Commissioning: further issues - Health Committee Contents


Written evidence from the Urology Trade Association (CFI 19)

EXECUTIVE SUMMARY

—  Given the invasive nature of urology products and the range of conditions that require ongoing continence management, it is vital that patients can access the most appropriate choice of clinically effective and cost effective urology products that suit their individual clinical and social needs.

—  National policy arrangements such as Part IX of the Drug Tariff should be maintained once the new commissioning arrangements are in place, as they provide essential protection on patient choice, safety and quality for patients and ensures that the NHS is guaranteed a fair price.

—  Where such national supply arrangements apply, steps should also be taken to ensure that all those who are to be involved in commissioning decisions, are aware of these principles. The UTA believes there is a role for the Commissioning Board in ensuring that these principles are upheld by GP commissioning consortia.

—  GP consortia need to ensure that there is sufficient specialist clinical knowledge within their ranks for all the various services and products that will be commissioned. The knowledge of the independent sector, which in urology also provides services to patients through the opportunity to have annual Appliance Use Reviews, should not be disregarded and could be called on to provide training and advice to commissioning consortia on specific products.

INTRODUCTION

1. The Urology Trade Association (UTA) is a membership organisation representing 95% of manufacturers and suppliers of urology appliances and service providers who supply the urology appliance market. An estimated 6 million people in the UK are affected by continence problems and many rely on urology appliances on a daily basis. High quality urology appliances allow users to manage their conditions, maintaining their quality of life and independence and avoiding repeated medical consultations.

2. The UTA welcomes the opportunity to submit evidence to the Committee's follow-up inquiry into the Government's plans to reconfigure commissioning of health services in England.

3. The UTA has become increasingly concerned about arrangements made by PCTs which restrict patient and prescriber choice in the selection of stoma and urology appliances. The Government's proposals to reform commissioning could potentially address some of these issues. However, there is still a large amount of uncertainty as to how a revised system will work, and it is possible that the existing problems could be exacerbated under the new arrangements.

4. This submission aims to highlight some of the key questions still to be answered and to make recommendations as to how the new system can ensure adequate commissioning for urology services.

BACKGROUND - PART IX OF THE DRUG TARIFF

5. In 2009, the Department of Health (DH) published The new arrangements under Part IX of the Drug Tariff for the provision of stoma and urology appliances - and related services - in primary care. The Department of Health consulted widely on this review process and developed guidance which keeps the best interests of patients at heart, ensuring they have the ability to choose the product or service that is right for them.

6. One important benefit of these arrangements is that they prohibit a postcode lottery for stoma and urology appliances. No matter where a person is in the country, they and their GP or Nurse Prescriber should be free to choose any of the appropriate products on the Drug Tariff. This provides important protection for patients who use urology devices, many of whom rely on specific products for their clinical health, comfort and wellbeing. While to non-clinical commissioners, two urology appliances may seem very similar, for the people who use them slight variations can cause serious discomfort, jeopardise clinical outcomes and impede their ability to live relatively independent lives.

7. The Drug Tariff also helps commissioners by providing a comprehensive list of products which have already been assessed and approved as clinically effective and cost effective at a national level, meaning that GP commissioners can have confidence in the products they are purchasing and recommending to patients. The Drug Tariff also sets a pre-defined price for each of these products to ensure that commissioners know that these care items are procured at a balanced and fair price to both the NHS and industry. More importantly, it also guards against the possibility of industry exploiting different commissioning procedures across the country to drive up prices.

8. It has been brought to our attention that an increasing number of PCTs are seeking to supply urology devices through alternative local arrangements that bypass the provisions set out in The new arrangements under Part IX of the Drug Tariff for the provision of stoma and urology appliances. These local arrangements often only prescribe and supply a restricted list of urology care items. This is reinforced by the introduction of local formularies which provide prescribers with a restricted list of products that can be recommended to patients. In many cases, formularies do not make it clear that all products on the Drug Tariff should be available to patients, and the bureaucracy involved for clinicians to prescribe off-formulary products is prohibitive.

9. In practical terms, such alternative supply routes can limit the choice that patients and prescribers have when determining how best to manage continence conditions. These developments run fundamentally contrary to national policy as laid out in the Part IX arrangements, which stipulate that all products listed on the Drug Tariff should routinely be made available to patients on prescription.

CONSULTATION ISSUES

—  We intend to examine further the assurance regime which it is proposed to establish around commissioning consortia in order to satisfy itself that the NHS Commissioning Board has sufficient authority to deliver its objectives defined in its Commissioning Outcomes Framework.

10. With the reforms outlined in the NHS White Paper, and as PCTs are replaced with GP commissioning consortia and a National Commissioning Board, there will be even greater scope for local variation in provision. The aim of this is to enable GP commissioning consortia to respond more effectively to the needs of local populations but it risks development of significant postcode lotteries. The UTA believes that, properly enforced, the national Drug Tariff ensures patients have access to the full range of approved products, while ensuring consistency, quality and value for money for the NHS, and prevents a postcode lottery in the availability of products and services. By giving GPs freedom to prescribe within nationally set parameters, the Government can ensure that GP consortia and prescribers uphold the ideals of patient choice and equality. The Drug Tariff ensures that patients have a full choice of approved products; assures prescribers that they are prescribing the most clinically effective products for their patients; and assures commissioners that they are getting a fair price for the products that they purchase.

11. However, it will be important to ensure that commissioning consortia abide by relevant national policies. As already noted, an increasing number of PCTs are seeking to bypass national policy through local arrangements which restrict choice. It is possible that GP Commissioning Consortia will do likewise. Robust monitoring arrangements will need to be put in place by DH, the NHS Commissioning Board and/or HealthWatch to ensure that national policies operate and that patients who experience difficulties accessing the right products and services can notify the national authorities of a failure to abide by national policy.

—  The Committee believes it is essential for clinical engagement in commissioning to draw from as wide a pool of practitioners as is possible in order to ensure that it delivers maximum benefits to patients. GPs have an essential role to play as the catalyst of this process, and under the terms of the Government's changes they, through the commissioning consortia, will have the statutory responsibility for commissioning. They should, however, be seen as generalists who draw on specialist knowledge when required, not as the ultimate arbiters of all commissioning decisions. The Committee therefore intends to review the arrangements proposed for integrating the full range of clinical expertise into the commissioning process.

12. In September 2010, the Royal College of Physicians published a National Audit of Continence Care, which examined the quality of continence services in England, Wales and Northern Ireland. It identified a number of significant weaknesses in the care and choices offered to patients with continence needs. Among the criticisms highlighted in the report was that there was often no designated lead for continence services in each PCT and an unacceptable variation in the choice of type, quality and quantity of continence supplies made available to patients As GPs do not have specialist urology training, there is a need to ensure that patients can access specialist urology services and that the right care pathways are put in place to ensure early referral.

13. It will be essential for GP commissioners to ensure that relevantly skilled staff are available to meet the needs of their population and involved in the commissioning process for their specialist clinical area. Where this is not possible, the GP consortium should be encouraged to bring in specialist advice or consultation. This specialist advice could come from other GP consortia, from clinical specialists, from user groups and representatives or from the independent sector. The knowledge of the independent sector, which in urology also provides services to patients through the opportunity to have Appliance Use Reviews, should not be disregarded and could be called on to provide training and advice on specific products where appropriate.

14. The UTA believes that there is also a role for the NHS Commissioning Board to ensure that GP consortia receive training on commissioning specialist products and services and that prescribing clinicians also receive suitable training and support. This could help to tackle the current problem that often prescribers do not know enough about the products that are available to make informed choices for their patients. There is a wealth of experience in the private and third sectors which could help inform this training for GPs.

—  The Committee intends to review the arrangements proposed in the Bill for enabling consortia to reconcile this potential conflict [between patient choice and commissioning] by enhancing patient choice at the same time as delivering the consortium's clinical and financial priorities.

15. The UTA believes that, properly enforced, the national Drug Tariff ensures patients have access to the full range of approved products, while ensuring consistency, quality and value for money for the NHS, and prevents a postcode lottery in the availability of products and services.

16. It is essential, however, that clinicians are fully aware of the principles of public policy about choice and access to products. Users of continence products have also frequently found difficulty in accessing the number of products which they need. Patients should be given choice on type and amount of urology products and commissioners should not endorse the rationing of care items.

17. Arrangements also need to ensure that incentives are aligned with a focus on prevention to ensure that patients can choose products and services that reduce the incidence of flare ups, re-admissions and increased dependency. Due to the invasive nature of many continence products, any difficulties experienced can result in a need for emergency hospital treatment or even the need for surgery to tackle avoidable infections or replace unsuitable products. Incorrect prescriptions can cause significant clinical repercussions as well as cost implications. The average cost for the admission of emergency urethral catheterisation resulting from infection, is estimated in the region of £1,500 per patient, per visit. Rather than encourage participation in social or working life, the wrong urology product will hinder social or public activity. Products that do not fit the needs of the individual user cause over reliance on carers, thereby restricting opportunities for users to meet the demands of standard working practice or to pursue independent lifestyles. If commissioners are only concerned with their own direct costs, there is a danger that prescription of inappropriate products will not only result in medical problems, discomfort and distress for patients, but also in additional costs for other parts of the health service dealing with the consequences of inappropriate prescription.

CONCLUSION

18. We recognise that the Government's NHS reform agenda offers an excellent opportunity to address some long standing issues within the NHS and we hope that these can be addressed. We are, however, concerned that the reforms should not operate so as to deprive users of urology products and access to the full range of products.

19. The UTA therefore recommends that:

—  The national Drug Tariff should be maintained, as these national arrangements provide essential protection on patient choice, safety and quality for patients as well as price protection for the NHS.

—  The Department of Health should guide GP consortia to follow the principles of national policy as set out in The new arrangements under Part IX of the Drug Tariff for the provision of stoma and urology appliances - and related services - in primary care.

—  GP consortia should ensure that there is sufficient specialist clinical knowledge within their ranks for all the various services and products that will be commissioned.

February 2011


 
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Prepared 5 April 2011