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

NHS England’s decision about the future configuration of congenital heart disease services got a bit buried by the row over the Budget at the end of last year.

Over the past couple of years, the national commissioner appeared to believe that there were too many sites carrying out specialised surgery (a view shared by many experts over recent decades) and seemed serious about putting a stop to it.

With the centre often imploring change in outdated patterns of provision (a message we will hear a lot during the NHS’s 70th birthday year) and NHS England as the single commissioner indisputably in the driving seat, it seemed an opportunity to do the brave, right thing and lead by example.

The position the board reached, though, looks on the face of it like a ducking of the most difficult decisions. Centres in Leicester and west London, earmarked to close, both had weighty lobbies behind them. They were given a reprieve on the basis that they have ambitious plans to meet required standards in coming years.

That these will all be achieved is far from certain (NHS England acknowledges this – it will be reviewing progress). If they are met, then if commissioners still believe there are too many centres in the country, enhancing these particular ones might only be at the expense of future safety and stability in the round.

To some informed observers it looked like NHS England had marched its troops up the hill then decided – with other fights on its hands – it didn’t want this battle.

NHS England would reasonably argue that it is achieving improvements in Leicester and London, and that several less controversial changes have also been made under its “standards based approach”, which is a lot better than nothing. These include removing surgery from Manchester.

Commissioners might also argue that their hands were tied by process and legality – the standards based approach doesn’t seem entirely consistent with the principle that services must be sustainable into the future not just present, or the view that there’s a maximum number of sites needed in England. If NHS England had been decisive about Leicester and/or the Royal Brompton, it would likely have been taken to court.

Sir Bruce Keogh, who has been deeply involved with the debate over children’s heart surgery for years, was excluded from the final stages of the process on the basis that he is conflicted as he is imminently joining Birmingham Women’s and Children’s Foundation Trust. But he gave an impassioned speech (even by his high standard) to introduce the item at the board meeting – you can watch the discussion online.

One of his main points was that the long running uncertainty in the specialty was highly damaging and needed to stop. It is difficult to see how the board’s decision, which includes ongoing review of several important things, achieves that.

The wider issue is NHS England’s appetite for dealing with service standards, efficiency and configuration among the specialised services it commissions and could have huge leverage over. It has occasionally been blunt about suggesting that the “long tail” of trusts providing small bits of specialism should be cut, and in theory there is a rolling programme of service reviews. There are one or two examples of progress.

But it’s not clear much progress is being made. Regional and national reconfigurations are out of fashion, not being in tune with NHS England’s focus on putting place based decision making back together, and integration of more general care.

Within specialised service commissioning, the big focus is on staying in budget by containing drug and device costs. On its own terms that appears to have been successful. But it does leave a hole where there might be more of a strategy to address variation, inequity, quality and efficiency in the pattern of specialised services.