opinion

Running a patient information service such as the College of Health's national waiting list helpline is arguably the best training ground for learning how to draw blood from a stone.

I have been trying to get factual information about the arrangements for specialised services and 'out of area treatments' but have not met with much success.

My starting point for regionalised specialised commissioning was straightforward but, in retrospect, perhaps a touch naive. I asked the regions, prompted by reassurances from the government's spokesman in a debate on the Health Bill in the House of Lords.

'The arrangements for specialised services commissioning recognise that these services form much too important an element of the NHS to be left to chance, or to the goodwill of individual clinicians, units or individual commissioning bodies, or indeed to the urgings of patient groups,' said Lord Hunt of Kings Heath during the third reading in the Lords.

'That is why we have charged NHS Executive regional offices with ensuring there are proper, coherent arrangements in place to plan, commission and (through long-term service agreements) fund specialised services.

'This is essential, both to ensure patients have fair and appropriate access to specialised services when they need them, and to enable the units concerned to plan ahead with confidence.'

So how did I fare with the regional offices? I might as well have rung the White House and asked for details of how to get into Fort Knox.

The initial response ranged from suspicious: 'What do you want to know for?' (answer: 'So that our health information service can tell patients when they ring after 1 April,') to defensive: 'Well, we haven't got a list, as such,' and a straight admission: 'The arrangements are all over the place. Some are extra-contractual referrals, some are block contracts, most are ad hoc.'

There is a list, of course. It took the form of a health service circular.1 But it was not immediately apparent that it was intended to be indicative only. In other words, health authorities, through their regional offices, need only make arrangements for a limited list of national priorities such as paediatric intensive care, renal replacement, medium and high- security psychiatric services and specialist cancer services.

After that they can, it seems, choose one or two a year from, say, specialist neurology or specialist ophthalmology.

It is not immediately clear what this would mean for a patient who needs some specialist neurology now, not next year or the year after.

If it sounds as though I'm being a bit thick here, I am not alone. The following is an extract from a fax from my personal assistant, on her dealings with a man from one of the regions.

'Having read, if not understood, the circular on commissioning, I realise he was talking the official line and carrying out his duties dutifully. He said that no region would be tackling all the services on the list apart from the national priorities, obviously. In theory, the need for ECRs would be reduced as these arrangements are planned into service agreements.

'Then he said there is something called OATs, but he is not the lead on that. He was talking mainly about the flow of funds and the fact that the new system would encourage HAs to plan better instead of falling back on ECRs as a failsafe.

'As far as patient choice is concerned he did not think there would be any difference - ie principle of GP free to refer to consultant of choice - and assumed GPs would be well informed or go back to their relevant HA contracts manager if in doubt.

'Basically the only problems he could foresee were inevitable teething problems, some confusion while the new system beds down, but he agreed that potential for referring patients to new treatments would be limited since the idea of building partnerships doesn't allow for flexibility and he could not see where the money would come from.

'Of course, as far as the patient is concerned all would be invisible, and he said not to worry because patients would get the urgent treatment they needed wherever, and the funding would remain a headache for the commissioners/providers: ie going back to invoice system where not part of service agreements.'

She added: 'I still don't understand OATs. Would these effectively be ECRs that eventually get incorporated into service agreements in future planning, and does it mean out of area or out of contract/ agreement or are they the same thing? I'm sure I'm missing the point somewhere. I got lost in the health improvement programme process and who works with who and who agrees what and where the money goes to or comes from. Think I need an idiot's guide to commissioning services and how you quality-assure.'

Now that is a good idea. I can see a whole series of idiot's guides selling like hot cakes. The only problem is, who do you ask to spell it all out in words of few syllables?

My own investigations have come to a temporary halt, and I still don't know what we're going to tell patients about how the system works in this modern and accessible NHS with its robust new arrangements.

Maybe I need a brain transplant, but I don't think my region has got round to commissioning those yet.REFERENCE

1 Health Service Circular HSC 1998/198. Commissioning in the New NHS: commissioning services 1999-2000.