Description
Commissioners abandon specialised Immunology
Concern about the delivery of PID services in Greater London prompted the development of a definition of the service which came to be called ‘Specialised Clinical Immunology’ (see CPD Bulletin Vol 2 No 2 60-64 2002; http://www.dh.gov.uk). Defining this service, with the potential to cost it reasonably accurately, encouraged the commissioners for Specialised Services in London to consider this area for centralised funding. The process got underway about 2 years ago and much energy was put into it by various London immunologists and the commissioners themselves, and latterly by financial managers in some Trusts who have managed to produce accurate costings for the service.
Specialised Clinical Immunology seemed ideal for a commissioned service since it involved less than 500 PID patients in London at the expensive end of the spectrum. There was already good interaction between the clinical immunologists managing the PID patients in London, boding well for the development of an active clinical network that would encourage good clinical governance. The hope was that if the commissioned service in London was a success then the model would be adopted elsewhere in the UK.
Earlier this year the London Commissioners announced suddenly and unexpectedly that they were abandoning the commissioned service for Specialised Immunology. No proper explanation was given for this decision; except that our area was low priority and that there had been some problems in costing the service in some London Trusts. Nevertheless, a robust banding system for costing different intensities of diagnosis and treatment for PID patients has been successfully set up in more than one London Trust and could have easily been adopted by other Trusts involved in PID services.
This decision is a potentially serious blow for the delivery of PID services nationally, but particularly in London. The Department of Health, through the Commissioners, seem to be saying to immunologists that the management of PID patients does not need to have a protected budget, and can fight its own corner within General Medicine. This does not sit comfortably with the efforts of the United Kingdom Primary Immunodeficiency Network (UK PIN), and the Primary Immunodeficiency Association (PiA) who over the past 5 years have been developing accreditation procedures for PID clinics which require a certain level of expertise in managing these patients. Although a clinical network for PID in London still meets every 3 months, the lack of a commissioned service is likely to sap the enthusiasm for maintaining a high level of clinical governance in this area; furthermore, Trusts with a current major commitment to PID services may not wish to support this area in the future, particularly if there are problems in getting reimbursed from PCTs. Moreover, larger London PID centres may not feel it is in their interests to help smaller centres to gain accreditation for PID services, this being the preferred model to enable small centres to grow under the general guidance of a larger and more experienced centre.
It seems that we are entering a period of ‘survival of the fittest’, the winners being those PID centres that can maintain a critical mass of clinical expertise and good support from their Trust managers. An unstable period is likely with some patients in London loosing access to expert clinicians. Leadership from within the younger generation of clinical immunologists is urgently needed to protect standards of care for PID patients.
