Published: 15/07/2004, Volume II4, No. 5914 Page 21

It is time specialised services shook off their semi-detached status - policies like payment by results could help, says Baroness Hayman

The term 'specialised services' is probably here to stay. Sadly, it sets 10 per cent of commissioning apart from mainstream services, when the two are interdependent. As a result, specialised services have tended to be an afterthought in public policy. This needs to change, not least in the context of a coherent approach to chronic-disease management.

Specialised services cover a wide range of rarer conditions, cumulatively affecting large numbers of patients. For example, there are some 200,000 people with chronic liver disease, 85,000 with multiple sclerosis, 50,000 with HIV and 37,500 with end-stage renal failure.

When the Specialised Healthcare Alliance was formed in 2003, the dearth of information on specialised commissioning was apparent. A survey to discover how primary care trusts and strategic health authorities were faring highlighted the need for:

a map of who is responsible for what;

improved access to pooled data;

SHAs to fulfil their assigned role in that regard;

improved patient involvement.

However, the critical requirement was for more and earlier consideration of specialised commissioning in the formulation of public policy. A number of current developments make this a particularly pressing concern.

The priorities and planning framework for 2005-2008 is expected shortly and likely to confirm the shift in emphasis from acute care to management of chronic conditions.

We would like to see some recognition of the larger planning populations involved in the commissioning of specialised services.

Commissioning of all kinds also warrants a mention in the healthcare standards being elaborated by the Department of Health. We see considerable merit in the national definition set being referenced, most probably in the developmental standards.

In turn, the healthcare standards will exert a considerable influence on Healthcare Commission activities. The Specialised Healthcare Alliance looks forward to working closely with the commission so that the importance of specialised services is properly reflected in its work.

The difficulty of addressing specialised services at a later stage in policy development can be seen in relation to payment by results.

Clearly, payment by results has considerable attractions. But early publicity focused on elective procedures with a relatively narrow spectrum of complicating factors. Only at a later stage did the gulf in costs between the generality of providers and their specialised cousins begin to impinge.

Payment by results elegantly accommodates the comparison of apples with apples. It remains to be seen whether it can be modified in a way that recognises the complexity of the specialised sector.

Much is at stake. Under-compensation would jeopardise patient welfare and service viability. Over-compensation would prove ruinous for commissioners and bring the system into disrepute.

Equally, a decision to leave specialised services on the sidelines could compound their semi-detached status, making service development and timely introduction of new treatments all the more problematic.

Baroness Hayman is chair of the Specialised Healthcare Alliance.