing timetables.
Action: NHS to reconsider this policy. (see secretary’s note below)
5 Examples of strategic plans without specific detail.
a) NHS Brighton and Hove SCP 2010-15
SECT asked for the SCP in Oct 09 and received it from NHS on 12.3.10. It is entitled ‘Improving Health and Developing World Class Healthcare 2010-15. The 175 page document is undated beyond many references to Dec 09. It contains many statements such as: ‘We will empower staff, patients and the public….We will be customer-focused…..We will take our responsibilities seriously…We will promote innovation, and be confident to try new things…We will do more to support Practice Based Commissioning…
However, it does not contain the detail that is needed to fulfil its primary purpose as described in paragraph 4 above. Using the railway company metaphor, it is a collection of statements that: ‘this train, and that train, and the other train, will be first class and will run on time’ but without giving timetables, destinations, ticket prices, nor the overall budget for the company. For example, take mental health, table 23 titled ‘Summary of the Mental Health Priority Transformation Programme 10 Transforming Mental Health, on page 78, which is quoted in full below:
‘Our future model.'
We will improve mental health for all adults in the city through commissioning services to meet people’s needs earlier, effectively and wherever possible in a community setting. We will do this by commissioning a much greater number of services for low level need and we will do this by reinvesting money from efficiency savings. Key phases are as follows:
2009/10 Pilot a referral gateway for non emergency referrals.
Implement NICE guidelines for well-being and access to psychological therapies.
Combine commissioning for adults and older peoples functional
mental health into single strategy for the city based on need.
Realign contracts to revised service outcomes and against models
of early intervention, ongoing support and personalisation.
Implement the serious mental Illness enhanced service in Primary
Recommission access services, including the model for access to psychological therapies.
Implement a new memory assessment service.
2011/12 Develop dementia specific service models.
2012/13 Commence implementation of new service models.
2013/14 New service model operational including new care pathways.
Outcomes and benefits
Improvement in the service user and carer experience
Reduction in length of stay for acute mental health admissions
Reduction in A&E attendances relating to mental health crises
Reduction in waiting times for assessment
Reduced barriers between the NHS, housing, leisure and education and employment
Improvement in mental wellbeing of the population
All this is excellent as far as it goes, but it does not go far enough. There are 10 ‘trains’ listed on this table, (5 in the forthcoming year starting 1.4.10) but the ‘plan’ for them does not state how many trains (treatments) will be run, and with what capacity for patient journeys. All it says about money is that by 2013-4 about £2 m will be reinvested out of about £2 m efficiency savings. The ‘destinations’ (outcomes) are so vague that it is impossible to judge whether or not the train has arrived.
The failure of NHS commissioners to drill down to this timetabling level of detail has the knock on effect of providers doing the same in their own Strategic Plans. In their defence, they cannot be expected to do otherwise. They have no means of knowing which treatments the commissioners will pay for, and no incentive to do better than the example of their boss. All they publish is the same sort of platitudinous statements of good intent. These are too vague to be measured, so that they cannot be held to account for the service they provide.
5b) Sussex Partnership Foundation Trust (SPFT) SCP
SPFT employ 4,800 staff of whom about 1,000 are clinicians to provide mental health services to Sussex with a population of 1.5 million people. For the 250,000 in the city, the cost for mental health services is around £56 mpa of which £44 mpa goes to SPFT. SPFT’s ‘Strategic Programme 2010-14’ for Mental Health services to Sussex, titled ‘Better by Design’, dated Dec 2009, contains the following quotes:
‘Delivering the very best possible services that are completely focussed on the people who use them, that offer real choice and that put them in the driving seat’.
Being as good as the very best providers of similar services.
- Delivering services that are externally measured as being of outstanding quality, supported by high standards of professional practice.
We will develop our clinicians and leaders, and introduce new working methods to realise the full potential of our skilled, flexible workforce.
Challenge stigma and discrimination, whilst promoting equality and positive attitudes.
Put the human rights of the people who use our services at the centre of everything we do.
High quality care for all people using Sussex Partnership services.
Employer of empowered, engaged, well trained and motivated staff.
Create new partnerships to provide new services, especially in substance misuse, alcohol misuse, and psychological therapies.
As part of the IAPT programme we have recruited an additional 120 therapists.
We are developing new specialist services for people who have long term complex mental health conditions, such as eating disorders, personality disorders, perinatal mental illness, autistic spectrum disorders and various degenerative conditions.
We are developing a psychologically minded organisation.
We want to support our staff to develop skills to recognise and manage their feelings.
We will also prepare for the introduction of payment by results into NHS mental health services.
All this is excellent as far as it goes, but it does not go far enough. The above 14 statements of intent cannot be measured or verified. If SPFT was a railway company, they are advertising 14 trains, but do not even state the year in which they are supposed to run. SPFT may not be able to get away with such vague documents much longer. From 1.4.10, providers such as SPFT will be required by the DoH to produce quality accounts.
The criteria for judging quality is safety, effectiveness and patient experience. The accounts are supposed to show what patient satisfaction ratings resulted from treatments. In other words, quality accounts will have to drill down to this level of detail for each and every treatment.
SPFT are unlikely to score high on quality, as nearly all the service users that SECT members have met regard the mental health service as appalling. Waiting times are measured in years, and treatments frequently do more harm than good. We recently met a patient who said ‘Prozac is ruining my life.’ The very idea that we can improve our health by poisoning our body with drugs is absurd.
6 What treatments should be de-commissioned and commissioned?
SECT argued that the AOP and SCP should specify the number of each and every conventional and CAM treatments in each year, giving the following examples:
a) Prozac should be de-commissioned, as there is good evidence that it does not work better than placebo, is addictive, and has harmful side effects. If 80,000 prescriptions were paid for in 2007, (pro rata 16 million prescriptions written in UK) the SCP should specify that the number to be paid for will reduce, say to only 60,000 in 2009, 40,000 in 2010, 20,000 in 2011, and none in 2012.
NHS argued that ‘the jury is still out on whether or not Prozac works.’ SECT did not agree, quoting the meta study of 35 studies on which was based the media headline in Feb 2008 ‘Prozac doesn’t work’. They also tabled a 12 page article published in the New York Times of 1.3.10 titled ‘Can psychiatry be a science?’ (1) This is a review of 2 new books which demolish the evidence base of conventional treatment for mental sickness, both drug-based and CBT.
NHS argued that the New York Times is not a peer–reviewed journal, so should not be regarded as ‘evidence’. SECT argued that what appears in the New York Times is read by patients, so forms ‘patient-perceived’ evidence. It has been government policy for decades to create a patient-centred NHS. It is patient perception which influences patients’ decisions on whether to consent to treatment, so commissioners should take account of patient-perceived evidence (rather than ‘provider-perceived’ evidence) in SCPs and AOPs.
b) Mindfulness Based Cognitive Therapy (MBCT) courses should be commissioned, as they are NICE –approved for anxiety and depression for staff and patients, as an alternative to antidepressant drugs, such as Prozac. SECT has been informed (2) that SPFT has only one MBCT practitioner who offers 4 courses pa for up to 20 participants, ie only 80 places pa.
SPFT is supposed to provide treatment for all mentally sick people in a population of 1.5 million. To create a mental health service worthy of the name MBCT courses need to be commissioned and publicly paid for in bulk. We have suggested that one course pa is needed for 1 in 20 of the population, so 70,000 places pa are needed for Sussex, of which 30,000 should be in the city. This is nearly a thousand times more than SPFT presently provide. The details of this proposal are contained in report ‘Improving health by ending the Prozac nation’ dated 19.8.08, published in section 9.28 of www.reginaldkapp.org, and contained inter alia in book titled ‘Transforming the NHS’ book submitted in December 2009. Action NHS to consider these proposals and report back to SECT.
7 Should generic CAM be provided in the city as a pilot project?
SECT has applied for a grant from the Social Enterprise Investment Fund to set up this company, and expects to hear from them whether they have been awarded one by the end of March. Action SECT to report back to NHS.
8 Should there be future meetings between SECT and NHS?
SECT said that NHS has a statutory duty to consult the public under the 2007 Act that set up Local Involvement Networks (LINks) and that the NHS gains brownie points for meeting with SECT. NHS agreed that there should be future meetings, and invited SECT to be involved in the forthcoming review of the mental health access services, which SECT are happy to accept. Action NHS to invite SECT to a meeting.
9 Meditation classes for staff
NHS said that they still wish to provide meditation classes or courses for the staff at Prestamex house, and would consult with staff to guage demand. SECT offered assistance in setting this up. Action NHS.
10 Prevention of sickness
SECT said that the Darzi/Boorman requirements to prevent sickness as well as treat it, is like asking Tates garage mechanics to prevent accidents as well as fixing crashed cars. They have not been trained to do so. John is writing a paper for the NHS entitled ‘How to Prevent Sickness’ to address this new requirement, which he hopes to complete before Easter.
11 Big cut in PCT management costs in 2 years
NHS informed SECT that the PCT management costs nationally have to be cut by 30% in 2 years time, but in Brighton and Hove the cut will be 39%. This will mean that the commissioners will have to manage with almost half the present number of staff. SECT were shocked at this news, which contrasts with the prime minister’s public statements that ‘frontline jobs will be secure.’
1. 12page article in New York Times on 1.3.10 entitled ‘Can psychiatry be a science?’ by Louis Menand It reviews 2 books, ‘Manufacturing depression’ by Gary Greenburg, and ‘The Emperors new drugs’ by Irving Kirsch ‘Both authors are hostile to the current psychotherapeutic regime’. New York Times article
2. Letter to LINks dated 9.11.09 from John Rosser (SPFT manager for Adult Mental Health Services) in response to LINks request dated 12.10.09.
Secretary’s note. The following conference made some ot the same points.
COMMISSIONING AND INTEGRATED CARE
Report on a conference held on 16.3.10 at the Kings Fund, London
by John Kapp. 22.3.10
Jennifer Dixon, Director of the Nuffield Trust (and formerly of the Audit Commssion, the Healthcare Commission, and policy advisor to the CEO of the NHS) quoted David Colin-Tome as describing PBC as ‘moribund’, and Kevin Barron MP, (chairman of the Commons Seclect Committee on commissioning) asking: ‘Why is commissioning so weak as to have allowed A&E admissions to have risen 12% in 5 years?’ Also ‘Why is commissioning not geared to prevention?
Jennifer launched a new report: ‘Where next for commissioning in the English NHS?’ by Judith Smith et al. It defines commissioning: ‘A commissioner decides which services or healthcare interventions should be provided, who should provide them and how they should be paid for.’ (p12) This requires the detail that SECT have been asking for.
The report concludes: ‘Perennial attempts to boost commissioning in its influence over service provision look increasingly tired and possibly futile…….Another direction points to the need to take more decisive steps to energise the practice/locality part of the commissioning continuum and encourage groups of clinicians (including CAM practitioners) to assume resource management responsibility together with accountabliity for the health outcomes of a population. ‘ (p39) (SECT added the italicised words.) … All commissioning organisations need to become more accountable for commissioning functions and outcomes…..by increasing local democratic accountability……To make a reality of the more radical and hopeful prognosis for NHS commissioning, PCTs will need to increasingly reinvent themselves as the designer, resource allocator, and performance manager of a local or regional health system. (p41) (SECT will post a copy of the report to you).
SECT can answer Kevin Barron’s question. The Tory-initiated commissioner/provider split in 1990 has never happened because there has been an unholy alliance between commissioners and providers to maintain the provide-centred NHS status quo, irrespective of the wishes of patients, CHCs, PPIFs, LINks, SHAs, DoH, and Acts of Parliament.
The commissioners are part of the regulatory system, and what has happened is known as ‘regulatory capture’. The staff of commissioners and providers belong to the same trade unions, which naturally have a vested interest in maintaining the status quo of a provider-centred NHS. Despite the political rhetoric, we have had 13 years of a Labour government, whose MPs and ministers are selected and funded and hence unduly influenced by these unions, so have had no interest in enforcing the law to make the NHS patient-centred.
SECT believes that the time is ripe for this cosy relationship to be broken, and commissioners to be separated to ‘arms length’ from providers, as done in all previously nationalised industries. ‘He who pays the piper (patients and public, through LINks) should call the tune.’ We (SECT and LINks, on behalf of the public) call on you NHS commissioners to list in your SCPs and AOPs exactly which treatments you will fund, how many per year, at what tariff, how you will pay for them, and to open the market to CAM providers as we have proposed. SECT will be pleased to assist you in this task.
It may be argued that the time is not ripe for this change of policy with cuts in NHS funding looming in the next few years. SECT argues that these cuts makes this change of policy imperative to get best value out of the funds remaining. CAM treatments are far more cost effective than conventional ones, so the integration of CAM as proposed in SECT’s ‘Business Plan for Free CAM on the NHS’ will deliver a better value service, with better health outcomes for patients from smaller budget allocations.
The conference had presentations of good commissioning practice from NELondon PCTs (Whipps Cross and Redbridge) and Halifax in Yorkshire. In a break John met Ian Manovel of Analytics Bupa Health Dialog, who produces software programmes to help PCTs to drill down to the level of detail required by SECT. Their website is Analytics Bupa Health Dialog , and Ian’s phone number is 01223 451384.
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