What NHS England isn’t telling you, and more indispensable weekly insight for commissioners, by Dave West.

Difficult decisions

There’s always some background noise about commissioning treatment restrictions coming in and out, which is of no great interest, but the uptick over the past year, and past few weeks, is unmistakable.

West Kent is the latest to hit the headlines, and shortly before that we shone a light on restrictions in Worcestershire.

As the NHS plunges into the financial U-bend and more commissioners hit the bottom of the bowl, we can only assume this will arise again and again, in the absence of a clear blanket ban. 

So far NHS England’s approach to local restrictions appears ad hoc. Well placed observers say it has intervened from the top in certain cases, but declined to block others with similar characteristics, such as in York.

The sense I get is that many senior folks regard most instances as the folly of misguided and politically naive local commissioners.

But at the same time, on the quiet, parts of the hierarchy presumably accept that some of these moves are unpalatable but necessary to manage urgent financial pressures. Is NHS England’s approach to review and rule on all cases which come up, only those which are referred to it, or just when there is sufficient media and political attention?

The Worcestershire case is particularly interesting as the clinical commissioning groups have said an NHS England Right Care adviser was substantially involved in their decision. The official line is that Right Care doesn’t mean crude thresholds, but it’s always been a bit foggy how the programme can live up to hopes for short term savings without getting quite tough. I’ve yet to see a CCG say Right Care has shown it to be undertreating on something, prompting a decision to spend more in the short term, by the way.

NHS Clinical Commissioners is running a programme to help manage CCGs’ difficult decisions, presumably with a twin aim of offering moral support to members and encouraging them to avoid silly mistakes.

Continuing care

In another sign of “usual suspect” CCG cost dilemmas becoming chronic, our care quality correspondent Sharon Brennan has highlighted how local NHS Continuing Care spending limits are pushing people into care homes.

It’s occasionally overlooked that the NHS already spends a substantial and growing amount on non-healthcare; while this is another symptom of the broken system for people with ongoing care needs.

Recent work by our finance correspondent Lawrence Dunhill suggests commissioners were being leaned on heavily early this year to fill holes opening up in acute provider accounts following the December/January winter surge.

Remote control

Simon Stevens stands accused of being remote by Shrewsbury and Atcham’s Tory MP Daniel Kawczynski – who has, by the looks of it, been trying to get Mr Stevens to pay attention to Shropshire’s heated local reconfiguration dispute. I’ve lived in Shropshire and had thought anyone as familiar with the sprawling county as Mr Kawczynski would have a good grasp on remoteness. But I think he’s called it wrong in this case.

The NHS England chief executive is quick to get involved in local decisions when he thinks he needs to, but seemingly still has confidence in the Shropshire process despite its difficulties. By the standard of senior NHS officials, Mr Stevens is also close to many politicians. It’s just that they are, for England’s current polarised politics, the wrong politicians.

What Mr Kawczynski is probably frustrated at, and he’s not alone among MPs, is the nature of NHS England’s independence from government and Parliament, as created by the Health Act 2012 (which he voted for) and that Mr Stevens is flexing. This has made it harder for MPs to understand central processes; harder to take the “meeting with a minister” approach to local representation; easier for the NHS to avoid scrutiny on some issues; but also easier to point the figure at independent NHS officials trying to protect proper autonomy.