Commissioning: further issues - Health Committee Contents

Written evidence from the Chartered Society of Physiotherapy (CFI 27)

The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the UK's 50,000 chartered physiotherapists, physiotherapy students and support workers.

Physiotherapy enables people to move and function as well as they can, maximising quality of life, physical and mental health and well-being.

Physiotherapists use manual therapy, therapeutic exercise and rehabilitative approaches to restore, maintain and improve movement and activity. Physiotherapists work with a wide range of population groups (including children, those of working age and older people); across sectors; and in hospital, community and workplace settings, facilitating early intervention, supporting self management, promoting independence and helping prevent episodes of ill health and disability developing into chronic conditions. Physiotherapy supports people in a wide range of areas including musculoskeletal disorders (MSDs); many long term conditions, such as stroke, MS and parkinson's; cardiac and respiratory rehabilitation; children's disabilities; cancer; women's health; continence; mental health; and falls prevention.

Further to the written evidence submitted on 6 October 2010 to the Committee's earlier inquiry, the Chartered Society of Physiotherapy is pleased to offer the following evidence to the Committee as part of its follow-up inquiry into commissioning. We have restricted our comments to the questions where we feel we can most effectively contribute to the debate.

1.    The Committee intends 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.

1.1  It is currently unclear as to whether the NHS Commissioning Board will have a regional structure. The CSP believes that regional level organisation, on a par with the current provision of Strategic Health Authorities, will be important to ensure the GP Consortia have appropriate support to carry out their commissioning functions, particularly in those areas where services are best commissioned at a regional level. In addition, it would provide a strategic overview across the number of different sized GP consortia covering each region.

1.2  The CSP believes that the NHS Commissioning Board should be required to have a permanent Allied Health Professions (AHP) director. This post is vital to ensure that the important role of Allied Health Professionals, in delivering effective and cost efficient healthcare across all sectors, is not overlooked.

1.3  GP Consortia will be required to commission services which meet the quality standards set by NICE. The CSP broadly agrees with this approach, however, is concerned that the initial set of 150 quality standards will not be completed until 2015, by which time the structural changes and new commissioning arrangements will have been in place for at least two years.

2.    The Committee intends to review the arrangements proposed in the Bill for defining the lines of accountability between the NHS Commissioning Board, the Department of Health and the Secretary of State to prevent potential future conflicts arising.

2.1  The CSP has nothing further to add on this point.

3.    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.

3.1  The CSP welcomes the Committee's assessment of the need for a wide range of clinical input into the commissioning process.

3.2  We believe it will be important for commissioning decisions to be based on knowledge about which services are proven to provide best outcomes for patients - for example the provision of community based stroke rehabilitation, provided by physiotherapists, to support the recovery of stroke survivors.

3.3  The CSP is concerned that the knowledge and skills of GPs will vary and this could lead to a postcode lottery for patients. We would, therefore, argue for a statutory duty for other healthcare professionals to be involved in GP consortia commissioning decisions.

3.4  Furthermore, we would argue that to effectively deliver real long term improvements in the health of local communities, and to tackle health inequalities, it will be crucial to ensure the expert contribution of Allied Health Professionals, such as physiotherapists, is included on all Health and Wellbeing Boards, which will take a strategic overview of the commissioning and delivery of local services.

4.    Although the Committee understands the value of the separation of the commissioner and provider functions it believes it is important that this function separation is not allowed to obstruct the development of high quality and cost effective service solutions. The Committee therefore intends to review the arrangements proposed in the Bill for reconciling these conflicts.

4.1  The CSP believes that while the split between the commissioning and provision of health services can bring benefits, the evidence to demonstrate that it delivers higher quality services is mixed and in some cases value for money is not served because of the higher transaction costs associated with it.

4.2  The CSP is very concerned that the separation of the commissioner and provider functions in a context of enforced competition will make it harder for NHS staff to work collaboratively in multi-disciplinary teams, across organisational boundaries, to create the integrated care pathways that patients want and need, and that make services more efficient.

4.3  We believe that the sound principles of sharing best practice to drive up standards of care will be hard to maintain when different commercial entities are competing to provide services and will view innovations as competitive advantage. This was the experience of the NHS in the early 1990's when nursing and physiotherapy managers were instructed not to share best practice innovations with any other NHS organisations that might be rivals in competitive tenders for NHS contracts.

4.4  We are also concerned that the provisions in the Health and Social Care Bill which require Monitor to have regard for improvements in the quality of services are not strong enough. Clause 54 in the Bill places a duty on Monitor to have regard for the 'desirability' of securing continuous improvement in the quality of healthcare services. The CSP would argue that this should be a necessity, not merely desirable, particularly when, in Clause 52, one of Monitor's core functions is defined as promoting competition.

5.    The Committee agrees that local engagement with the commissioning of primary care services is important and therefore welcomes this development. The potential conflict of interest between consortia and local primary care providers does however remain. The Committee therefore intends to review the arrangements proposed in the bill for the commissioning of primary care services.

5.1  A fundamental choice which the CSP believes should be available to patients is self-referral into physiotherapy. Self-referral is a system for patients to make an appointment direct with their local NHS physiotherapy department, without seeing their GP first, which has been proven to reduce costs and time for GPs. Self-referral is readily available throughout the independent sector and private practices and recent research shows it is available in just under 50% of NHS physiotherapy departments.1 Physiotherapy self-referral started in Scotland and has spread very successfully internationally to Holland, Australia, Canada, the USA and many other countries. It has been proven to be cost effective and particularly beneficial, as highlighted above, for patients with both short and long term conditions, who understand their healthcare needs and are able to identify when they need access to further physiotherapy treatment. This includes both short term musculoskeletal disorders, women's health, and longer term neurological conditions, such as stroke, MS or parkinson's. NHS Evidence has recently included self-referral to physiotherapy for musculoskeletal conditions in QIPP,2 based on evidence of its ability to improve quality and productivity. Furthermore, self-referral to physiotherapy for NHS staff, to reduce sickness absence, is a major part of the Boorman Review3 proposals which have been accepted by the current Government.

5.2  The CSP is concerned that the need to expand and develop effective NHS self-referral schemes could be halted by the adoption of contracting out via the "any willing provider" approach for services that need to be part of integrated physiotherapy pathways. Furthermore, we would be concerned as to how the funding arrangements would work for self-referral to physiotherapy. The CSP believes that patient self-referral should be comprehensively available across England and would argue that it is a service that should be commissioned by the National Commissioning Board, under its responsibilities to commission primary care services.

5.3  We would urge a greater adoption and roll out of the patient self-referral to physiotherapy schemes across all of England, as this has proved successful in increasing timely access to physiotherapy services, improving outcomes for patients through early intervention and ultimately preventing costly onward referral to specialists in secondary care.4

6.    The commissioning of services that either work across [health and social care] boundaries, or are intimately linked is therefore an issue to which the Committee attaches great importance, and we intend to review the effectiveness of the structures proposed in the Bill which are designed to safeguard co-operative arrangements which already exist and promote the development of new ones.

6.1  The CSP would argue, that if the move is made to GP-led consortia commissioning, the consortia groups should be geographically coterminous with local authorities, to best support partnership working on Health and Well Being Boards. We would also argue that the consortia should have minimum and/or maximum population sizes, on which budgets can be based to ensure the financial risks are minimised.

7.    The Committee intends to review the arrangements proposed in the Bill to enable commissioning consortia to address these issues [cross-area collaboration by consortia in reconfiguring services] effectively; this will include a review of the ability of the new system to encourage commissioning consortia to cooperate in achieving the benefits to patients which may be available from major service reconfiguration.

7.1  The CSP has nothing further to add on this point.

8.    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.

8.1  The CSP is concerned that the 'any willing provider' model potentially restricts and/or impedes patient choice. With an increase in the potential number of providers, patients may have little information on each of them, or lack the ability to evaluate one against another. This may result in the most vulnerable patients being unable to exercise the choice envisaged by this reform and, in effect, still reliant on the recommendation of their GP, who may no longer be a truly 'independent or neutral' advisor in the new system.

8.2  We are also concerned that patient choice may be limited by the current economic climate. The impact of the £20 bILLIOn of savings the NHS is being asked to find may be reductions in the capacity of some services, and the closure of others.

8.3  The CSP believes that any increase in patient choice needs to be supported by robust and accessible mechanisms for patients, the public and staff to effectively challenge commissioning decisions to ensure they are based on evidence that they will result in an improvement in the quality of services, and health outcomes, for the local population.

9.    The Committee does not find the current stance on patient and public engagement in commissioning persuasive. The National Health Service uses taxpayers' resources to deliver a service in which a high proportion of citizens take a close interest both as taxpayers and actual or potential patients. While the Department may be right to point out that there is no special virtue in uniformity of structure, the Committee regards the principle that there should be greater accountability by commissioners for their commissioning decisions as important. The Committee therefore intends to review the arrangements for local accountability proposed in the Bill.

9.1  As indicated in point 3.4 above, the CSP is concerned that the Health and Social Care Bill does not make any provision for the inclusion of Allied Health Professionals (AHPs), such as physiotherapists, on Health or Wellbeing Boards, instead leaving the decision of who should be appointed to the board to the discretion of local authorities. We are concerned that this could lead to the voice of AHPs not being heard in many localities which will impact commissioning decisions and the development of Joint Strategic Needs Assessments.

9.2  We remain concerned about the mechanisms proposed to involve patients and the public more closely in local commissioning decisions. We are particularly concerned that the formal arrangements proposed will favour the well-educated over those who lack skills to interrogate local health decisions.

9.3  The Health and Social Care Bill is unclear as to whether Health and Wellbeing Boards will have the necessary powers to intervene in decisions about service reorganisations. We would like to see these powers clarified and where possible bolstered.

10.  The Government must support consortia and existing commissioning organisations to form clear and credible plans for debt eradication and for tackling structural deficits within their local health economy. The Committee intends to further review this issue in its further work.

10.1  We support the aims to secure financial stability in the local health economy. However, we are concerned that the additional costs associated with the reorganisation of the NHS, estimated at up to £1.45 billion by the Department of Health, will create additional burdens on the NHS at a time when it has to make unprecedented efficiency savings. We are concerned that these funds are being diverted away from delivering frontline services, which may impact negatively on patient care.

February 2011


1  Jones, R, Jenkings, F (2011) "A survey of NHS Physiotherapy Waiting times and musculoskeletal workload in England 2009-2010 report", CSP: London.

2  NHS Evidence (2011) Musculoskeletal physiotherapy: patient self-referral

3  Boorman, S. NHS Health and Well-being, Final Report, November 2009, DH; London.

4  Department of Health (2008) Self-referral pilots to musculoskeletal physiotherapy and the implications for improving access to other AHP services. DH; London.

5 Department of Health (2011) Health and Social Care Bill 2011: combined impact assessments. DH; London.

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Prepared 5 April 2011