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What's so special about specialised?

Our diarist gets his head round the new dynamic between the central NHS board and CCGs when he learns how specialised services will work



The story so far…..
Dr Peter Weaving is a GP and vice-chair of Cumbria CCG, whose final authorisation application is to go in front of the commissioning board’s wave 1 sub-committee any day. With the bulk of the authorisation process behind them, the CCG can get down to the nitty gritty of how to spend its £650m budget next year. And with the cash, the CCG will find itself walking into a new dynamic: the CCG and NHS Commissioning Board. Now, who is commissioning what again…?

One of the earliest lessons we learnt as clinical commissioners was the importance of being both big and small. An effective organisation, especially a membership one, had to be small enough to understand its practitioners’ needs and, ultimately, how they were going to spend the resources. However, when it came to effective commissioning we had to be joined up and have enough population leverage to implement heavy-duty commissioning. For example, to shift a diabetes service from a secondary care focus into a community setting, or to start up a cardiac revascularisation service requires all six of our localities to act in unison for the benefit of our half-million residents.
‘What’s your question?’ the presenter asked, curtly. I was jerked back to the present and reminded that my hand was raised. The rest of the group, clinical chairs and accountable officers for the 13 northern CCGs, had clearly clocked that I had drifted off, somewhat sedated by the slide series entitled Specialised Commissioning Structure. To exert even more commissioning clout, our 13 CCGs, sharing a single commissioning support unit, meet regularly to coordinate a unified approach but still recognise that the local requirements of central Newcastle will differ from those of the Eden Valley.
I found the pre-transition specialised commissioning structure indistinguishable from the specialised commissioning transition structure. My question was simple – what makes a specialised service ‘special’ and takes it from the remit of our CCGs and into the remit of the NHS Commissioning Board? The very next slide answered my question – specialised services should be commissioned by the board on the grounds of rarity, complexity, scarce expertise and financial risk.
Now, no one would argue that stereotactic radiosurgery and mental health services for the deaf come under this umbrella, and your average CCG wouldn’t touch them with a barge pole. However vascular disease, cardiac surgery and paediatric medicine seem part of the day job to me and explain why the specialised commissioning budget is going up by more than 40% next year. Further complexity is provided by splitting services under two commissioners – I will commission your care under a nephrologist for your deteriorating kidneys but, if you need renal replacement therapy, the same specialists will be commissioned by the board.
The next phase will be when you are being followed up after a specialised service intervention such as your coronary artery stenting. Will your follow-up appointment with a DGH cardiologist be
a routine payment-by-results affair billed to me at the CCG or Sir David at the board?
Can you think of a better way of disconnecting GPs from commissioning than leaving them with corns and haemorrhoids?

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