Commissioning SAS doctor Consultant England Wales

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Get involved in commissioning

We have put together this guidance for you to describe the benefits of collaborative working on commissioning and to give you advice on getting involved in commissioning as secondary and tertiary care clinician.

  • Why?

    The BMA firmly believes that successful commissioning requires close collaboration between GPs, secondary and tertiary care clinicians (senior hospital doctors, medical academic and public health medicine doctors).

    The legislation states there should be at least one secondary care doctor on the board of each clinical commissioning group (CCG).

    The most appropriate secondary care doctor may be an associate specialist or specialty doctor where their skills and experience are at an equivalent level of seniority.

    However, involving a wide range of clinicians and colleagues from secondary and tertiary care will require CCGs to also design local mechanisms that ensure consultants and other specialists are brought into the decision-making process.


    Your role

    As a consultant, or senior associate specialist or specialty doctor you are ideally placed to advise CCGs on secondary care pathways and planning strategy of secondary care.

    As a secondary care clinician you are likely to get involved in different ways at different stages of the commissioning process. The stage at which this is absolutely essential is in the designing and planning of patient pathways, because this is where your clinical knowledge comes into play.

    Both the BMA and the Medical Royal Colleges support secondary care involvement in commissioning and we have provided you with some examples to show some of the positive outcomes that can be achieved by such a collaborative approach.


  • How?

    If you are interested in engaging with commissioning you should discuss issues in the first instance via your medical staff committee, directorate meetings, divisional meetings and local negotiating committees before considering making direct contact with the Clinical Commissioning Group (CCG).

    There are some areas which have been identified as clear points of engagement for consultants and senior SAS doctors who wish to influence the delivery of care in their specialist areas, or in the course of their work on behalf of by their Trust. 

    These are:

    1. Positions on the CCG’s decision-making bodies

    You should contact your CCG to find out about opportunities to get involved in the CCGs decision-making bodies. Co-opting secondary care clinicians onto specific subgroups of the CCGs should be encouraged, particularly when exploring service redesign.

    Positions for secondary care clinicians on CCGs are regularly advertised on the NHS Jobs website.

    The Government has decided that the statutory position for a secondary care doctor on the CCG board must be given to a secondary care clinician from outside the CCG’s area - this, says the Government, will avoid conflict of interest.

    However, the BMA is concerned that this means that CCGs will not be able to take advantage of crucial local knowledge and expertise and has urged the Government to rethink.


    2. Clinical senates and clinical networks

    CCGs will also seek input from new Clinical Senates and Clinical Networks

    Clinical networks will be condition or service area specific and clinical senates will bring together a range of experts from different areas of health and social care.

    Both senates and networks are intended to pool specialist expertise and thereby support the work of CCGs and will be hosted by NHS England.


    3. LMCs and BMA Regional Committees

    As a means of supporting the development of CCGs, the GPC is encouraging LMCs to build wider relationships with a number of organisations including local hospitals, mental health trusts and community services.

    In turn, Regional Consultant Committees (RCCs) and Regional SAS Committees (RSASCs) should be encouraged to initiate contact with their equivalent structures in primary care to ensure an effective two-way dialogue takes place.

    To be as effective as possible, we would advise you to engage in these wider relationships through your existing committee channels rather than making contact on an individual basis.

    Where there is more than one hospital provider in the area, you would need to have discussions at directorate level to enable changes and new pathways to be implemented easily.

    Once there is some agreement on the Trust structure for engaging with commissioning then someone, possibly the chairman of LNC, could be delegated to initiate
    talks with the LMC and report back.


    4. Regional Councils – dialogue with LMCs

    Regional Councils are BMA bodies that bring together branches of practice into one setting. LMCs have been encouraged to build relationships with Regional Councils, particularly with consultants and public health doctors in mind.

    This is a clear and definable route for you to engage in.


    5. Local authorities

    RCCs and RSASCs should contact their local authorities or health and wellbeing boards to initiate engagement and seek to influence decision making.

    Each local authority upper tier will have a health and wellbeing board whose function will include encouraging integrated working between commissioners of NHS, public health and social care services.

    These boards will also lead on commissioning decisions based on the Joint Strategic Needs Assessment (JSNA).  Get more information about health and wellbeing boards.


    6. Local Directors of Public Health

    Under the new commissioning arrangements, responsibility and funding for public health will be allocated to local Directors of Public Health (LDPH) whose job will be to improve the health of local communities, through areas such as reducing the incidence of smoking and alcohol misuse and promoting physical activity.

    LDPH (Directors of Public Health (DsPH) in the Public Health White Paper Healthy lives, healthy people: Our strategy for public health in England) will be transferred from the NHS into local government.

    DsPH will support CCGs by helping to identify, prevent and manage a range of conditions but they will also need to have input into commissioning services for people with established diseases and long-term conditions.

    The Department of Public Health (DPH) also intends to engage in a range of regular informal and formal mechanisms for public health experts to advise other NHS colleagues. While the nature of this engagement has yet to be defined, we would encourage you to seek engagement via existing committee channels.


    7. NHS England

    NHS England will provide overall leadership on commissioning - it has been operating in shadow form as a special authority since October 2011.

    It will be responsible for:

    • providing national leadership on commissioning for quality improvement
    • promoting and extending public and patient choice
    • ensuring the development of CCGs including holding them to account 
    • commissioning a range of services including national and regional specialised services.

    Part of this responsibility will also involve developing high-level commissioning guidance for CCGs.

    NHS England will be responsible for commissioning services on behalf of CCGs who are not deemed ready for authorisation by April 2013.


    8. Monitor

    The BMA has successfully lobbied to change the role of Monitor away from promoting competition.

    The Health and Social Care Act now states that Monitor's main duty is to regulate healthcare providers, regulate prices for NHS services and address restrictions on competition that act against patients’ interests.

    Part of this function will include supporting the delivery of integrated services for patients where this would improve quality of care or efficiency or reduce inequality of access or outcome for patients.

    Monitor will operate a licensing regime allowing it to enforce standards by setting out how providers should operate. All providers of NHS healthcare services, unless exempted, will be required to hold a licence with Monitor.


  • Local examples

    Some localities are already encouraging more effective working between primary and secondary care in preparation for the changes outlined in the Act, as outlined in the following examples:

    Example 1 

    GPs in Tower Hamlets, London, have initiated discussions with their PCT colleagues, resulting in a number of positive developments including working much more closely with consultant colleagues.

    A primary care urgent care board has been set up specifically to manage urgent care more effectively in walk in centres and Accident and Emergency Departments, ensuring that consultants are able to spend time with major cases.

    The board contains equal numbers of GPs and consultants, along with managers and nurses. 

    Example 2 

    In Sunderland, collaboration between primary and secondary care has begun with the commissioning of clinical fora, involving representation from primary care and the relevant secondary care department with the objective of addressing service developments constructively.

    Example 3 

    In Coventry, secondary care professionals have provided a useful secondary care perspective to the City Primary Care Trust.

    Two consultants (1 physician and 1 surgeon) employed by the Acute Trust have enabled increased understanding between the two separate Trusts.

    By liaising with different departments, holding discussions relating to Key Performance Indicators and reporting back, these specialists have provided a useful knowledge base from which the two Trusts can appreciate each others viewpoint more fully.

    Example 4 

    In the North West, partnership initiatives have been key to improving breast screening uptakes in minority and deprived communities, providing tangible outcomes which benefit patient care.

    Several commissioners from the locality participated in a conference on 'Addressing health inequalities in breast cancer screening – A partnership approach' which was organised by a consultant from a local hospital.

    There was broad consensus agreement on the importance of improving communication with patients from these communities and engaging health professionals across various disciplines from these communities to improve the overall patient experience.

    As a secondary care clinician you are also a valuable source of advice on research evidence, clinical effectiveness and capacity planning.

    It is important that you seek advice from clinical academics to ensure commissioning plans incorporate appropriate safeguards to protect, and, if possible, enhance, clinical research activity.

    While NHS England will be responsible for promoting involvement in research and the use of research evidence, consultants have a good grasp of the evidence base in their fields and can help commissioners to identify published research evidence and gaps in the evidence base.

    You can also provide opinions on how to fill those gaps (for example with expert opinion, comparison with other new services or new research).


    Referral management

    Referral management is an important component of commissioning, including the design of an evidence-based pathway of care.

    Secondary care clinicians can and should be involved in referral management – too often they have not been, to the detriment of those systems.

    There are many ways you can do this. For example by helping with:

    • clinical referral guidelines
    • access to specialist telephone advice
    • rapid referral outpatient clinics
    • clinical referral guidelines
    • advice and help in urgent care centres.

    You can also advise on and support the development of care pathways outside secondary care. For example, commissioning imaging services for musculoskeletal conditions (there is an example of two specialty doctors working in partnership who have a successful service in a GP suregery), where GPs can access appropriate investigations before referring the patient to an intermediate level service (such as physiotherapy) or to a secondary or tertiary surgical service.  

    Example 5

    At an acute GP service in Plymouth, effective communication between GPs and secondary care colleagues has resulted in better management of pulmonary emboli.

    In an effort to avoid hospital admission for the treatment of this condition, responsibility for administering anticoagulants has transferred to GPs; this has proved popular with patients who prefer to receive treatment at the GP clinic rather than being admitted to hospital.

    Similar initiatives have been piloted elsewhere involving training from secondary care warfarin clinics and haematology consultants.

    Your detailed specialist knowledge allows you to advise commissioners to focus investment in new services on those areas likely to have viable and enduring futures.

    You may be able to advise on reconfiguration, cessation of older services which may no longer be considered to be best practice or if services are unviable.

    An example of this would be the increasing requirement for bariatric surgery for morbid obesity patients services - expert advice may allow commissioners to concentrate their investment on providers with proven expertise, optimum volume of patients, a bariatric surgery database, patient assessment procedures, selection criteria, MDT and skilled supervision of follow-up.

    Specialist obesity surgical services could be linked to receive referrals from a specialist medical obesity services led by an endocrinologist, according to an agreed local pathway.

    It is important such services have appropriate facilities and 24 hour emergency access arrangements for post-op complications.

    This collaborative way of working can benefit commissioners and empower consultants and SAS grade doctors who wish to be involved in service planning.


  • Conflicts of interest

    While there are significant benefits to consultant and SAS doctor involvement in the commissioning process, you should be aware that potential conflicts of interest may arise for those involved in the commissioning and provision of services.

    You may find it useful to read our guidance on avoiding conflicts of interest in the dual role of commissioner and provider.

    Avoiding conflicts of interest in the commissioning process