Jonathan Ellis, Director of Public Policy and Parliamentary Affairs at Help the Hospices, the national charity for hospice care. Jonathan explains how new healthcare reforms are having an adverse affect on hospices in the UK and what the charity recommends to ensure that the new structures work better for hospices and patients.
How are hospices faring in the brave new world of health care? As the dust begins to settle following wide-scale reorganisation within the NHS (National Health Service) and the biggest structural changes in its history, Help the Hospices wanted to find out how the new structures have affected hospices.
Hospices in the UK receive on average 34 % of their funding from the NHS with the rest coming from charitable funds. However, statutory funding for hospice care is patchy and inconsistent, with levels varying widely across the country.
Under the NHS reforms primary care trusts (PCTs) and strategic health authorities (SHAs) were abolished. NHS England (formerly the NHS Commissioning Board) and Clinical Commissioning Groups (CCGs) are now responsible for commissioning the vast majority of NHS services, with local authorities taking on new public health commissioning responsibilities. Commissioning is the process for identifying which healthcare services are needed in a local or regional area, purchasing these services and monitoring their delivery. CCGs are groups of commissioners, led by GPs (general practitioners), whose members come from the clinical sector and include doctors, nurses and other healthcare professionals.
Between March and May of this year Help the Hospices undertook a survey of our member hospices in England. It focused on new commissioning and contracting arrangements between the recently established Clinical Commissioning Groups and hospices for the 2013/14 financial year. The overall picture that emerged was one of complexity and confusion, which has created instability and uncertainty for hospices, as well as increased bureaucracy and additional costs.
What our survey revealed
A quarter of hospices we surveyed said they were working with four or more statutory commissioners, with 38 per cent working with three or more. One hospice even reported working with as many as eight separate commissioners. Most hospices are managing a hotchpotch mixture of arrangements, including service level agreements, block contracts, spot contracts and the infamous standard NHS contract. Nearly a fifth of hospices surveyed said they had three or more different forms of agreements with commissioners. Engaging with multiple commissioners and managing a mix of arrangements has created significant additional administrative costs for hospices.
The financial impact of the new commissioning and contracting arrangements on all hospices in England, primarily from new data reporting requirements, is conservatively estimated to be at least £3.2 million. There is widespread unease that new contractual arrangements are being imposed on hospices in the same way as much larger service providers in a ‘one size fits all’ approach.
Around half of hospices have signed or been asked to sign an NHS contract. This has meant hospices being required to replace straightforward service delivery agreements with a complex, lengthy contract that is not reflective of local needs. Hospices feel that much of the NHS contract is not relevant for commissioning hospice care, particularly where the NHS is only part funding the care delivered.
Some evidence of poor commissioning practices were also among the findings of our survey. Examples included the use of contracts for six months rather than the recommended three years, and eleventh hour changes to arrangements – creating instability and uncertainty for hospices.
We also found that many commissioners are not using the flexibility at their disposal to look beyond the NHS contract and explore alternatives such as co-commissioning agreements. (This involves hospices and commissioners working together to produce joint agreements.)
We are recommending several measures that could be taken now to improve commissioning of hospice care, including:
- Reducing the duplication of commissioning arrangements by encouraging
CCGs to collaborate, for example adopting lead commissioner models where possible.
- Reviewing and adapting the NHS Contract to make it more relevant for hospices.
- Developing a national framework for commissioning hospice care to improve local practices and reduce complex contract variations.
- Moving from short-term contracts to multi-year contracts to give hospices more stability for effective long-term planning of patient care.
The Government says it is committed to more public services being delivered by charities. However, our survey shows that there is plenty of room for improvement on commissioning and contracting processes if this is to become a reality.
We hope health decision-makers will take up our recommendations and make the necessary changes needed, to ensure the new NHS structures work better for hospices, and ultimately for patients.
Find out more…
Click here to read the commissioning report on the Help the Hospices website
Click here to read a longer article about the commissioning survey (which includes a case study).
About the author
Jonathan has 15 years’ experience of working in health and social care policy within the voluntary sector, and experience of political campaigning at a local and regional level. He joined Help the Hospices in January 2007. Prior to this, he worked for over eight years in the policy team at Help the Aged, where he was Senior Policy Manager for Health and Social Care, responsible for the charity’s care policy work.