Underestimating the costs of specialised commissioning and how recent changes would affect the service can be accounted for by the lack of rigour in the relationship between NHS England and providers, John Murray argues

John Murray

John Murray

After many years as an important - but largely disregarded - backwater of NHS policy, specialised commissioning is now in the headlines regularly.

The danger is that the wrong conclusions will be drawn from the significant overspend in 2013-14.

So what went wrong?

Before looking into the causes of this overspend, it is worth recalling why a radical change in specialised commissioning was mooted before, and proposed after the last general election.

The situation for patients with rare and complex conditions was far from halcyon prior to 2010, with large variations in access to care resulting in unacceptably different outcomes for patients with conditions like muscular dystrophy.

This, more than anything, precipitated the decision to bring budgets and responsibility for specialised services together under NHS England’s roof this year.

Almost uniquely, it was also a change that broadly attracted the support of all political parties in the context of an otherwise highly controversial health and social care bill.

So what has gone wrong?

The scope of specialised services was significantly extended in conjunction with this major reform. The specialised services national definitions set was taken as the starting point - with an estimated cost of £9.8bn - to which was added all radiotherapy, chemotherapy drugs and HIV outpatient care, taking the estimated bill up to £12bn.

‘Stevens’ remarks seem at complete odds with the rationale for the new arrangements in specialised commissioning’

At the same time, the number of staff assigned to specialised commissioning was roughly halved.

Notwithstanding the greater efficiencies anticipated for the new arrangements, this now looks like a triumph of hope over experience.

The confidence attached to these figures was also largely specious with substantial swathes of expenditure previously uncounted, and the estimates provided by disbanding primary care trusts inevitably suspect.

The Specialised Healthcare Alliance understands that the resultant underestimate might account for about a third of the overspend.

However, the lion’s share can be attributed to the lack of rigour in the relationship between NHS England and providers, touched on by Simon Stevens in his recent interview with the HSJ.

However, these remarks seem at complete odds with the rationale for the new arrangements in specialised commissioning.

Missing the point

Specifically, in reply to a question about the future of the 23-year-old purchaser-provider split, the NHS England chief executive suggested the problems in specialised commissioning show what happens when you have open ended provider funding, detached from an active commissioning function related to population needs.

This may be how things looked to Mr Stevens on arrival at NHS England, but nothing could be further from the intention behind the new arrangements.

‘If NHS England can’t deliver the best for patients while looking after taxpayers’ interests, bring the shutters down on the purchaser-provider split’

Historically, local commissioners struggled to recognise and plan for the needs of smaller patient populations.

The often high and unpredictable costs of treatment for rare and complex conditions have posed problems for local budgets, while the highly fragmented customer base for tertiary trusts resulted in a provider dominated relationship where commissioners had little or no clout.

Extraordinary to say, but the expectation was that NHS England - as a sole specialised commissioner commanding a very high market share at such trusts - would be in a powerful position to exert its will, based on greater parity of expertise.

Put another way, if NHS England cannot deliver the best for patients needing specialised services while looking after the interests of taxpayers, the time really will have come to bring the shutters down on the purchaser-provider split.

Premature perspective

From the alliance’s perspective, however, that conclusion still seems premature.

To have a national risk share for specialised conditions makes sense. The introduction of service specifications and commissioning policies for rare and complex conditions represents a huge leap forward from the fragmented approach of the past.

The ability to distinguish between genuinely exceptional cases and service developments when viewed from a national perspective also has considerable merit, providing it is accompanied by speedy policy formulation to protect the patient and public interest.

‘NHS England must grasp the nettle and deliver stronger commissioning with clear leadership’

Most of what has gone wrong with specialised commissioning over the last 18 months has been due to poor execution - partly related to inadequate capacity, rather than the conception itself.

To take the most glaring example, Lord Carter’s review in 2006 recommended that regional commissioning groups should cost care pathways in specialised commissioning. This failed to happen in the following six years and explains in part why the 2013-14 budget was so awry.

As a single commissioner now armed with national service specifications, the means should be at NHS England’s disposal to put matters right fairly swiftly.

Conversely, devolving chunks of specialised commissioning back to clinical commissioning groups before the job is done simply risks perpetuating the problems less visibly elsewhere.

Integration between specialised and other services is, on the face of it, a greater weakness in the new arrangements, but the supposed strength of PCTs in that regard proved largely illusory, while more and better communication should be capable of developing networks centred on the patient, regardless of administrative divides.

The task in specialised commissioning to and through the next general election is therefore to recognise and put right what has gone wrong in arrangements that continue to hold much potential.

NHS England must grasp the nettle and deliver stronger commissioning with clear leadership. Anything else would be a counsel of despair and a complete disservice to patients.

John Murray is director of the Specialised Healthcare Alliance