When the UK National Health Service (NHS) was established in 1948 the overriding philosophy is that patients will get what ever treatments they require and that any doctor could refer any patience to any specialist and it was an important feature of the low administrative costs that money did not change hands during the process.

This meant that patients got the treatment that they required although if a lot of patients were referred to the same specialist or department then waiting lists would develop and some patients have to wait a long time

It was also strange that hospitals received their funding based on historical accounting that is what was provided last year plus various adjustments brought in by the Department of Health according to the political flavour of the day.

Long waiting lists and financial crises in hospitals led to successive governments developing in various ways of trying to "manage" the health service.

We now have a system where money from the Department of Health is provided to Primary Care Trusts (PCTs) who are charged with responsibility of purchasing care from providers, mostly hospitals although others such as General Practitioners (GPs) and pharmacists can provide anticoagulants services.

PCTs are under continuous pressure to reduce the costs and therefore if they perceive a service to be expensive they will invite others to provide the service.  In terms of anticoagulation this can mean that if the service is hospital-based then GPs pharmacists or a neighbouring hospital could provide service.

After conducting a small survey through e-mailing a large number of various providers, I received a fair number of replies from people who had worked hard to develop a high quality service and to find that their PCT was effectively saying that they were not prepared to fund an expensive service and that rather discussing quality issues they would try and find an alternative provider at a lower cost.

I did find one hospital that had successfully devolved the service to the community whilst keeping overall control of professional standards and providing advice when required.  The major difference between this and the other examples is that they were able to impress the PCT is that their willingness to change and the financial issues never became the overriding concern.

The commissioning process is relatively new and most commissioners are not clinicians and do not understand relevant quality parameters .  Fortunately the UK National Patient Safety Agency

(NPSA) has spelt out the all that and quality standards that need to be met which hopefully will enable commissioners to appreciate what makes for a safe service.

Experienced providers of anticoagulants services with high standards will now be able to illustrate to PCTs that they provide a service to the NPSA standard .  Having a detailed database, as provided by Dawn AC will greatly facilitated demonstrating that the service can provide the quality and audit standards as required.