Liberating the NHS: commissioning for patients
11 October 2010
RNIB Group response to the Department of Health consultation on GP commissioning
About us
RNIB Group is an association of RNIB and Action for Blind People. We are pleased to have the opportunity to respond to this consultation.
RNIB is a membership organisation with over 10,000 members who are blind, partially sighted or the friends and family of people with sight loss. 80 per cent of our Trustees and Assembly Members are blind or partially sighted. We encourage members to be involved in our work and regularly consult with them on Government policy and their ideas for change.
As a campaigning organisation of blind and partially sighted people, we fight for the rights of people with sight loss in each of the UK’s countries.
During the next four years we want to tackle the isolation of sight loss by focusing on three clear priorities:
1. Stopping people losing their sight unnecessarily.
2. Supporting blind and partially sighted people to live independent lives; and
3. Creating a society that is inclusive of blind and partially sighted people.
Action for Blind People is one of the largest charities in the UK providing confidential support for blind and partially sighted people in all aspects of their lives. Action ensures that visually impaired people receive help with anything from finding a job. Applying for benefits, housing issues, aids and adaptations, holiday breaks or information on local services.
General comments
1. As organisations that are involved in the prevention of blindness and represent the interests of blind and partially sighted people RNIB and Action for Blind People are keenly interested in the way health services for people with eye disease and those with sight loss will be delivered in the future. Eye health promotion, the provision of treatment for sight-threatening eye diseases and the support of people who have lost their sight currently have low priority in the NHS and social services despite the growing number of people facing both due to the ageing of the population.[1] Within the existing performance frameworks there have been very few direct performance indicators linked to this area of health and social care (waiting time targets for cataracts, targets in relation to diabetic retinopathy screening being offered to patients with diabetes), NICE guidance on a limited number of treatments and only one NICE treatment guideline (for glaucoma).
2. The new proposals for GP Commissioning and the arrangements that link this to public health and social care together with the proposed new outcomes framework have the potential to ensure that the population’s eye health needs and the support needs of blind and partially sighted people are recognised and acted upon.
3. However, for this to happen, the Commissioning consortia will need to be set up to ensure representation of all relevant professionals, not only GPs either on a permanent or on an ad hoc basis, financial incentives need to be provided to drive joined up commissioning, ideally with a much stronger push for pooled budgets, and Quality Standards in relation to eye health need to be developed as quickly as possible to facilitate best practice commissioning in eye health.
4. Research conducted by Doctors Net UK on behalf of RNIB suggests that there are concerns about GPs’ understanding of eye conditions and referral pathways. This lack of understanding could translate into increased health inequalities, for instance where people in rural areas find it difficult to access eye health services or where work to address health inequalities in minority ethnic and low income groups focuses on other disease areas (heart and lung disease, stroke) and does not take account of their increased risk of eye disease (due for instance to the higher risk of glaucoma and diabetic retinopathy in minority ethnic groups and the higher risk of age-related macular degeneration in people who smoke).
5. It will be essential to ensure that GP Commissioning consortia buy in commissioning advice from competent sources who base their advice on comprehensive joint needs assessments and are aware of the increasing number of people with sight problems (predicted to increase from the current 1.8 million to almost 4 million by 2050 due to the ageing of the population unless detection and access to treatment are significantly improved)[2]. The Consortia will need to ensure that the sources of advice that they rely on agree to specific rules of engagement, e.g. that they are driven by patient and public involvement and local democracy. To ensure this happens transparency of agreements between the Consortia and providers of commissioning expertise and accountability at local and national level are of paramount importance. This should involve clear tendering procedures for contracts.
6. As an organisation representing patients with eye disease another area of concern is the ability of GP Consortia to generate and use input from patients and their representative organisations. Meaningful patient involvement that avoids tokenism is, and will continue to be, a major challenge.
7. In summary, we believe that the proposed reform could present an opportunity to improve the population’s eye health and the support provided for people with sight loss as long as the system is allowed to evolve at a reasonable pace with input from all stakeholders and a focus on meaningful patient engagement.
8. Without such engagement of the people most affected by the suggested change it is difficult to see how the sceptical views of blind and partially sighted people canvassed by us for this consultation will change.
9. Out of 150 people 57 per cent disagreed with the statement that the proposed changes will lead to a better NHS, 24 per cent were unsure and only 19 per cent agreed. Comments received include:
“Yes overall [the changes will lead to a better NHS], however there does need to be a system of checks and balances to ensure that the hospitals which do not perform so well are supported to help improve their performance - rather than rewarding the hospitals which are already good.”
“No. Change for the sake of politics, is never a good idea.”
“This will lead to fragmented services”
“Anything has got to be better than the way it is right now!”
“No! I believe if you have a complicated illness you will be denied access to Specialist Treatment, which in the long term will cause loss of life.”
“As with equipment services for people with physical impairments, this may lead to providers tendering for contracts, and may lead to gaps in provision potentially.”
“There must be less money expended on unnecessary tiers of management and due weight given to the views of expert.”
“The only big potential problem I foresee is a continuation of the postcode lottery of services to people with sight loss. We need to apply national standards and benchmarking across the country.”
“Millions will be wasted on bringing in financial managers instead of asking the workers who are really the experts.”
“It is not obvious that all of the changes will contribute to producing a cheaper service model for the NHS. They have the potential to offer better patient involvement and some efficiency savings, but some of the changes seem likely to cost more to produce better results. If as a population we want better healthcare then of course we want our money to be used effectively and efficiently, but where all possible savings have been made, adding bells and whistles may still end up costing us more.... If you enjoy the system or like the potential benefit of having it there as a safety net, then put your hand in your pocket for it!”
Please find below our responses to those questions in the consultation document where we feel we have specific expertise.
Section 3: Responsibilities
In what practical ways can the NHS Commissioning Board most effectively engage GP consortia in influencing the commissioning of national and regional specialised services and commissioning of maternity services?
How can the NHS Commissioning Board and GP consortia best work together to ensure effective commissioning of low volume services?
Are there any services currently commissioned as regional specialised services that could potentially be commissioned in the future by GP consortia?
How can other primary care contractors most effectively be involved in commissioning services to which they refer patients, e.g. the role of primary care dentists in commissioning hospital and specialist dental services and the role of primary ophthalmic providers in commissioning hospital eye care?
10. Optometrists play a key role in identifying people in need of secondary eye health care. However, not all optometrists will have a good understanding of secondary care and the way services are delivered at that level. Not all optometrists are therefore in a position to influence the commissioning of eye health services and it will therefore be important to devise a mechanism to identify those that have most to offer in relation to commissioning.
11. Where community optometrists play a crucial role is in the provision of shared care schemes in glaucoma and in future it is likely that similar schemes will need to be developed for age-related macular degeneration and other retinal diseases that are causing considerable capacity problems in hospital eye clinics. When these shared care schemes are commissioned it is vital for optometrists to be involved and they should therefore be members of the Commissioning consortia or join them on an ad hoc basis as appropriate. The membership of the consortia needs to allow for relevant expertise to be represented or co-opted and that should include eye health expertise.
How can GP consortia most effectively take responsibility for improving the quality of the primary care provided by their constituent practices?
What arrangements will support the most effective relationship between the NHS commissioning Board and GP consortia in relation to monitoring and managing primary care performance?
What safeguards are likely to be most effective in ensuring transparency and fairness in commissioning services from primary care and in promoting patient choice?
12. We do not have any suggestions for this section and it might have been beneficial to run a number of pilots to answer the questions posed. Also, it is important to recognise that not all patients want choice and many are concerned about their ability to accept any choice they are being offered. This certainly applies to many of the blind and partially sighted people whom we surveyed for this consultation.
13. In total 150 blind and partially sighted people responded to a number of questions in relation to the NHS White Paper.
14. Please find below the answers to a couple of questions that related to patient choice.
1. Patients will be more involved in the decision making process?
Agreed 55 per cent
Disagreed 45 per cent
1a. Are there any benefits for blind and partially sighted people?
“Unsure, but as with all things that go through changes the successes or failures remain to be seen until it is up and running properly for a period of time and the results and feedback start coming in. I just hope that it is a move forward rather than backwards and that people’s lives aren't put at risk.”
“None I believe they will stop patients travelling distances to have specialised treatment and pick a cheaper option”
“It will make it more complicated to receive services”
“Not necessarily: At present, information in regards of appointments and hospital procedures are not routinely available in accessible formats and this is unlikely to change.”
“How can blind people in particular make informed decisions on available treatments if they cannot access information and are mainly reliant on what GP’s choosing to offer?”
“People need to receive accessible information in the same time scale as sighted people and not have to wait several days or weeks for this to happen”
“NHS managers are not trained in sensory awareness.”
2. Patients will be able to choose where they are treated and by whom (except A&E)
Agree 44 per cent
Disagree 56 per cent
2a. Are there any benefits for blind and partially sighted people?
“Again another lie where and who treats you is dictated by where you live especially if you are blind or partially sighted”.
“It depends upon the knowledge that the visually impaired person has about service provision in their area”
“So long as the advantages and disadvantages are made clear to them”
“They want to reduce the NHS services”.
“This is just a cost saving exercise”
“Services should be equal service throughout the country regardless of where you live”
“Severely sight impaired people will find it difficult to travel distances to access care so should have access to equal care near them. There should be high quality services no, matter where you live”.
“Blind & partially sighted people can elect to go for eye treatment to a centre of excellence for their particular eye condition”.
How can the NHS Commissioning Board develop effective relationships with GP consortia, so that the national framework of quality standards, model contracts, tariffs, and commissioning networks best supports local commissioning?
Are there other activities that could be undertaken by the NHS Commissioning Board to support efficient and effective local commissioning?