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NHS Clinical Commissioners response to the DH Consultation on the transfer of Dialysis

In this consultation response we strongly object to the timescale for the proposed transfer of the two services proposed and want to raise
significant concerns about the rationale that has been presented for it.

Extract from the full report reproduced below >

9th January 2015
NHS Clinical Commissioners response to the DH consultation on the transfer of renal dialysis and
morbid obesity services to CCGs


Dear Sir/Madam
NHS Clinical Commissioners (NHSCC) have written this letter as our formal response to the DH consultation
on the transfer of renal dialysis and morbid obesity services to CCGs. As the membership body of clinical
commissioning groups (CCGs), we welcome the opportunity to outline the collective views of local
commissioners.
NHSCC has 85% of CCGs in membership and growing. To develop this response we have:
• Held a webinar with members on the 15th December 2014, which had input from the DH and NHS
England. During our webinar we focused discussion on the 4 areas of the consultation, namely – the
implication for patients, national support required, CCG readiness and timeliness.
• Taken views from our membership via our Monthly Leaders Bulletin and engagement with our Core
Cities CCG network.
• Taken in the views and steer on our democratically elected Board (made up of 10 regional
constituencies and our 6 member networks).
Our response
Overall we believe that the transfer of any commissioning responsibilities for specialised services to CCGs
must be for the purposes of improving pathways of care for patients and joining up the commissioning
system; and be conducted with the agreement of CCGs as statutory bodies. In this consultation response
we strongly object to the timescale for the proposed transfer of the two services proposed and want to raise
significant concerns about the rationale that has been presented for it.
As a way forward we ask to see a more detailed clinical and non-clinical case from NHS England for the
proposed transfer of the two services to CCGs and ask for a delay of the transfer to April 2016 to allow for
the rationale to be presented to CCGs and a clear planning timetable to be set. 2
To outline our concerns we have themed our response into the following areas:
1. Risks to CCGs and patient care as a result of the April 2015 timescale
2. Gaps in the proposals which CCGs require clarity on
3. Our proposed way forward and outline of the support/engagement CCGs require
(1) Risks to CCGs and patient care as a result of the April 2015 timescale
The proposed timescale for the transfer of renal dialysis and morbid obesity surgery services to CCGs is not
supported by our members. NHSCC feels that the engagement and development of these proposals with
our members at a national level has not been adequate to date and creates significant risks in the system
with regard to CCG readiness.
We must remember that CCGs are statutory bodies that have been given a mandate to commission for the
needs of their local populations. The transfer of commissioned services from NHS England to CCGs must
therefore be planned, safe and take a mature approach. Our members are concerned that the proposals are
being rushed through and therefore imposed on them in a manner which disregards their local priorities and
plans. Of particular concern is that the timetable does not support the ambition for CCGs to redesign and
improve pathways – they are being given a set of services they have no time to strategically plan for.
The concerns and risks we would like to flag to Ministers specifically on the impact of the timescale are
listed below.
• April 2015 is an unrealistic deadline that is out of touch with the reality of local decision
making. The proposals suggest that the full commissioning responsibility of the two services will be
transferred to CCGs. This will require more than legislative change: NHS England will need to work
with CCGs to develop its national guidance and CCGs will need time to understand the impact of the
transfer on their organisations, populations and any added financial burden. CCGs may also need to
agree risk sharing arrangements with neighbouring CCGs. This simply cannot be undertaken in less
than 3 months and will risk population level commissioning if it’s not planned and implemented
correctly.
• The context of proposals for wider transfers. Context is a key issue for us in this consultation. We
know there are plans underway to involve CCGs in collaborative commissioning arrangements for a
large range of specialised services from April 2015 and to develop place based commissioning from
April 2016. We believe it makes more sense to change responsibilities for these two services at the
same time as formalising the placed based commissioning plans. We must see a compelling case for
why this transfer must happen prior to that. For example renal dialysis services will require CCGs to
work across their current footprints - so collaborative arrangements will need to be put in place or
existing ones used but this may as well be done for a much larger group of services. This would also
enable scarce but expert specialised commissioning staff to be shifted at the same time to support
shifts in responsibilities. The same will apply for obesity services – local arrangements must be
agreed. We must not have a piecemeal approach to the transfer and would prefer movement to
happen using a planned strategic approach.
• There is a misalignment between the proposed deadline and the current contracting round.
CCGs will be in contract negotiations with providers during February and March 2015. This means
that there is very little time for CCGs to digest the commissioning data that NHS England is currently
preparing for mid-January – ideally this locally disaggregated data should have been available prior 3
to the DH consultation. It’s also unclear if CCGs will be able to align the services to local plans in
time. The risk is that CCG take on more financial burden than they are ready for – again this risks
their capacity for the commissioning of routine patient care.
• The timescale will add extra commissioning activity onto CCGs at a time when they are taking
on wider commissioning responsibilities. A number of CCGs will be taking on more
responsibilities for primary care commissioning and delivering against their local Better Care Fund
plans in 2015/16. Our members are concerned that if they take on additional commissioning
responsibilities for renal dialysis and morbid obesity surgery services at a time when they are
managing new responsibilities it will impair effectiveness. This is at a time when CCG running costs
are being reduced and under significant pressure. Our members are in danger of losing their ability to
commission baseline services for their populations. We are also concerned about whether NHS
England has the capacity to support this transfer locally. Area teams are being restructured and there
is significant pressure on them to support/work with new arrangements for primary care cocommissioning.

(2) Gaps in the proposals which CCGs require clarity on before the transfer can occur
Our members have highlighted a number of areas for further clarity in relation to the proposals as laid out.
Firstly, NHSCC is concerned that the consultation for the proposed transfer of the two services has been
launched with very little local information to support CCGs to agree it or identify risk. We note that much of
the commissioning data that CCGs will require in order to agree to the transfer at all is available after this
DH consultation closes. As mentioned, CCGs must, as statutory organisations, weigh up all the risks so as
to not compromise their financial stability and that of their wider commissioning functions.
NHSCC would like some assurance that this transfer is not simply moving financial risk from one
part of the commissioning system to another. For example, it is not evident from the consultation
document whether the plan is for resource for both of the services will be allocated on capitation or historic
utilisation basis. If it is utilisation, it could move some CCGs further from equity and/or fair shares. If it is
capitation then it could expose some CCGs to cost pressures. In addition we know that renal dialysis is an
area of growth in recent years. According to the HSJ (25th November 2014) NHS England spends almost
£700m on renal dialysis annually to treat around 23,000 patients. It is one of the six specialised services that
between them accounted for 50 per cent of growth in the budget.
Secondly, the guidance that NHS England will be producing for CCGs in relation to the transfer must be
just that and not attempt to tell CCGs how much care they need to commission to a national specification,
where they do not need to. We would ask that NHS England works with CCGs to produce this guidance. As
a matter of principle CCGs are a commissioning authority and have the responsibility for deciding the nature
of how services are delivered and then reflecting that into a service specification (which is then part of a
contract). CCGs must have the freedom to develop their own service specifications for any services for
which they have responsibility. The proposed arrangement in the consultation document states that NHS
England would wish to impose a service specification onto local commissioners: this is counter to the
principles and practice arrangements within the commissioning environment. Our members believe that this
is a fundamental principle which cannot be compromised. We would ask that NHS England works with
CCGs to produce the proposed national guidance.
The third area for clarity focuses on the level of monitoring or assurance that is proposed to go
alongside the transfer. As mentioned, CCGs are statutory bodies and so already accountable at a number of
levels. They must not be subject to additional monitoring burdens set by national government. If CCGs are
taking on the full commissioning responsibilities for these two services it should be treated with the same
assurance as other CCG-commissioned services. 4
Finally, we have some concerns to raise on the two services specifically:
Morbid obesity surgery services
• There are potential cost pressures that could come in the light of NICE guidelines on morbid obesity
surgery services which require identification, assessment and management of overweight and
obesity in children, young people and adults. How is it possible to support the transfer of
responsibility until the costs and impact of this approach are understood and consistently
implemented?
• The Five Year Forward View sets the direction of travel for the NHS – which is about commissioning
the right services for the future. The immediate transfer of morbid obesity surgery to CCGs in April
2015 will just add more confusion and delay to a commissioning system under pressure. Local
stakeholders and CCGs need time to work together on a better local strategies for weight
management.
• The proposals for obesity services focus heavily on the transition from tier 3 to 4 services. We know
Tier 3 obesity services are commissioned by local authorities in some areas (with Public Health).
This means that in some areas the commissioning system will still not be fully joined up as a result of
the proposed transfer.
Renal dialysis services
• The case for CCGs to commission renal dialysis individually requires much work. Dialysis education,
PD training, satellite dialysis units all serve populations larger than the average CCG footprint and
lend themselves to be planned and delivered on populations of 1-2m - so a set of co-commissioning
arrangements (including risk shares etc.) would need to be developed if they are not already in place
unless there is a risk of a deterioration in the service model in place.
• Specifically our members would like clarity in relation to the following for renal services:
o We know that of the 46,000 people who have received treatment for kidney failure only 50%
are on dialysis. The rest have had transplants. Is there evidence that patients often move
between these services – if so transplantation is still a specialised service? Why are renal
services non-specialist?
o A service that is expensive when commissioned nationally does not suddenly become cheap
when devolved to CCGs. It is not apparent that the whole life costs for the dialysis patient
were considered when the data was presented to PSSAG.
o Given relatively low patient numbers, any additional activity above that which is planned will
create significant financial fluctuations which are difficult to manage even if CCGs grouped
together locally.
o The fact that CCGs commission patient transport services is a red herring. If there are issues
for renal patients accessing transport services then this needs to be alerted to the
commissioner of the service with the evidence and impact. It should not be used as part of
the rationale as to why commissioning of renal services should be devolved.
We would like to see how the clinical and non-clinical case for the transfer of the two services was
made (i.e. the detail). We understand it was recommended by NHS England and then PSSAG. The makeup
of any national advisory bodies such as PSSAG requires a balance between those who have expertise in
the clinical services discussed and those that can provide non expert challenge. In any such group it is
important that a process of due diligence exists, in terms of how those involved in such groups seek advice 5
from and feedback to their peers. This is an important element in order to ensure that all views are
represented when these types of decision are made.

Some of our members have said their regional clinical networks were not in agreement to the transfer of
renal services due to concerns around CCG readiness, the time needed to set up pan CCG commissioning
structures and the infrastructure that would be needed to work with the complex nature of current service
delivery/monitoring data. Some have gone as far to say they cannot agree to the transfer of the service on
that basis alone.
(3) Our proposed way forward
We believe the proposed transfer of both renal dialysis and morbid obesity surgery services should be
moved to April 2016. To ensure the transfer occurs safely and at the right pace, we have identified a number
of gaps in the rationale which need to be clarified with CCGs before the formal transfer takes place.
While we have highlighted some of the capacity and financial consequences of the proposed transfer for
CCGs, our main concern is that a rushed transfer will impact negatively on patient outcomes. We want the
discussion on this transfer to focus on the best ways to support commissioning strategies and pathway redesign
– we cannot do this in a rushed timetable which lacks critical evidence on the rationale for the
transfer.
Furthermore we are not clear if all the options have been explored. There may be other ways to improve
renal and obesity services for patients in 2015/16 and pathways could be more integrated without a change
in commissioning responsibilities. We would be keen to work with NHS England to identify other options.
Once a new timetable for the transfer is set, much better engagement on the transfer can occur with CCGs.
This engagement should ensure NHS England and CCGs work through detailed plans, evidence, the data
and the full financial implications for the transfer. We suggest this engagement occurs within the wider
architecture set up to support and review the transfer of wider specialised commissioning responsibilities to
CCGs, these are:
• The Commissioning Assembly Working Group for specialised commissioning
• The NHSCC reference group for specialised commissioning that works alongside the working group
to provide independent challenge and is chaired by Dr Steve Kell, NHSCC’s Co-Chair.
In terms of the support CCGs require to take on commissioning responsibilities: firstly, our members would
like to have various types of information available to them at a CCG level in order to inform their
decisions and planning, these include:
• Data on patient flows for the two services – i.e. referral numbers and routes, information on activity,
demand and levels of growth
• The proposed footprint for commissioning the two services – i.e. will it be moving from a provider
footprint to a commissioner footprint – how will that look? Will this be modelled by capitation or
utilisation?
• The resource (people/funds) available to CCGs for taking these new responsibilities on. Our
members are particularly keen to understand the impact on allocations and running costs. 6
• While the services are on the national tariff – CCGs would like to take in any information that
suggests the services were being commissioned using off tariff prices locally.
At a national level our members would like access to best practice when commissioning the pathways for
these two services, and space to develop collaborative arrangements with other CCGs.
The consultation also mentions an enhanced role for Clinical Reference Groups (CRGs). We are not sure if
that will add value to CCGs or indeed is a sensible way of ensuring effective engagement and involvement
and we would like to discuss the ongoing role of CRGs as part of the development of collaborative and
ultimately place based commissioning for the bulk of specialised services, through the established working
groups upon which NHSCC and CCGs are represented.
If you would like any further detail on our response please do not hesitate to contact our Head of Policy and
Delivery, Julie Das-Thompson at j.das-thompson@nhscc.org
Yours Sincerely,
NHS Clinical Commissioners