NHS facilities in Dumfries and Galloway have been given a massive boost after Michael Matheson, the Scottish Public Health Minister, unveiled a multi-million pound investment project in the region.

More than £27m will be spent on a new acute mental health unit at Midpark Hospital in Dumfries and a further £250,000 for a Satellite Renal Dialysis unit at Kirkcudbright Cottage Hospital.

A £900,000 respite care centre for children at Acorn House is also planned.

Mr Matheson said the projects will allow the NHS to provide “more sustainable, high quality and continually improving healthcare services close to home in Dumfries and Galloway”.

In addition to the new services, a £6m Primary Care Centre in North West Dumfries is also set to open by the end of 2012. The area will also benefit from a £3m investment in projects identified for delivery through revenue funding via the hub initiative. These schemes include a £1m health centre in Dunscore and a similar facility in Dalbeattie.

“Having the right facilities in the right place is important to people across Scotland and that is why we are determined to ensure both staff and patients the length and breadth of the country can work and be treated in the best possible surroundings,” said the Health Minister.

The ABPI has raised concerns around the public’s general knowledge on the cost and value of medicines in the UK after a survey highlighted a series of misunderstandings.

The survey showed that the majority of respondents thought new medicines cost less than £10m to research and develop and more than a third believed drugs take up a large proportion of the NHS budget.

Stephen Whitehead, ABPI Chief Executive, said it was vital the public understands the facts of medicines and how they compare to the economic and health benefits they provide.

More than 1000 people were interviewed as part of the survey commissioned by the trade body. It revealed that 59% seriously underestimated the cost of R&D efforts with new products generally costing £1bn and taking 12 years to create.

Also, 35% of respondents indicated a belief that the NHS spends a fifth of its budget on medicines. Whereas in reality, the ABPI said, that only 9.7% was spent on drugs last year – a fall from 12.5% in 1999.

More than three-quarters of respondents (77%) indicated that more should be spent on medicines.

Stephen Whitehead said the survey highlighted some concerning outcomes. “To create new treatments in the UK, the pharmaceutical industry undertakes huge risk and investment and is still able to provide the NHS with amongst the lowest priced medicines in Europe,” he said. “These medicines are the bedrock of the NHS, and have saved and changed the lives of millions of people.”

The Chief Executive added that serious health problems such as HIV, diabetes and heart disease are now “manageable conditions” due to the effect of medicines and that treatments become cheaper in time due to generics entering the market.

“As well providing real value, we also contribute billions annually to the UK economy and provide 67,000 jobs.”

The ABPI said it will now increase its efforts to educate people about the facts of medicines in the UK.

Serco’s management of an out-of-hours GP service in Cornwall, already criticised by the Care Quality Commission (CQC), saw an increase in local A&E attendance.

Since Serco took over the GP service in May, the number of people seen in A&E has risen from an average of 216 (at the same time last year) to 228 per day.

According to Royal Cornwall Hospitals Trust (RCHT) board papers, the privatised service has experienced problems due to its call centre system.

The new system uses medically untrained staff, reading computer-generated scripts, to ‘screen’ calls before passing them on to clinicians.

The A&E figures were reviewed by the trust after it failed to meet its four-hour waiting time target.

The new Pathways answering system was developed by the NHS and promoted by the DH as a means of referring fewer patients to A&E – but Serco’s implementation of it had the reverse effect.

RCHT called the negative impact of the Pathways system a “teething problem” and said it was now working well locally.

Jo Gibbs, RCHT’s Chief Operating Officer, said there was now a “co-ordinated effort of all services across the health and social care community” to reduce the incidence of emergency admissions.

According to a CQC report in July, Serco had failed to meet legal requirements in its staffing levels and monitoring of results, and its employees had tampered with daily performance reports.

New plans for NHS immunisation are clinically inadequate and at risk of poor implementation, according to medical experts.

The division of responsibility for vaccination between the NHS Commissioning Board and Public Health England means the new vaccination programme faces “substantial challenges”, according to the Faculty of Public Health.

In addition, the Royal College of GPs (RCGP) has said the new vaccination plans developed by the DH’s Joint Committee on Vaccination and Immunisation (JCVI) do not go far enough to prevent the spread of infections.

After April 2013, the NHS CB will commission immunisation services – but PHE will set their quality standards, assess their performance, fund and manage their development or extension, and purchase and distribute the vaccines.

Dr John Middleton, Vice President for Policy at the Faculty of Public Health, said this new system faced “substantial challenges” and would require “excellent communication and very close collaboration between GPs and their teams, public health staff and hospital services”.

He warned that the new system “is untried and untested and will disrupt many well-established working relationships”, and concluded: “We are gravely concerned about... how the complex new arrangements will be made safe and effective”.

The new changes to the NHS vaccination programme include offering a pertussis (whooping cough) vaccine for babies; a meningitis vaccine for adolescents; and a shingles vaccine for the elderly.

RCGP immunisation spokesman Dr George Kassianos said these JCVI recommendations amount to “very restricted action” and do too little to protect vulnerable people.

He argued that the pertussis vaccine should also be offered to school leavers and to healthcare professionals working with babies; the meningitis vaccine should be extended to cover more strains; and the shingles vaccine should be supported by a chickenpox vaccine for children.

CCGs are the core of the new NHS – but are they running the game?

The emerging clinical commissioning groups (CCGs) embody a core principle of the new NHS: that commissioning decisions should be made locally, by clinicians, and be focused on community-based care. According to Andrew Lansley, the defining feature of the NHS reform is a “shift of power” from national and regional organisations to local ones, of which the CCGs are the most important.

The role of CCGs in the new NHS is both structural and dynamic. They will commission healthcare at a local level, spending £60 billion of the £80 billion NHS commissioning budget, and will hold together the relationship between patients and providers. They will also work with providers and business partners to redesign local services, and those new solutions will spread through the NHS. The CCGs will thus be the drivers of healthcare innovation.

However, given that GPs are meant to lead the CCGs, the concerns raised by many GPs about the new system are significant. Will CCGs really have the opportunity to improve care, or will they simply have to drive through spending cuts? Will they really be run by clinicians or by the private sector? Is the heart of the new NHS dynamic and responsive, or divided and unstable?

Development of CCGs

In July 2010, the white paper Equity and Excellence: Liberating the NHS spoke of “putting GP commissioning on a statutory basis” through the development of ‘GP consortia’. These new organisations, to which every GP practice would belong, would run each local health economy: they would contract providers, partner with local authorities, and be accountable to patients and the public for outcomes. They would be authorised by a new national body, the NHS Commissioning Board, which would also commission GP services.

The initial reaction of the GP community was positive. Being in the driving seat of a fast-evolving NHS, able to redesign local services for their patients, appealed strongly. However, the codification of the reforms in the Health and Social Care Bill led to growing opposition among GPs. Issues raised included the power of the Board to direct GP consortia and the requirement that consortia embrace provider competition. Above all, the deepening economic crisis made GPs fear their role would be one of rationing services, not finding solutions.

The Government’s ‘listening exercise’ did not resolve the concerns about competition and rationing, but it led to a stronger assertion of the autonomy of the consortia. An important change concerned the scope of clinical representation: the new ‘clinical commissioning groups’ were defined as including specialist consultants and nurses as well as GPs. That was a step towards the ‘integrated care’ that the BMA had highlighted as a priority.

Breaking the waves

The NHS Commissioning Board Authority, set up in October 2011, has the primary responsibility of putting in place a nationwide system of CCGs to replace the PCTs by April 2013. A total of 212 CCGs have been approved to go through the authorisation process in four waves: 35 in wave 1 (commencing in June 2012), 70 in wave 2 (July), 67 in wave 3 (September) and 40 in wave 4 (October).

The authorisation process is designed, according to the Board, to ensure that CCGs have a “strong clinical and multi-professional focus”; have meaningful patient engagement; have credible plans to “deliver the QIPP challenge”; have proper governance arrangements; are set up to collaborate with other CCGs, local authorities and the Board; and have strong leadership.

It has not always been a smooth road, however. The Board, concerned at the prospect of CCGs competing for providers of commissioning support, announced it would take over the appointment of leaders to Commissioning Support Services. One CCG has already protested that its authorisation has been delayed by this.

Another issue is lack of GP leadership. Clare Gerada, chair of the Royal College of GPs, said that only “about 25 GPs” in England were actively interested in leading local commissioning. The reason, she said, was that the “transactional” aspects of commissioning as a business did not appeal to them. 

GP-led commissioning

CCGs will be responsible for commissioning community health services (including mental health care and services for children and elderly people) and hospital care (both A&E and elective care). The NHSCB will be responsible for commissioning primary care as well as pharmaceutical and dental services. Local authorities will be responsible for public health, with the NHSCB covering certain aspects.

Collaborative working between CCGs and the other statutory organisations involved in healthcare is anticipated, but the model is not one of top-down control – rather, it is one of business partnership. The NHSCB can provide assistance or support to CCG commissioning; this may take the form of extra funding or access to staff and other resources. CCGs have a duty to co-operate with local authorities in supporting aspects of public health, including child health and mental health.

CCGs are able to buy in support from external organisations, including the CSUs whose development is currently being governed by the NHSCB. For more details on the CSU landscape. CCGs can also buy in support from the private and voluntary sectors, but will retain control of commissioning decisions. These relationships will differentiate CCGs, as some are keener than others to engage in private sector partnerships.

Commissioning of hospital services is also likely to differentiate CCGs, especially as many hospital trusts are facing financial challenges as they shift to foundation trust status. CCGs will influence the development of FTs through their commissioning strategies – for example, they may promote private providers both within and beyond FT-provided services. The acute sector will have a voice in CCGs, though its representatives on a CCG board cannot come from the local area.

The GP-led nature of CCGs is variable. Fewer than 50% of current CCG board members are GPs, and there is potential for the management of local commissioning to be outsourced. CCG boards should include a non-practice nurse and a specialist consultant, but local government are excluded.

Life after April 2013

Securing GP ‘buy-in’ remains an issue for the NHS reforms, but those GPs who support the reforms have been most active in developing CCGs. The CCG boards thus represent a more pro-market segment of the GP profession. Pharma companies may find that their CCG customers and GP customers require a nuanced and varied approach.

Each CCG will have a different mix of GPs, hospital clinicians and financial or management specialists. It will also be dealing with local health issues, which are also impacting on local government and the local Healthwatch body. Every CCG will have to find its own balance between clinical outcomes and economic success.

CCGs will also face a tension between the ‘autonomy’ stressed by the NHSCB and the need for partnership with other stakeholders, within and outside the NHS. Will this tension lead to fragmentation and paralysis, or to dynamic innovation driven by the local synergy of clinical and commercial talent? Whatever the answer, the CCGs hold the key to the success or failure of the new NHS.

A Birmingham GP who called the NHS reform plans “unworkable” is one of two clinicians newly appointed to the Medical Directorate of the NHS Commissioning Board.

Professor Steve Field (pictured), who as Chair of the NHS Future Forum argued that the Government’s plans for hospital competition would destabilise the NHS, has been appointed Deputy National Medical Director (Health Inequalities).

Like Business Secretary Vince Cable in the Government, Field is a policy sceptic who has been kept ‘inside’ by the leadership to provide a more critical dynamic.

Field, who is Chair of the DH’s National Inclusion Health Board, will lead the NHS CB’s work to reduce health inequalities.

Professor Keith Willett, the current National Clinical Director for Trauma Care, has been appointed Director for Acute Episodes of Care with responsibility for Domain 3 of the NHS Outcomes Framework (“helping people to recover from episodes of ill health or following injury”).

Willett, who has been an orthopaedic trauma surgeon in Oxford, will lead the Board’s work to assist rapid recovery from illness or injury.

The NHS Commissioning Board Authority’s National Medical Director, Professor Sir Bruce Keogh, said that both recruits “have a strong track record of leadership and innovation which will be of enormous benefit to the NHS”.

A new £12m health centre has opened in north Brixton to provide general practice, community health and social care services under one roof.

The state-of-the-art Akerman Health Centre brings together a range of services to provide convenience and access to support for local residents.

Services will be provided by Guy’s and St. Thomas’ NHS Foundation Trust Community Health Services, King’s College Hospital NHS Foundation Trust and South London and Maudsley NHS Foundation Trust.

Angela Dawe, Director of Operations at Guy’s and St. Thomas’ NHS Foundation Trust, said the centre would become the “health hub for local people”.

The centre will house three separate GP practices. In addition it will provide care for long-term conditions, such as diabetes and heart disease, access to mental health services and dentistry. It will also be used as the main base for district nursing and specialised maternity services in Brixton.

Dr Adrian McLaughlin, Chair of NHS Lambeth Clinical Commissioning Group, said the “great strength” of the facility will be its integration of healthcare and social care services.

“We hope that the centre will also bring shorter waiting times and better access to services for patients,” he said. “For us as clinical commissioners, reducing inequalities and improving healthcare for local people is a priority, and the Akerman Health Centre will go some way to achieving this.”

The Rarer Cancers Foundation (RCF) has called for action to ensure that when the Cancer Drugs Fund ends, access to drugs for rare cancers continues.

Over 16,000 NHS patients per year may lose access to life-extending drugs when the fund ceases in March, the charity warns.

It suggests that a “transitional” continuation of the Cancer Drugs Fund (CDF) may be needed while steps are taken to ensure that new pricing and prescribing arrangements maintain these treatments.

The CDF provides £200m per year for trusts to purchase cancer drugs that do not have NICE approval.

According to the RCF’s new report on the fund’s impact, it has enabled over 3,600 patients with rarer cancers to access treatments in the last year.

The report points out that the fund has enabled NICE to increase its cancer drug rejection rate from 40% to 60% by making cost a higher priority.

It recommends that NHS authorities examine variations in access to cancer drugs according to location and age, leading to “an urgent review” by the NHS CB of “population cohort policies for funding cancer treatments”.

The RCF also calls for “national protocols” for off-label cancer treatments to be established, allowing their efficacy and safety to be assessed.

Looking forward, it says the DH “should clarify as a matter of urgency how it intends to ensure access to treatments currently reimbursed through the Cancer Drugs Fund in 2014 and beyond.”

The review proposes two measures:

• a mechanism to include these treatments in the new value-based pricing framework, with the CDF being extended as a “transitional” system if necessary

• a national system for off-label prescribing of rare cancer drugs that cannot be covered by VBP.

After April 2013, who will commission which health services?

The new NHS structure is designed to promote integrated care by making the roles of a number of different commissioners interlock. The GP-led clinical commissioning groups (CCGs) are the core of the system, responsible for dealing with most areas of patient need in the local community. Around that, however, three other commissioning bodies are engaged with supporting patient health and wellbeing:

• the NHS Commissioning Board (NHSCB) is responsible for primary care and specialised services
• local authorities are responsible for improving public health
• Public Health England (PHE) is responsible for protecting and promoting health though intervention in health and social care services and public awareness.

A map of services

The Commissioning Board Authority’s Commissioning fact sheet for clinical commissioning groups maps the new health landscape by comparing the responsibilities of the four organisations. For each new commissioner, it lists the main functions and the similarities to other commissioners – thereby making the point that service integration is vital for effective care.

The fact sheet states that CCGs will need to work collaboratively with local authorities and the NHSCB – and that to do so, they may pool budgets or have joint commissioning arrangements. For example, it is suggested that responsibility for sexual health and for addiction-related services will need to be divided between the CCG and the local authority to avoid duplications or gaps in provision.

Clearly, the matrix of healthcare is a dynamic one that can be interpreted by local commissioners in a range of ways. The map is not a final one in any case: some details, including the specialised services covered by the NHSCB, are still to be confirmed by Parliament in the autumn.

Community healthcare

The fact sheet compares the responsibilities of CCGs and the NHSCB for commissioning patient care. It notes that local authorities will provide “public health advice” to CCGs, but will not commission at that level. The role of local authorities in commissioning social care is not covered, but is a further dynamic that CCGs will need to be aware of.

The core elements of CCG commissioning relate to: emergency care; out-of-hours primary medical care (where not covered by the GP contract); elective hospital care; community health (such as physiotherapy and continence services, but not health visiting or family nursing); rehabilitation; maternity and newborn care (except where intensive); paediatric care; mental health and learning disability care; and infertility treatment.

The core elements of NHSCB commissioning relate to: primary care through the GP contract; community pharmacy; primary ophthalmic care; all dental care; health services for people in prisons and other custodial institutions; health services for members of the armed forces; and specialised services.

The fact sheet draws out some detailed differences between the two lists in order to avoid confusion – for example, noting that health services for offenders in the community are covered by CCGs. Sometimes, as where the GP contract varies, certain services may be commissioned by the CCG in some localities and by the NHSCB in others. None the less, overall there is a clear division of responsibilities.

Public health services

With the commissioning of public health services, the picture is significantly more complex. Responsibility is divided between the NHSCB, the local authority and Public Health England. In some cases – notably immunisation programmes – these services can relate to provision of medication. In other cases – notably epidemic preparedness – they can relate significantly to medicines management and other aspects of primary and secondary NHS care.

Public health services to be commissioned by the NHSCB include services for children from pregnancy to age 5. This responsibility will transfer to local authorities in 2015. It covers health visiting, family nurse partnership and responsibility for child health data. The NHSCB will also be responsible for immunisation and national screening programmes – both being areas of increasing NHS spend, as evidenced by recent investment in cervical cancer and prostate cancer screening and in vaccines against HPV and influenza. With hepatitis C vaccines on the market and HIV vaccines a real prospect, this area of medication will become increasingly crucial for the NHS.

Local authorities will be responsible for providing or commissioning a wide range of public health services that relate mostly to preventative measures and raising awareness, including: children’s public health for ages 5 to 19; sexual health; public mental health; obesity management; drugs, alcohol and smoking services; dental public health; and seasonal mortality. Active medical intervention, including medication, features strongly in the sexual health and drug, alcohol and smoking services to be provided; the transfer of sexual health services from NHS to local authority control is a major change in the provision of UK healthcare. Notably, however, HIV treatment will be commissioned by the NHSCB.

PHE is taking over the functions of the Health Protection Agency and will impact significantly on the health protection activities of CCGs, the NHSCB and local authorities. Sometimes all relevant health stakeholders will work together – for example, PHE has a strategic role in influenza and other epidemic preparedness, to which local authorities, CCGs and the NHSCB will contribute. PHE’s role also covers behaviour change campaigns around early diagnosis and other issues; public oversight of infection prevention and control; and general intelligence on health protection and improvement, including the current functions of the Cancer Registries. These initiatives will also impact on GP services.

Joined-up care

CCGs will be the glue in the new healthcare commissioning system: the first port of call when gaps or inequalities in service provision arise. While they cannot commission GP care, their close professional connection to it should ensure that what impacts on CCGs will be taken to heart by GPs. But given that austerity measures will dominate the NHS for the “foreseeable future” (in David Nicholson’s words), it is inevitable that funding and staffing shortages will create holes in the patchwork of the new health system. The pharmaceutical industry will thus need to be alert to partnership opportunities opening up at local and national levels.

The switch to GP-led commissioning is already proving to be a success, according to the Conservative MP Chris Skidmore.

The Kingswood MP – who also sits on the Health Select Committee – said that results from new schemes introduced by CCGs across the county were encouraging.

Writing in a blog on the Conservative Home website he admitted that the Health and Social Care Act was one of the “most controversial pieces of legislation” to pass through this Parliament.

But he insists that despite the structural reforms the NHS “remains alive and well”, and Andrew Lansley’s plans to localise decision making are improving health services.

Mr Skidmore pointed to three examples where CCGs have used new powers to introduce local health improvements. These include NHS Nene CCG where nurses have been trained to provide minor injuries care to keep patients out of secondary care; NHS Corby CCG where referrals were cut by 25% and saving £300,000; and at NHS South Devon and Torbay CCG where blood tests are taken locally instead of in outpatient centres.

“As Conservatives, we have always been there for the NHS,” he said. “But we are also prepared to take bold decisions in order to deliver the best service possible, maximising its productivity and reducing waste. In the teeth of the vested interests of those who would preserve the status quo, enacting change can be uncomfortable. But we must argue our case, continuing to press home that the changes we make will benefit every patient. We know that for their sake, reform is not an option but a necessity.”