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BMJ No 7119 Volume 315 Editorial Saturday 22 November 1997
Commissioning specialist services in the NHSA national clearing house could pave the wayA white paper is expected in the next few weeks which will set out the UK government's vision for the NHS - possibly the most important document for the service since Working for Patients in 1989.(1) The government faces the tricky task of coming up with a formula which recognises the potential benefits of a purchaser-provider split - greater accountability and responsiveness to local needs - without the competition, fragmentation, and transaction costs of an internal market. The role of district health authorities and their performance since 1991 will be central in their considerations. Much attention has recently been paid to health authorities' capacity to commission specialised services, such as those for haemophilia(2) and cochlear implants,(3) which account for about £1.4bn (6%) of NHS expenditure. Before 1991 these services were funded centrally and managed at a regional level. Since then responsibility has largely been devolved to districts. Yet despite some transitional arrangements to ensure continuity, specialist providers have felt increasingly vulnerable. Is such concern justified? An inquiry by the Audit Commission, published this week, finds few gains from this shift in responsibility.(4,5) This failure, it is suggested, results from the difficulties health authorities face in assessing the appropriateness of services which change rapidly; coping with the financial risk posed by low volume, high cost services (where one patient with haemophilia might exceptionally cost more than £500,000 to treat); specifying high cost services in separate contracts in the absence of adequate information; and making meaningful comparisons between hospitals. Given these challenges, the duplication of effort which occurs, with neighbouring authorities reviewing the effectiveness of the same new treatments, wastes precious skills and resources. In addition, authorities may arrive at different conclusions, resulting in inequities in access. Despite these problems, the Audit Commission concludes that health authorities remain the best placed organisations to commission specialised services because such services must be balanced against the need for other, less specialised services.(6) So if responsibility should remain with health authorities, how can the system be made to work better? The Audit Commission's proposal is for greater central support combined with more effective local partnerships. The central support could be achieved through a national clearing house, built on existing NHS research and development work, to consolidate research evidence about those treatments which satisfy basic cost effectiveness criteria. A more systematic approach to the introduction of new technologies is also suggested, with central financial support being provided for new treatments while services are still being developed. These recommendations are complemented by suggestions that health authorities should build partnerships locally with other districts and work with trusts both to share risk and to explicit criteria for prioritising patients and treatments. While many of the best practices identified by the Audit Commission came from large health authorities, it does not recommend structural changes but notes that many benefits can be realised by strengthening existing informal alliances between authorities. The report also identifies ways in which authorities can work more effectively with trusts, highlighting the role of public health as an important bridge to specialist clinicians and the value of sharing information with providers. The report provides a timely and constructive contribution to the current debate about changes in the management of the NHS. But would the proposals work? A national clearing house would certainly complement the health technology assessment programme, but it would need to adopt a broader perspective than just the cost-effectiveness of technologies,(7) which has tended to be the focus of research activity so far. Even then, there is no guarantee that a national centre will be able to generate unambiguous guidance for health authorities because scientific evidence about new technologies is rarely clearcut. Much of the existing variation in local commissioning decisions reflects variation in interpretation of the same research evidence. There must, therefore, be some doubt whether local specialised providers will accept national guidance, particularly if a competitive market is replaced by the notion of contestability, dependent on a greater degree of collaboration and trust between purchasers and providers.(8) The other principal suggestion, the encouragement of health authorities to become more active in commissioning through greater use of consortia and other methods of collaboration, is also welcome. In practice, the Audit Commission recognises this will require greater involvement by public health practitioners, and not just those with a medical background. This suggestion, however, coincides with calls for public health staff to shift their attention from personal health services to more traditional concerns such as housing and environmental hazards. In addition, more active commissioning will inevitably require more resources for health authorities at a time when the government is keen to reduce management costs. And improvements in the performance of health authorities are unlikely to be achieved until the current high turnover of staff can be halted. Commissioning specialised services is yet another example of the complex interplay of factors that have to be considered when pursuing organisational change. Nick Black Professor of health services research Health Services Research Unit,
References
1 Secretaries of State for Health, Wales, Northern Ireland
and Scotland. Working for patients. London: HMSO, 1989.
2 Lee C, Sabin C, Miners A. High cost, low volume care: the case
of haemophilia. BMJ 1997;315:962-3.
3 Challenges to health authorities. Health Serv J
1997;30 Oct:8.
4 Audit Commission. Higher purchase: commissioning
specialised services in the NHS. London: Audit Commission,
1997.
5 Wise J. Clearing house needed for specialist treatments.
BMJ 1997;315:1327.
6 Choudhry N, Slaughter P, Sykora K, Naylor C D. Distributional
dilemmas in health policy: large benefits for the few or smaller
benefits for many? J Health Serv Res Policy 1997;2:212-6.
7 Battista R N, Hodge M J. The development of health care
technology assessment: an international perspective. Int J Tech
Assess Health Care 1995;11:287-300.
8 Ham C. Replacing the NHS market. BMJ
1997;315:1175-6.
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