The Department of Health is moving to “bring into line” commissioners who are increasingly restricting access to treatments and medicine, HSJ has learned.

A letter from NHS medical director Sir Bruce Keogh revealed by HSJ this week warned primary care trusts against referral restriction policies, particularly bans on procedures of allegedly “marginal or limited clinical effectiveness”.

It is also understood the DH is considering a tougher regime for checking whether commissioners are following clinical guidance in the future.

Sir Bruce wrote to strategic health authority medical directors telling them to inform PCTs that the department had ruled out “blanket bans” on treatments.

The letter said there had been “press and parliamentary interest in PCTs looking to address their current financial challenges through restricting patients’ ability to access… some services.”

Sir Bruce said the DH wanted to ensure referral policies included the potential for individual exceptions, where clinically justified, and were drawn up with clinical involvement.

He said the DH would not set out a national list of procedures of “limited clinical effectiveness”, but he would arrange a meeting of all PCT medical directors and agree a more “consistent” set of policies. Sir Bruce said: “While there is room for some variation [among PCTs’ approach to treatment restriction] there need to be good reasons for that.”

Sir Bruce said “the way we get the best value and most successful results is when managers’ and clinicians’ roles are aligned, and they are working together” on local referral and treatment policies.

British Orthopaedic Association president Peter Kay welcomed Sir Bruce “trying to bring the PCTs in line”. He warned that waiting times were “getting worse” for trauma and orthopaedics because PCTs were restricting access in “panic moves” to save money.

Mr Kay said there was “tension” in the localism policy. “If you allow local determination it allows the development of inequity because people start doing things very differently,” he said.

Meanwhile, PCTs have also been accused of limiting access to drugs approved by the National Institute for Health and Clinical Excellence, also to save money.

Senior figures in the pharmaceutical industry have said PCTs are grouping together and establishing “mini NICEs” to set stricter drugs funding policies, and are misrepresenting guidance to justify their restrictions.

A spokesman for the Association of the British Pharmaceutical Industry said the use of recommended drugs was “often variable”. He said there should be “mandatory adherence to NICE guidance and guidelines”.

HSJ understands DH officials are looking at whether and how the NHS Commissioning Board will be able to enforce commissioning guidance. The board will draw this up itself, incorporating evidence including NICE guidance and “quality standards” which set out how to provide the best quality services.

Officials are looking at whether they can take an approach described as “comply or explain”, which would see the board asking clinical commissioning groups which do not follow guidance to explain their decision. The aim is to encourage compliance and discover more quickly where there are good reasons to change the guidance.

The plans reflect NHS chief executive Sir David Nicholson’s expressed intention for the board to “put the N in the NHS”. In February he said the board would provide “support and direction” and would be “confident about leading change at scale”.

The pharmaceutical industry is understood to be hopeful that the “comply or explain” approach may be supported by recommendations of a review of innovation in the health service, being carried out by NHS South of England chief executive Sir Ian Carruthers.

Asked about PCTs restricting access to drugs, NHS Confederation deputy chief executive David Stout said: “If [PCTs] can’t afford it they have to limit what they do. [But] if you choose to [go against guidance] you should be willing and able to explain why.”