Conclusions and recommendations
1.NHS England still does not have a clear plan for the future configuration and delivery of specialised services. NHS England told us that its objectives for specialised services are to: (a) deliver consistent high-quality care through the levelling up of standards nationally; (b) maximise what they get for what they pay; and (c) provide seamless care for patients through better linkages between specialised and other health services commissioned locally by clinical commissioning groups. However, NHS England has not communicated to service providers, patients and other stakeholder its plans for the future configuration and delivery of these services. In addition, NHS England has not clarified how specialised commissioning sits within the Five Year Forward View for the NHS or how specialised services will contribute to the £22 billion efficiency challenge faced by the NHS over the next five years. This lack of direction has affected NHS acute trusts and clinical commissioning groups’ ability to plan and develop their services. An increasing number of NHS trusts, including specialist trusts, are now in financial deficit. While the Government has provided a £1.8 billion sustainability and transformation fund to help trusts in financial difficulty achieve financial balance, we are concerned that the approach to NHS funding across the board is not joined-up.
Recommendation: NHS England should set out publicly, by October 2016, how specialised services fit within: the NHS Five Year Forward View; the £22 billion efficiency challenge that the NHS faces; and the transformation funding aimed at addressing provider sustainability.
2.Accountability, to both patients and taxpayers, is undermined by the lack of transparency over NHS England’s decision-making in relation to specialised services. We received a number of submissions from patient interest groups and pharmaceutical companies that raised concerns about the lack of transparency over NHS England’s decision-making on the funding of new treatments. While recognising that there is a need for commercial confidentiality in some situations, we are concerned that NHS England does not make any of the minutes or meeting notes of its key decision-making groups, such as the Specialised Commissioning Oversight Group, publicly available. This lack of transparency has undermined NHS England’s credibility among patients and other stakeholders and led to legal challenges to some of its decisions. We welcome the fact that NHS England has recognised this as an issue and is consulting on a new decision-making process for the introduction of new treatments.
Recommendation: As a matter of urgency, NHS England must ensure that a consistent process is put in place to ensure its decision-making is transparent and equitable. It must improve the transparency of its decision-making by publishing a document, by September 2016, which sets out the roles of its advisory committees and decision-making bodies, the decisions they make, how these decisions will be documented, and when and to whom they will be made available.
3.NHS England has yet to overcome the barriers to collaborative commissioning with clinical commissioning groups. For many patients, specialised services often only cover part of their care, with other commissioners involved in the rest of the patients’ care pathways. For example, if you are a cancer patient and you need surgery, it will be funded by local clinical commissioning groups; but if you need chemotherapy or radiotherapy, it is likely to be funded by NHS England as a specialised service. For some patients this division has impacted on the continuity of care, and in some cases access to services. To address this, NHS England intends to commission many specialised services collaboratively with clinical commissioning groups. The NAO found that most clinical commissioning groups support a more joined-up approach to commissioning these services but these groups believed that more clarity about costs and better engagement with NHS England were needed.
Recommendation: NHS England should engage with clinical commissioning groups to address barriers to collaborative commissioning and, by October 2016, set clear milestones and timelines by which measurable service change and patient benefit from this initiative will be demonstrated.
4.NHS England does not have the information—on costs, access and outcomes—necessary to assess how to improve services. There is a lack of consistent data on cost because NHS England uses three different payment arrangements for specialised services. For about one-third of the specialised services consistent data are available because payments are based on the level of activity and unit prices (tariff) set at national level. However, there are no consistent national data for the remaining services—those paid for according to locally agreed prices and those where the costs of medical equipment and high-cost drugs are reimbursed at the price paid by providers to suppliers—because local commissioning teams collect data differently. There is also a lack of data on patient outcomes. NHS England acknowledges that it is challenging to collect robust outcomes data for many of the specialised services it commissions. The lack of consistent data means NHS England does not know whether it is meeting its objectives in improving patient outcomes and reducing inequalities across geographic areas. It also means that NHS England cannot make strategic decisions about where and how services are delivered to achieve better value for money. NHS England told us that it is improving the use of standard reporting formats on cost and activity.
Recommendation: NHS England has told us that it will be collecting more consistent data. By April 2017, it should use this data to link spend, by service provided, to service quality, patient outcomes and patient experience; to allow clear comparison between different providers and to improve value for money.
5.New drugs and medical equipment are putting pressure on the budget for specialised services that may affect NHS England’s ability to resource other health services. NHS England has found it challenging to live within its budget for specialised services, overspending by £377 million in 2013–14, and by £214 million in 2014–15. In 2014–15, the Cancer Drugs Fund accounted for £136 million of the overspend. The increasing volume of expensive but often effective high-cost drugs (about £3 billion in 2015–16) and high-cost medical equipment (about £0.5 billion) are contributing to the rising costs of specialised services. NHS England recognises that if it is unable to live within its budget for specialised services, this will affect its ability to resource other health services. NHS England told us that the different elements of medicines pricing, access and funding arrangement (the voluntary pharmaceutical price regulation scheme, NICE technology appraisals and NHS England funding decisions) are not working together ‘optimally’ at the moment. For example, NICE approves drugs that are to be routinely funded by commissioners but NICE does not always consider affordability when approving these drugs (about two-thirds of the new drugs approved by NICE are used in specialised services). NHS England highlighted that NICE had taken a more thoughtful approach for a new Hepatitis C treatment, enabling NHS England to adopt a phased approach to introduction. However, The Hepatitis C Trust has filed court proceedings challenging NHS England’s decision to adopt this approach.
Recommendation: The Department of Health and NHS England should, in collaboration with NICE, ensure affordability is considered when making decisions that have an impact on specialised services. For example:
- By building in consideration of how the cost of implementing NICE recommendations can be kept affordable within available commissioning budgets.
- By using national bargaining power to get best prices for high-cost drugs.
6.There are significant variations in the extent to which providers are meeting national service standards, but NHS England cannot be sure what impact this is having on patient outcomes. NHS England requires providers to meet the generic quality and safety standards set by the Care Quality Commission for all services. It has also set additional national specifications and standards for specialised services that all trusts are expected to meet. NHS England told us that these ‘gold standards’ reflect the best available clinical evidence or practice and were set with a view more towards the quality or excellence of outcomes rather than affordability. In February 2016, only 83% of services were compliant, with the compliance rate varying from 74% in the North West to 95% in the East Midlands. NHS England told us that it did not think that the variation in compliance with standards reflected a “radical difference in the quality of care for patients”. However, given the variation in performance in different areas and the fact that these standards are supposed to reflect best practice, we remain unconvinced that NHS England can indeed be confident that failing to meet these standards does not reflect significant difference in actual service standards.
Recommendation:NHS England should undertake an evaluation of the impact of not meeting service standards on patient outcomes. It should reclassify service standards where appropriate in light of these reviews and set out clear timelines for resolution where patient outcomes are adversely affected by service standards not being met.
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12 July 2016