Consultation on Specialised Services clinical commissioning policies and service specifications

NHS England has today (04 March 2016) launched a 30 day public consultation on a number of proposed new products for specialised services, (including service specifications and clinical commissioning policies).

There has already been extensive engagement on these national specifications and policies. They have been developed with the support and input of lead clinicians and tested with stakeholders. This approach has helped ensure that the views of key stakeholders have informed and influenced the development of the specifications and policies to date.

Please note this is one of several public consultations on a proposed new draft products for specialised services. We now wish to test them further with wider stakeholders through public consultation.

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  1. Sheila Hyde says:

    As a pensioner who resides in West Yorkshire, I am concerned regarding information I have read in the Daily Mail of proposals to no longer supply hearing aids. There is the possibility of patients having to pay for their own at a cost of £2,000 each. How the CCG s expect people to find this kind of money when on reduced incomes is alarming.
    I have been wearing hearing aids for 13 years and without them my day to day life would be badly affected. These aids have to be checked periodically and at some point replaced so i M assuming charges would be made for this service too.

  2. Adrian Sugar says:

    1. Cleft lip and palate (CLP) is one of a very small number of services which
    has been subjected to a CSAG (Clinical Standards Advisory Group) study
    and report by DoH, accepted by government in 1998.
    2. This report showed major deficiencies in the service including
    a. No significant and very poor commissioning
    b. 57 units claiming to provide care
    c. Hardly any proper multi-disciplinary care
    d. Poor results
    This resulted in a major reorganisation and centralisation of the service and
    to clinicians very committed to providing a quality service
    3. The CRG for CLP has developed a National Service Specification with
    standards of care and a Quality Dashboard. It is working (with NHSE in
    Leeds) to develop a currency for CLP in NHSE and has responded on
    several occasions to requests from both the DoH and NHSE to develop a
    Year of Care Tariff which Monitor would consider. After years of effort by
    the CRG/CLP, agreement has now been reached for implementation of a
    Treatment Function Code for CLP to be mandatory on April 2017. How will
    this work now be progressed or will it just be wasted and forgotten?
    4. Abolition of the D07 CRG in CLP (including velopharyngeal dysfunction) All
    Ages runs the risk of turning the clock back and allowing deficiencies to
    develop and be ignored with nobody involved in the service representing it.
    Who will develop the Quality Dashboard and close its audit loop? Who will
    update the NSS? Who will continue the work on currency? Who will
    ensure that the commissioners actually ensure that standards are met?
    5. Please see the long terms plans for this service developed within the NHSE
    CRG structure – 5 year plans to 2019 (attached below if the site allows).
    How will this now be developed?
    6. Moving CLP to the Women and Child Health NPOC makes some sense as
    does listing it under Paediatric Surgery but the CSAG report showed why
    this service was special and specialised – it is truly multi-disciplinary and
    has to be. And the service treats a substantial number of adults (hence its
    description as “All Ages”) who can easily be forgotten in a CRG only
    concerned about children.
    7. Today, cuts in funding locally are resulting in speech and language therapy
    for children with clefts not being available and this is causing serious
    damage to children’s speech development (see report commissioned by the
    CRG/CLP and just reported). To correct this requires direct involvement in
    changing the national process for provision of SLT to children with clefts
    and how it is funded. Who will ensure this happens?
    8. The CRG for CLP should be retained but if not it should be properly
    represented on the Paediatric Surgery CRG.


    Completed by: Adrian Sugar and Michele Davis, on behalf of D07 CRG for Cleft Lip and/or Palate All Ages

    Need to achieve a network of providers with an appropriate balance of hub, spoke, outreach and locally provided services with equity of access and meeting the needs of all children and adults and their families with clefts of the lip and/or palate (CLP), all meeting the national service specification (NSS) with sufficient staff at the appropriate grade

    CLP services in UK reorganised after DoH Clinical Standards Advisory Group (CSAG) report of 1998 criticised the standards, delivery and outcome of care and commissioning. 57 hospitals were carrying out cleft surgery, few with proper multidisciplinary care. 9 regional cleft centres were created in England, some based on two sites, some with separate adult and paediatric sites. No guidelines for staffing levels or funding and lack of consistency in commissioning in the regions has resulted in variation in service delivery across the country.

    Current State
    • Not all centres able to provide all the specialties required by the NSS
    • Not all centres able to provide sufficient staff to deliver the NSS
    • Specific problems in specific disciplines in some areas, for example,
    paed dentistry, clinical psychology, nursing, speech and language therapy
    • Increasing number of cleft births experienced generally and in certain areas
    putting increased demand on stretched services and on some surgeons
    • Existing and committed senior staff of a single generation
    • Cuts/CIP, downbanding especially in nursing, psychology and SLT,
    redirection of resources
    • Reduction in local services especially SLT, dentistry and orthodontics
    • Lack of equity of access for those living in remote and rural areas and the
    • Lack of beds and operating lists in some areas, lack of provision for
    adolescents and sometimes adults
    • Good hearing services locally but poor coordination with cleft services
    • Lack of education on clefts for health care professionals looking after the
    general health of cleft patients

    Root Cause Analysis
    • Lack of understanding and consistency in Trust management of the needs
    of the service
    • Lack of consistency in commissioning before the introduction of the NSS
    • Lack of resources which is variable between the centres and often closely
    related to targets of cost reductions
    • Retirements sometimes used as an opportunity to save money rather than
    to strengthen the service
    • Lack of any serious research work on staffing levels and grades required to
    deliver the service or how it should be delivered

    Future State.
    • Need to determine the staffing levels and grades required in each discipline
    and distribution of care between hub, spoke/outreach and local to meet the
    NSS. Consider central funding of some staff for local service provision to
    address any shortages in some disciplines in some areas
    • Down-banding, cuts/CIP and redirection of resources should cease and be
    • Ensure a Paediatric Dentistry presence in every service to provide
    prescription of treatment
    • Work with Public Health England to obtain recognition that having a cleft
    alone should be a criterion for acceptance of a child into the salaried dental
    services for primary dental care
    • Address and correct the lack of beds and operating lists where present and
    ensure adequate provision for adolescents (e.g. adolescent beds) and
    • Introduce a carefully managed surgeon expansion in certain areas ensuring
    no dilution of numbers treated per surgeon as per the NSS
    • Put in place in every centre a protocol for temporary periods of surgeon
    absence through illness/injury, and a protocol for succession planning
    • Initiate and encourage a more coordinated approach to the often excellent
    provision of hearing services locally so that better data on needs and
    outcome can be obtained and those local services can be more integrated
    with the cleft centres
    • Strengthen links between services and patients/carers and parent /carer
    organisations especially CLAPA
    • Strengthen the national cleft database CRANE so it can be an effective
    vehicle for national audit
    • Educate health professionals looking after the general health care of cleft
    patients about clefts
    • Ensure equity of access to cleft care services for remote and rural areas
    including the islands with specific protocols in place
    • Consider further the data and discuss with PICU colleagues the issue of co-
    location of cleft services with PICU, of protocols for surgery on specific
    problem cases in proximity to PICU, and of protocols for retrieval in
    unexpected situations


    To achieve a national service based on the existing 9 cleft centres which is fully compliant with the national service specification and is fully staffed at an appropriate level in all disciplines with numbers and grades, providing services locally when possible and centrally when necessary.

    Encourage patient and staff participation in clinical research, for example the Cleft Collective studies which can help patients with clefts in the future.

    Share and replicate best practice

    Maximise the use of modern technology in the delivery of services (eg Skype)