NHS England has agreed more than 1,000 temporary contract variations when providers of specialised services have failed to meet new service standards, HSJ has learned.
The variations, known as derogations, could include failure to meet a range of standards laid out in any one of 128 specifications for services including organ transplantation and secure mental health provision.
The specifications were drawn up by NHS England during 2012-13 ahead of the organisation taking on responsibility for commissioning specialised services in April this year. It was always expected some providers would struggle to meet the standards but HSJ understands the scale of failure to comply with the specifications exceeds expectations.
NHS England’s interim policy on derogations anticipated they would be agreed only “occasionally”.
An NHS England presentation, seen by HSJ, says there are “in excess of 1,000 derogations against the basic required elements of service specifications”, creating a “substantial” work programme for the 10 local area teams responsible for specialised services.
HSJ understands the reasons for derogations could range from not having a specialist nurse on a multi-disciplinary team, something relatively easy to rectify, to a service that is not treating a large enough volume of patients, meaning it is unlikely the provider will be able to continue to provide the service long term.
The slide, titled “confront the brutal facts”, continues: “There are service reconfigurations required at regional and national scale that will shape the future of the specialised hospital.
“These include the unfinished business of services such as paediatric cardiac surgery, burns, vascular.”
Specialised Healthcare Alliance director John Murray said: “[There is] a big question for NHS England about whether it’s going to use these specifications as originally envisaged, to identify strong providers that are fully geared up to provide a full tertiary service, or whether it’s going to continue in time honoured fashion and settle for levelling down rather than levelling up.”
University Hospitals Bristol Foundation Trust has 18 derogations in place across seven services.
Its chief executive Robert Woolley told HSJ some of them were issues that “just needed time” to address while other would involve conversations with commissioners about resources.
He said the move to national specifications marked a “step change” in the commissioning of specialised services.
The slide also predicts the gap between resource available and the cost of specialised services over the next five years is “in excess of £3bn”.
It adds: “Clinical access policies are the only mechanism by which service growth can be contained.”
There are currently 23 clinical commissioning policies, governing when patients should be able to access treatment such as complex obesity surgery, and a further 14 interim policy statements.
The presentation said there was a need for 200 policies with “resources to complete in the region of 30-40 per annum”.
A further sign of the concern about the specialised commissioning funding gap comes in an email from clinical director for specialised services James Palmer to NHS senior clinicians, seen by HSJ.
Mr Palmer says there is an “estimated £900m gap in funding” during 2014-15 and calls for money saving suggestions, however “off the wall”.
In a statement Mr Palmer said the presentation described “early raw thinking” and was “designed to trigger internal discussion”.
He added: “We are still collating information from trusts about their services, and as more data becomes available, the number of derogations is decreasing. We will publish the latest information in January, once the compliance process is complete.”