Commissioning needs to be reformed and strengthened at every level, writes Sophia Christie

The question of where decision-making authority should sit in any given system bedevils all attempts by autonomous bodies to co-operate. Access and cost in acute care and the interface with local government have both driven primary care trusts' concerns about establishing core commissioning capacity of accountable organisations.

However, the Carter review of specialised commissioning in May, parallel to Commissioning a Patient-led NHS, drew attention to the need to reform and strengthen commissioning at every level.

Sir David Carter focused on the delegation of commissioning national specialised services and on preserving diversity for handling high-cost low-volume activity.

There has existed a spectrum of arrangements, with some regions (notably the North West and West Midlands) enjoying a long history of formal collaborations. In other areas collaborative boards have met but without a dedicated infrastructure. In some there has been little experience of collaboration at all.

Specialised services, by definition a niche market, benefit from knowledge and understanding on the part of commissioners. The average GP is no more likely to feel confident in commissioning medium secure mental health services, cardiac ablation or pulmonary hypertension than any other member of a local commissioning team. Carter recommended regional commissioning teams, building on the North West and West Midlands models and proposed work to clarify the definitions of specialised services and to review which services should be commissioned at which level.

World-class commissioning raises further interesting questions about the scope of commissioning activities and whether it is possible to develop full competency at every level. Learning to date suggests that collaborative commissioning has more to offer than has yet been realised: sharing of rare expertise, building leverage in a provider-dominated market and enabling proactive commissioning for outcomes, rather than reactive paying for services.

There are other advantages. Some years ago the then National Institute for Clinical Excellence decided that while any pharma company, professional or patient group could respond to and appeal against a technology assessment it would be too difficult to allow every commissioner to do so. For each intervention under review, NICE now randomly identifies two PCTs from England to respond. This means that every day a chief executive may get an invitation to submit evidence on a new drug or procedure.

There will be nothing to indicate that this invite is limited to only two PCTs and that the assessment could have significant financial and ethical implications. Most PCTs do not understand the process or have the technical resources to participate.

The new regional collaborative arrangements could give us a set of decision-making bodies which collectively decides to each invest a small sum to support a single process. Then any PCT asked to comment could draw on expertise, enabling commissioners to join pharma and the professions in the NICE process.

This approach could also be applied when building a collective register of the specialist interests of public health practitioners, sharing rare knowledge more widely.

We also increasingly need a collective position on difficult investment priorities.

As a service we face an explosion of 'orphan' drugs. Usually relatively new gene-related technologies with huge development costs, orphan drugs affect tiny numbers of people globally. With no critical mass to support randomised control trials they lack an evidence base on effectiveness.

Development cost drives a desire to see early return on investment, so there is little information taken over a long period in the research trials. Instead, pharma companies promote a new treatment to the families and patients on trials (raising significant expectations). Often the rarity of the disease also means a rarity of specialists, most of whom have built professional careers on the back of drug trials and pharma-sponsored research. Demand is based on the 'rule of rescue', which can be roughly summarised as 'it is possible to do something, so we should, regardless of inherent cost, opportunity cost or individual outcome'.

It is the NHS equivalent of the urge to save the whale stranded in the Thames: expensive, doomed to failure but fuelled by a wave of empathetic passion.

This approach has resulted recently in the DoH deciding that 'we must' invest in enzyme replacement therapy, which will benefit a tiny number of people a year and commit the service to over£300m over the next three years. The newly delegated National Commissioning Group has rightly just rejected an approach to fund an orphan treatment for the rare blood disorder paroxysmal nocturnal haemoglobinuria. Rather than this being interpreted as a rejection of the commissioning in itself, pharmaceuticals companies are seeking local approaches to individual PCTs to fund the drug at a cost of£350,000 per person a year - with no established evidence of medium-term outcome.

This is not commissioning for outcomes and it does nothing to tackle health inequalities. To challenge it, we need our collaborative structures to build an understanding and consensus which enables us to act as one.

The delegation of the rare and the expensive to the service provides a real test of our ability to commission collaboratively with a focus on outcome. Alternatively, we could just be the meat in the sandwich between pharma-induced public outrage and political assessments that a few million here and there is nothing between friends - until the annual Audit Commission use of resources assessment.

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