Exclusive: Clinical egos driving specialised commissioning costs

This was just one of the warnings issued by senior health leaders who were asked by the commissioning body last year for advice on how to cut the what was at that point predicted to be £900m deficit in its 2014-15 specialised commissioning budget.

Although NHS England now expects to break even on this year’s £13.5bn budget, the responses to last year’s appeal for ideas offers a worrying insight into senior healthcare leaders’ views of the sector.

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Among the 81 responses submitted to NHS England and seen by HSJ, one clinician warned the “full implementation” of new specialised services specifications over the next few years would lead to a “much greater overspend” than the £900m cited. These specifications were drawn up by 75 expert clinical reference groups last year, and were intended to establish the criteria for good quality services.

Some of the proposed savings ideas would likely prove highly unpopular among frontline staff. One submission from a member of NHS England’s national team suggested restricting the periods during which staff could take holidays “to eliminate unplanned seasonal variation in elective admission”. Such an idea would reduce the number of beds needed for specialised services.

As well as proposals by members of NHS England’s national team, the 81 money saving ideas were also submitted by other tiers of the commissioner’s management and members of CRGs.

Several clinicians from CRGs blamed the spiralling costs of specialised services on the lack of a prioritisation process to weigh up the relative benefits of different treatments.

A member of one CRG said members were “enthusiasts” for their specialty and tended to interpret evidence for treatments “in the best possible light”.

They continued: “The CRGs were not asked to prioritise treatments and there was then little constructive challenge to the proposed service specifications.”

NHS England has said that the creation of national specifications by CRGs had led to a “levelling up”, where services previously only available in some parts of the country were now offered everywhere.

However, one CRG member said many new treatments were being “introduced (and funded) by the NHS with little understanding of efficacy”.

They added: “Clinicians wish to give the best treatment to their patients. They are also competitive by nature and wish to be ahead of perceived clinical competitors.”

A proposal from another CRG member to halt the rollout of robotic assisted surgery appeared to have been adopted by NHS England almost immediately.

An NHS circular distributed in February banned any further hospitals from being commissioned to deliver robotic assisted surgery until a policy on the treatment had been produced.

The proposer said that although robotic assisted surgery had been shown to benefit patients in some procedures, it was also used for operations where there was no evidence for its use.

“This is happening because surgeons want kudos, centres want kudos and some surgeons are unable to do standard laparoscopic surgery, which in some instances is more than adequate.”

While NHS England is now forecasting a break-even position in 2014-15 with the help of £400m from previous years’ surpluses, concerns remain that there could be a repeat of the substantial overspend seen last year.

HSJ understands that the development of its five year strategy for specialised services has been temporarily put on hold while the internal specialised commissioning “taskforce” seeks to bring its budget under control.

While there are no current plans to revisit CRGs’ national specifications, one of this taskforce’s workstreams is developing a prioritisation framework to enable the fair comparison of the benefits of new treatments against each other.

A spokeswoman for NHS England said all the proposals were being considered by the taskforce’s “clinically driven change” work stream, led by clinical director for specialised services James Palmer.