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

Scrutinising specialised commissioning

The string of well publicised problems surrounding specialised commissioning in recent years, some of which were documented by the National Audit Office last week, make it sorely tempting to reach for descriptors like debacle or disaster. This week a High Court judge stuck his boot in over what he said was a “totally irrational” drug funding decision by NHS England which should be overturned.

It’s not difficult to argue, in NHS England’s defence, that specialised would not be attracting so much scrutiny had it not been centralised nationally, making it a glaringly unmissable target. Would there be such attention if it were a single local commissioner, or a regional group, denying drugs, or overspending? Would the NAO be paying such attention?

There’s also the monstrous size and difficulty of the task. A £13bn-odd annual budget reflecting a very wide set of services; a rapid flow of expensive, high profile new treatments; providers across the country which have massive catchments doing some very complex work, some of them pretty aggressive; particularly emotive conditions and services; a rich pharma lobby with a reasonable argument about the need to innovate; and patients whose treatment paths are all the time crossing into the purview of 209 CCG commissioners and 150-odd councils. All of these are good reasons why it’s been very hard for national specialised commissioning to tick over smoothly.

All that given, though, while NHS England didn’t ask for this lot in life (and has been trying to shake some of it off via co-commissioning), for now there’s no escape – it will inevitably and rightly be held to account for what it does and how well it does it. In fact it is surprising its succession of problems hasn’t attracted wider attention so far.

Many of NHS England’s specialised screw-ups are, I think, not contested. For the first year or so of its responsibility (2013-14) the basics of commissioning like keeping an eye on activity and spending were simply not being done - leading to massive and uncontrolled overspends. Few of those involved would dispute this. In recognition of a wider problem, there were various internal reorganisations and attempts to bring in new leadership. In the last six months, two widely respected figures - Jonathan Fielden and John Stewart - have joined the specialised team, as overall lead and policy director respectively.

There are now glimmers of light. Spending was more under control in 2015-16, although there was still a “recovery” belt tightening under way in the south of England. A consultation is under way on what will hopefully prove, at last, to be a robust method of prioritising new treatments (the past three years have seen several failed efforts). Given the circumstances described above, though, keeping a lid on finance and basic delivery will still take lots of sustained attention.

Where are the biggest outstanding gaps to deal with? The NAO is right to point to the absence of a strategy. NHS England never made sense out of the early declaration by ex-chief exec Sir David Nicholson that it would use its specialised powers to reshape the regional hospital centres he described as “the commanding heights of the health economy”. Since then, no coherent plan has filled the vacuum.

Back in 2013 commissioners boldly revealed there were thousands of instances of specialised services falling below acceptable standards

What progress has been made? We don’t know: NHS England won’t say. It needs to begin addressing variation in cost and quality in earnest, including by tackling providers in some specialties which should not be providing at all. Trying to do this across the board in one go is probably unwise but a more coherent and ambitious approach is achievable.

In relation to new treatments and technologies, the new cancer drugs fund compromise and forthcoming accelerated access review are not going to solve the issue. It will never be possible to always reconcile the apparent effectiveness of treatments with affordability. NHS England won’t avoid frustration or criticism by being more consistent, bringing transparency to its decision making (as it has tried for attempts to sort out gender identity services, for example), or by taking its collective head out of the sand to explain the trade-offs it has to make. But it should do both these things anyway.


This week’s: CCG meltdown

An external review of Kernow Clinical Commissioning Group has found “evidence of a culture of bullying and harassment” at the troubled organisation. Kernow has been subject to legal directions since December, discovered a large deficit in-year during 2015-16, and its chief officer is currently suspended. The review, key findings of which have been published this week, found a string of serious problems including “confusion and dysfunction” in governance and management.

Dave West, senior bureau chief

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