Senates and networks – do they have a role in the new NHS?

pharmafile | June 19, 2012 | Feature | Business Services, Manufacturing and Production, Medical Communications, Research and Development, Sales and Marketing |  NHS, health forum, reforms, senates and networks 

The recent Westminster Health Forum meeting on ‘Developing Clinical Senates and Networks’ focused on one aspect of the new NHS reforms which many remain mystified by.

Readers in the pharmaceutical industry may well be forgiven for having forgotten about clinical senates and clinical networks entirely, as the whirlwind of NHS reform has thrown up such a dizzying array of new structures and decision-making bodies.

So are these bodies going to play a serious role in the new NHS, or as Sir Bruce Keogh, the Department of Health’s own medical director has warned, might they simply ‘wither on the vine’?

The Future Forum

The plans for senates and networks emerged during the ‘pause’ in the Health and Social Care Act’s progress through Parliament in summer 2011. The extensive ‘Future Forum’ consultation eventually came up with a long list of new ideas, many intended as checks and balances to the reforms contained in Lansley’s original bill.

Clinical senates were an entirely new idea, intended to advise and monitor the GP-led Clinical Commissioning Groups. One of the main purposes for senates was to counter-balance the power of GPs with the proposed system, with a multi-disciplinary body.

The Future Forum report recommended: “multi-speciality clinical senates should be established to provide strategic advice to local commissioning consortia, health and wellbeing boards and the NHS Commissioning Board.”

Meanwhile, clinical networks have been around for some time now – cancer networks were set up in 2000 – but these organisations had been earmarked for abolition by Lansley, only to be saved as part of the Future Forum exercise.

Clinical senates and clinical networks are now being discussed together for a number of reasons. Firstly, both will sit between Clinical Commissioning Groups and the new central authority of the NHS Commissioning Board. Secondly, they are meant to foster cohesive and integrated care between regional organisations. Thirdly, no-one really knows how they can fit into the bigger picture, particularly in the case of clinical senates.

Another role is meant to ensure commissioners – within Clinical Commissioning Groups, in the NHS Commissioning Board and elsewhere – have ready access to expertise and advice when dealing with the wide range of services patients require.

The Westminster Health Forum meeting provided a powerful reminder of how little time there is available to set up these organisations – and revealed the Department of Health’s uncertain and consensus-seeking approach to the problem.

But it still isn’t clear how these organisations will work, who their members will be, or what will be the difference between success and failure. More answers are likely to emerge from the DH and the nascent NHS Commissioning Board – but in the meantime there is a lack of clarity, and many stakeholders are putting forward their own competing proposals.

NHS Confederation deputy chief executive David Stout began the day by laying out the problem to an audience made up of clinical practitioners, pharmacy and nursing leaders, NHS managers or patient groups, as well as many of pharma industry execs directly engaged with the NHS.

Stout warned that Clinical Senates could be good news for the NHS, or bad, depending on how well they operate in reality. He said Senates could foster strategic, integrated planning: “Where the whole of the NHS comes together, be it secondary, primary or tertiary care and potentially social care as well.” This would help connect specialist and local services in the system which is in danger of being much more fragmented than before.

But he warned that on the other hand senates could turn out to be ‘just a talking shop’ and protect organisational interests, and help resist change and service reconfiguration. “At a very basic level, they could simply be another level of bureaucracy and another impediment to fast effective decision-making,” he added.

“So I think the jury is out as to what a Clinical Senate is going to be exactly and whether it will be a force for good or not.”

The Department of Health’s woman in charge of sorting out exactly how these components will work within the new system, is Dr Kathy McLean. Following a successful medical career including a spell as medical director at Derby Hospitals, McLean is now the DH’s clinical transitions director.

This means McLean is responsible for developing clinical networks and clinical senates to contribute to improving care quality across the NHS. It’s a big role that includes Clinical Commissioning Groups, and the NHS Commissioning Board, including specialised services.

It also means that, more than anyone, she knows how the argument is going over where commissioning influence will lie in future.

The role of senates and networks

Dr McLean says senates are intended to improve health outcomes, focus on NHS Constitution rights, and ensure NHS bodies work within resource limits.

Networks and senates are also intended to help give the public more choice and control over services, and help providers innovate and a reduction in inequality in access to healthcare. Furthermore, they are expected to support innovation and increase productivity and efficiency.

There is also a widespread expectation that senates will contribute to service reconfiguration – aka ward closures and hospital mergers. McLean revealed that there will be five clinical leads within the Commissioning Board, one for each of the outcomes in the NHS outcomes framework. They will be supported by professionals including nurses, doctors, scientists, and associated healthcare professionals.

Most Commission Board commissioning will be from offices across the country, and carried out by a team of around 100 commissioners in regional and local area teams working with senates and clinical networks.

Partnerships with clinical and professional groups are needed, said McLean, because of the huge amount of clinical leadership to be done. What form does the DH see the networks taking? There are to be a series of networks focused on activities the DH sees as strategically important – but NHS organisations will be free, even encouraged, to set up more as they see fit.

“Networks is a word people [in the NHS] use to describe many, many different things,” said McLean. “We’ve described what we’re talking about as strategic clinical networks, and we will be prescribing the areas in which we will set these up very soon.

“There’s no reason why other networks should not exist, and we hope there will always be local networks, and that CCGs and providers will engage with that. But these local networks will underpin the strategic networks.

“Without presupposing anything, if a particular area wanted additional funding for additional networks, it could be found,” she said.

The strategic networks will support CCGs and the Commissioning Board, support innovation and increase productivity and efficiency. They will be non-statutory management bodies, and the DH view is that they should represent their members, not the management supporting them.

They will be centered on disease areas or aspects of life-course – so for example, while McLean said there will be cancer networks, a children’s network could also be established. There will be a standard operating model outlining how networks will be structured and supported.

“We anticipate they will be supported for five years,” said McLean. “They will be reviewed during that time, and if their work has become part of normal business there will be an opportunity to move onto other things. However, if there is work to do, there will be nothing to stop a network continuing,” she quickly added.

The networks will be supported by secretariats and other management services provided by the NHS CB. “There will be 14-15 support hubs, and work is being done to decide what geographical areas these should cover. That does not mean there will be 14-15 strategic networks, however.”

For example, she said, while there are 26 cancer networks there won’t necessarily be 14-15 cancer networks in future – although she said the current total is expected to be reduced.

One of the key tasks facing officials in setting up a raft of new bodies and institutions is receiving appeals and lobbying from interested parties. “We’ve been hearing that it’s very important that the right expertise is available to networks,” said Dr McLean.

“We see potential for alignment between clinical networks, clinical senates, academic health science networks and other organisations being developed at the moment, such as local education and training boards.”

Clinical networks – what should they do?

• Act as honest broker

• Analyse and collect data

• Support commissioning

• Engage stakeholders in delivery of national strategies

• Ensure the provision of quality care and services.

Source: Cancer Campaigning Group report; quoted by David Stout.

Senates

Asked why senates were required when some believed clinical networks could be developed to fulfil their role, Dr McLean said the networks would not cover the whole of healthcare.

“So the clinical senates will have a different focus: they will be at a more strategic level, although it would make great sense for the head of a clinical network sitting on the Senate, and to have that tie-in.

“The specific role of the senates is to provide as non-conflicted clinical advice as possible – you don’t have to take the advice, but we hope that the senates will have credibility,” she said.

Responding to the often-expressed fear that senates would be yet another body set up to performance-manage healthcare professionals, McLean said they were not statutory bodies, and were not being set up to performance manage anybody.

“We see the clinical senates and networks as being part of a wider clinical advisory capability both for the CCGs and the NHS CB,” she suggested. Senates will operate across a broad area of care, and while they bring their skills and background, their members will need to act on behalf of that geographic health community – not for the benefit of colleagues or disciplines.

“They will not work unless their members forget their interests in their own professional groups and instead focus on what will benefit patients,” said McLean. “One of the things senate members will be able to bring is their knowledge of place – their knowledge of the area. They will also help with outcomes and quality at the heart of the commissioning system, and promote the needs of patients.

“They will not dabble in day-to-day CCG commissioning – absolutely not – but we see them having a strong role in spreading innovation and making sure evidence-based practice is spread, and also a key role in reconfiguration, because that is one of the big challenges that everybody faces going forward.”

McLean cited the example of a change in a vascular service. “When you change a service it quite often has knock-on effects – if you change what a vascular service does it may affect a variety of things in other organisations. What we envisage is that clinical senates will ensure the other services affected will not be forgotten.”

Senates will have a public profile in each area, and will only be successful if they are credible and seen as working alongside the public, she said. There will be some 14-15 clinical senates covering England, one for each support hub. Beyond that, the form the senates will take seemed far from decided.

“We suggest each senate should be a relatively small group of members – if you like, a steering group,” said McLean, “but it will be interesting to see what other people think about that.”

This small group will have the ability to draw on a wider range of advisers, including the clinical networks as the need arises.

“We’ve had all sorts of views about what sort of person the chair of a senate should be, but it seems the majority feel having a senior clinician in the role will be quite important, and that the membership should be a multidisciplinary and comprehensive as it can be within the constraints of size.

“Rather than being dictatorial, we’re hoping to create a framework that will allow local CCGs to shape how the senates are built up individually,” she said. “We expect them to share the supporting resource with the clinical networks, and that this will be key in enabling senates to know what’s going on in their patch.”

The next steps

What will be the next decisions to be made in creating the networks and senates?

“We’re talking now about how we can align senates and networks, specialised commissioning and the other bodies,” said McLean. “We need a map of geographical areas and also funding, and we want to get the operating model for the senates and networks finalised.

“We’re continuing with engaging with stakeholders, but will also being focusing on the needs of CCGs and the health and wellbeing boards. How do we make sure the senates and networks are positioned appropriately to enable them to fulfill their roles?

“In particular we have to think about the proposal that senates should have a core group and a broader group – is that the right thing?”

Pilot programmes will not be used to try out the senate model, but some areas will see them launched before others – for example, London already has a senate.

Another issue is the human resources question of what is to happen to the large number of employees already working for networks – and that’s a big job that the primary care trusts and strategic health authorities must address.

By the end of the conference, Dr McLean had heard concerns from speakers from a string of different groups. For example, a representative from a network interested in pharmacy appealed to the audience to consider the help and advice they could offer.

Dr Donal Hynes of the NHS Alliance warned that there was a real danger the new NHS would be much like the old, and argued that the funding of services should be sourced exclusively from providing services commissioned by CCGs.

Services that did not meet their needs would then be allowed to wither, and this would give doctors a freer hand to provide patients with what they wanted, and the evidence showed this improved outcomes.

Dr Angus Bell, adult mental health clinical director and the NHS North East SHA, said the mental health world had much to teach the rest of healthcare about integrated services. “In mental health we’re ideally situated to guide a lot of improvements [elsewhere in care],” he said.

“We have early intervention services, we’ve had an integrated care approach since 1994, we are multi-disciplinary by culture, and we have demonstrated success in providing alternatives to hospital treatment.”

Conclusions

Many other speakers and questioners made points from their own perspectives, and  McLean was diplomatic in her summing up.      For her, the message from the conference was that in setting up senates and networks, the important issue is to focus on outcomes, not that it was a question of either one organisation or the other.

“We need to concentrate on working together to maximise the huge potential benefits in bringing together the clinical networks, senates, CCGs and all the other organisations. It’s going to be a challenge, but it’s entirely possible if we step up to the leadership challenge.”

McLean says the DH will shortly reveal its detailed models for networks and senates. “We want the senates and networks to be in place for January 2013 to allow some slippage ahead of April 2013 – so there’s a lot to do in a short time.”

Gavin Atkin