• NHS England outlines detailed methodology for choosing which specialised treatments to fund
  • Methodology has been in development for 18 months after previous approach dropped because of fear of legal challenge
  • National body accused of giving itself “wiggle room” to help it get grip of specialised commissioning costs

NHS England has outlined its long awaited methodology for choosing which new specialised treatments to fund.

The development of a process for prioritising new treatments has been much delayed, after NHS England was forced to go back to the drawing board in December 2014 when its proposed approach was threatened with a legal challenge.



The evidence base for treatments for rare conditions is often limited

Under the new approach, which has been put out to consultation, NHS England’s clinical priorities advisory group (CPAG) will categorise each treatment proposal on whether it delivers a “high”, “medium” or “low” benefit to patients.

The treatment will then be placed on a “matrix” plotting the patient benefit against the intervention’s cost. Cost will be measured on the basis of cost per patient over five years, with each treatment ranked on whether they are “high”, “medium” or “low” cost.

The cost thresholds will depend on the range of treatments in each commissioning round, meaning they are likely to differ from year to year.

Depending on where each treatment appears on the matrix, they will then be given a priority level from one to five, with level one as the highest priority.

However, CPAG will be able to make “adjustments” to these rankings based on “consideration of four principles… which reflect NHS England’s broader strategic ambitions”. These are whether the treatment significantly:

  • benefits the wider health and care system;
  • advances parity between mental and physical health;
  • stimulates innovation; and
  • reduces health inequalities.

The evidence base for treatments for rare conditions is often limited, so CPAG will be able to recommend prioritisation in these cases even where there is little published evidence on their clinical effectiveness.

The final say on which treatments to fund will be for NHS England’s specialised commissioning committee, though it will be required to record its reasoning “for any variation from the advice” it receives.

Ed McIntosh, from the consultancy Incisive Health, said NHS England was seeking to give itself significant “discretion” over what it funds.

“These proposals are the latest in a series of reforms as NHS England continues to struggle to get a grip on specialised commissioning costs,” he said.

“The proposals might be about transparency but the real issue is that NHS England is trying to give itself more wriggle room on what it has to fund.”

He added: “Although doctors and patients will not automatically object to flexibility, there will be an outcry if it is a one way street to cut costs.”

John Murray of the Specialised Healthcare Alliance said at first glance the proposals seemed “broadly sensible”.

However, he said it was of “key importance” that NHS England “exercises judgement” in its use of the matrix “to avoid falling into the trap of simplistic scoring”.

He said: “A clearer idea of what is meant by rarity is also required as well as an assurance that a proper explanation will be published for the decisions taken.”

A NHS England spokesman said: “Like the NHS as a whole, specialised commissioning faces significant challenges to use its budget for the best value for patients; whilst we have allocated significant increases in its budget there have been even more demands from NICE directions and other clinical innovations and demographic pressures.

“It is therefore right that we have taken a rigorous approach to ensuring our decision making is transparent and reflects the needs and priorities of patients. In working through these challenges NHS England’s approach leads the world in ensuring we can prioritise our limited funds in the best way for patients and the public.”

The consultation closes on 11 May.