Annex A > Chapter 7 - Supra Regional Services > The national framework > Rationale for supra regional funding
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Rationale for supra regional funding
11 The concept of focused, specialised centres for, amongst other specialities, NICS, was something discussed within the medical profession from at least the 1960s.
12 Dr Norman Halliday (Medical Secretary, SRSAG 1983-1994) said in evidence:
`The reason for setting up the supra regional service and the reason for selecting any particular service was principally funding ... But of course from the Department's point of view, we recognised that there was also a benefit in that. There was a benefit in that we could control the development of the services, which would be beneficial in terms of cost, but also beneficial in terms of benefits to the patients, because the experience worldwide was that the more a doctor does a particular form of treatment, the better are his results. So by controlling the development of these services, we would be giving benefits to the patients.' [1]
13 The process by which the system was gradually established began in earnest from 1974 onwards. It included the setting up of a Joint Working Party between the Department's Medical Policy Division (MPD) and representatives of the medical profession to consider how specialised clinical services should be delivered. [2]
14 This Working Party met regularly and, in 1983, the need for specialist services was agreed between the Department, the RHAs and the Joint Consultants' Committee (JCC) such that, consequently, SRS arrangements would be introduced. A view was taken that, in order to be economically viable and clinically effective, the small number of specialised health services (serving a population substantially larger than that of any one region) could not be funded through the usual mechanism.
15 In his formal written statement Dr Halliday stated that, in relation to designation:
`An essential criterion which was agreed with the medical profession during the protracted discussions leading to the establishment of the SRS arrangements was the requirement that a designated service should not be provided outside of designated units.' [3]
16 Dr Halliday defined the `medical profession' as the JCC, the Royal Colleges and the British Medical Association (BMA). [4]
17 In oral evidence he also described his understanding of the role of advice from the Royal Colleges, in designating particular units as part of the SRS:
`I think you would have to ask the Royal Colleges what they were looking for, but what we would expect from the Royal Colleges is their expert opinion as to the facilities available in the unit, the staffing of the unit, the qualifications and experience of the staff, and in their opinion, the ability of that unit to provide that service.' [5]
18 In respect of proliferation, the SRS was able to nurture the chosen specialties, many of which were new forms of treatment or treatments for small groups in the population, thus allowing expertise to develop within the funded Centres. It appears to have had some success in limiting the spread of some specialised services, e.g. transplant surgery. Dr Halliday's view was that the overall supra regional system had `proved to be a complete success'. [6] He said:
`If one can implement the arrangements effectively, you should have the services concentrated in a few centres.' [7]
However, paediatric cardiac surgery had already been provided in a number of units before the scheme began and proliferation in this area was always difficult to control.
19 The SRSAG knew that there were `too many' units undertaking NICS, as Dr Halliday explained:
`... the supra regional service arrangements were set up for any service that fitted the criteria. We took neonatal and infant cardiac surgery into the arrangements knowing that there were more units than we needed. We hoped we could bring about a rationalisation. That was not achieved. That is not a failure of the supra regional service funding arrangements, that is a failure of trying to change an established service, which had been in existence for decades, and, in the absence of any formal powers that will allow anyone to tell doctors what to do, I do not think it is in the interests of anyone to tell doctors what to do.' [8]
20 The Department had no binding powers to limit services only to designated centres and, indeed, recognised this. For example, on 27 October 1986 Mr Antony Hurst (Administrative Secretary of the SRSAG, 1983-1987) wrote to the South Western Regional Health Authority (SWRHA), indicating that the supra regional arrangements were:
`... essentially funding arrangements, and we have no powers to determine referral practices which remain a clinical responsibility; HN(83)36 discourages health authorities from providing supra regional services in units that are not designated as supra regional centres, but this is not binding on clinicians.' [9]
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Footnotes
[2] WIT 0049 0002 Dr Halliday
[3] WIT 0049 0013 Dr Halliday
[4] WIT 0049 0018 Dr Halliday
[6] WIT 0049 0003 Dr Halliday
[9] UBHT 0062 0213; letter dated 27 October 1986 from Mr Hurst to SWRHA