NHS Buckinghamshire and NHS Oxfordshire CCGs
Louise is the chief executive of NHS Buckinghamshire and NHS Oxfordshire CCGs and led on the successful bid for Buckinghamshire to become one of the first eight ICSs. Previously, she has board level experience within NHS provider and commissioner organisations and worked for a commercial healthcare company. Louise maintains her nursing registration and has a strong patient-focused approach to commissioning services, recognising the importance of sustainable primary & community health and care to support out of hospital transformation.
We work closely with Oxford University Hospital as a tertiary provider and with Buckinghamshire Healthcare Trust, which provides specialist spinal services. The movement to try and get local CCGs involved in specialised commissioning is relatively immature but we have clear plans to set up our ICS specialised commissioning planning board.
This isn't just about doing our bit of specialised commissioning for our population – specialised services have to be commissioned at scale. We don't want to lose the subject matter experts we currently have, but there is a need to develop the network of specialised commissioning. We should be further developing specialised commissioners to work alongside and in partnership with tertiary, secondary and primary care providers to really understand, technically and managerially, how best to commission that end-to-end service for populations.
Ensuring specialised commissioning addresses clinical concerns
The biggest frustration I experience are the letters of complaint, often from the patients themselves, who are trying to get hold of their next prescription or their next episode of local care. We don’t link up pathways very well for the person, either with their local district hospital or into primary care.
For example, prescribing for gender dysphoria starts with a tertiary referral. The consultant sees the patient and recognises they are suitable to start medication. There's often no need for that tertiary centre to see the patient for some time afterwards, so the referral for prescribing passes to a GP. The incidence of gender dysphoria in general practice is low so the GP may only see one or two patients during their career. They can be rather alarmed at having to support this patient psychologically as well as prescribing medication. There needs to be improved clinician to clinician links, so that clinicians in every care setting feel confident in what the plan of treatment is and are therefore happy to support the patient.
This is not a criticism of specialised providers – commissioners have got to look at the whole pathway. We need to describe what that end-to-end pathway looks like from a best practice perspective, but we don't do that very well, because specialised commissioning is segregated from local CCGs. Linking clinicians in tertiary centres to local hospital clinicians and out to primary care is key. Our specialised commissioners don’t commission beyond the tertiary provider – that's why CCGs are keen to get involved.
Embedding commissioning expertise in the regions
In terms of end-to-end pathway commissioning, I could see an approach where regions specialise in the commissioning of specific specialised services. This would involve working in partnership with providers to describe best practice in terms of planning care at every stage of the patient journey, through their tertiary referral and back into primary care. If we can get this right, there would be a coordinated approach in each of the regions, sharing their commissioned pathways across this new network of specialised and generalist commissioners. Regional commissioning would be a pretty good start, but let's not have all regions doing everything.
With the digital capability we have now, and with the information flows that allows us to develop further, we should be able to improve our patient engagement – many specialist patient groups have virtual online communities we could tap into to learn about real life experience of services.
If properly coordinated, then for a time we will need some national oversight to make sure everyone does get up and running. There are some services that require national level commissioning. These could also be handled at regional level, with specialised and local commissioners in partnership, as this would facilitate whole pathway oversight.
In terms of end to end pathway commissioning, I could see an approach where regions specialise in the commissioning of specific specialised services.
Resolving tensions between investing in research and financial efficiency
Specialised services attract the benefits of research and development funding – clearly there is a benefit to local populations of having a nationally renowned tertiary centre in your local vicinity. Specialised commissioning spend tends to be higher for populations located closer to a tertiary centre.
Oxfordshire is overspent in terms of specialised commissioning activity, but when I speak to clinical colleagues, they say we will only enhance our progress in medicine, surgery, nursing and allied health professions by offering more of these opportunities and furthering our research. The question is who should pay for this activity? I think there's a question over whether, if we require research in this clinical area, research should be helping to support the funding of the patient activity. Simply reducing this activity (and cost) may inhibit our ability to develop healthcare research and innovation.
One of the challenges my local scrutiny committee has raised is about engaging the local public when commissioning specialised services. For example, a recent procurement of positron emission tomography demonstrated that while the contract decision affected relatively few people in Oxfordshire, any change in provider would have a much wider significance in terms of Oxford University Hospital's specialised services and research activity. The local scrutiny committee had not brought together other scrutiny committees to think about what the change meant. Working across regional areas might offer an opportunity for some lay representation or patient voice to be better heard.
We have got to address the issues around research and acknowledge the richness of what that brings us.
I feel really positive that the direction of travel under the long term plan is absolutely the right one. The ICS approach will support this, because it looks at systems and at the experience of patients going through different providers on their pathways within the system. I just hope we manage to improve our end to end links for specialised commissioning, from tertiary through district hospital and into primary care. It isn't as black and white as being more efficient and trying to save a bit of money – we have got to address the issues around research and acknowledge the richness of what that brings us. It is ultimately one of the reasons why the NHS has the best and most innovative service providers in the world, and we mustn't lose that.