The Integrator: Time for difficult decisions

Consolidating specialised services

In 2016, the National Audit Office called out NHS England for not having an “overarching strategy or vision for commissioning specialised services”.

But 2019 might finally be the year where we see a shift from holding the line on the budget to developing a clearer plan to drive up patient outcomes.

There has long been a recognition that the number of trusts offering specialist services needs to be reduced, but moves to address this have been painfully slow as very few are prepared to give up the income and prestige the services can bring.

We only need to think of the children’s heart surgery debacle in which the Royal Brompton Hospital and Leicester made spectacularly expensive or difficult promises in order to be able to keep their units.

Earlier this year, NHS England said it would be scrapping its ‘gold standard’ quality requirements in favour of a broader set of indicators, which appeared to mean that fewer services are likely to be deemed unsafe and slated for consolidation.

But multiple services will remain unsustainable on safety and/or financial grounds, and the national commissioner has again started making tentative noises about reconfiguration.

Laura Norris, NHS England’s head of strategy and policy for specialised commissioning, told a Westminster Health forum event last week that “active steps” will be taken next year to reduce variation. This will involve taking “difficult decisions” as her team seeks to strike a balance between quality, access, and provider stability, she said.

As part of this, it looks like there will be a greater focus on data collection with a new information team being set up within the national spec com directorate, so it can better understand who benefits from its services.

Ms Norris hinted that the available data is not yet good enough to understand where care variation exists and whether that variation is unwarranted in comparison to the population’s health.

Better data would clearly help commissioners make those difficult decisions, but data doesn’t get better without lots of effort across the system, so this won’t be an easy task.

What else will change?

There will also be a “new drive for spec com integration,” as there is a need to “overcome the binary choice of services either being spec com or local commissioning”.

To help with this, I’ve heard that there is an ongoing internal consultation of staff at the 10 regional spec com hubs as NHS England looks to fit them into the seven new regional teams.

This in turn will make it easier to devolve spec com down to the regions if NHS England can find the appetite to do so.

From the established integrated care systems I’ve spoken with, there is a clear desire to take on some specialised commissioning duties but they will only do so if the financial risk is shared with NHS England as the new system beds in. It is a risk that the regulator is apparently not keen on accepting as it would lose control while retaining risk.

To overcome this regional stalemate, a new spec com framework is under development to help systems understand how best to integrate those services into local plans. It wouldn’t be a push either to imagine NHS England spec com staff devolved down to ICS or sustainability and transformation partnership level, as NHS England is doing with other roles, to help with that work.

NICE work

There looks like there may also be interesting changes afoot in how the more expensive drugs are made available on the NHS.

The new pharmaceutical price regulation scheme, which decides how much rebate the NHS receives from pharma, was agreed this month. The final document said the National Institute for Health and Care Excellence will review its increasingly troubled highly specialised technology process in the next financial year.

Vertex, the manufacturer behind the new generation of drugs to treat cystic fibrosis, has made lots of noise about the process failing to work for the new generation of genomic medicines, but I’m told at least three other genomic-based drugs are also stuck in the system.

The document also says NHS England will develop a commercial framework for how drug companies can work with the regulator. Industry has long complained about the slow uptake of new meds in England and this was a major feature of the PPRS negotiations. It is not clear what this framework will look like but we may begin to see a greater volume of drugs coming onto the market than we have done previously.

Oh Gee-nome

Finally, a mention must be made of Matt Hancock’s genome plans. This month he announced the UK has finally sequenced 100,000 genomes since the project was first announced by David Cameron in 2012.

Mr Hancock has said the UK will now sequence five million genomes in the next five years – a decision apparently made at the very last minute as he did not think the original plan to sequence a million genomes was bold enough.

We can expect him to be fretting next year as to how this target can possibly be achieved.