Alastair Whitington looks beyond the acronyms to explore the role of NHS England in commissioning specialised services and highlights its 2017–18 priorities
The Health and Social Care Act 2012, which came into force on 1 April 2013, significantly changed the way in which specialised services were commissioned, enabling a single, national commissioner (NHS England) to put in place national standards and service specifications across the country. This introductory editorial summarises how NHS England’s specialised commissioning arm is organised, its role and current priorities, and outlines the annual prioritisation process and management of the Cancer Drugs Fund (CDF).
NHS England is directly responsible for the commissioning of specialised services.1 Four factors determine whether NHS England commissions a service as a prescribed specialised service. These are the:
- Number of individuals who require the service
- Cost of providing the service or facility
- Number of people able to provide the service or facility
- Financial implications for clinical commissioning groups (CCGs) if they were required to arrange for provision of the service or facility themselves.
NHS England is responsible for commissioning 146 specialised services with a budget of £16.6 billion—15% of the total NHS budget—grouped into six national programmes of care (NPoC):2
- Internal medicine—digestion, renal, hepatobiliary, and circulatory system
- Blood and infection—infection, immunity, and haematology
- Mental health
- Trauma—traumatic injury, orthopaedics, head and neck, and rehabilitation
- Women and children—women and children, congenital, and inherited diseases.
Each NPoC has several clinical reference groups (CRGs).2 These groups consist of clinicians, commissioners, public health experts, patients, and carers. They lead on the development of clinical commissioning policies, service specifications, quality standards, and outcome measures, and advise NHS England on the best ways to provide specialised services.
- The specialised commissioning decision-making hierarchy is as follows:
- The Specialised Services Commissioning Committee (SSCC), which reports to the NHS England board, provides advice on the development and implementation of NHS England’s commissioning strategy and assurance of quality, performance, and value for money
- The Specialised Commissioning Oversight Group (SCOG) has operational responsibility for specialised commissioning
- The Clinical Priorities Advisory Group (CPAG) recommends the commissioning position of treatments and interventions for adoption, or otherwise, by NHS England
- Six NPoC
- A total of 42 CRGs.
NHS England commissions only from providers who comply with its service specifications. The Manual for Prescribed Specialised Services 2017/18 describes which elements of the 146 services are commissioned by NHS England and which by CCGs.3 In 2014–2015, 10 services accounted for 63% (£9.8 billion) of the spend on specialised services (see Figure 1).4 Total expenditure on specialised services will increase to £18.8 billion by 2020–2021.4
Figure 1: Specialised services with the highest costs, 2014–20154
National Audit Office. The commissioning of specialised services in the NHS. London: NAO, 2016. Available at: www.nao.org.uk/wp-content/uploads/2016/04/The-commissioning-of-specialised-services-in-the-NHS.pdf (Reproduced with permission).
Specialised commissioning is delivered through teams based in five regions:5
- North of England
- Midlands and East of England
- South West
- South East.
In 2015–2016, 489 full-time equivalent staff worked for NHS England on commissioning specialised services.4 Teams of service specialists and contract managers, with public health input, commission NHS and private providers of specialised services in their regions on behalf of NHS England.
Although health is a devolved policy area there is UK-wide cooperation on specialised commissioning through the Rare Diseases Advisory Group, which makes recommendations to all four nations on implementation of the 2013 UK Strategy for Rare Diseases.6
Around 300 health organisations are commissioned by NHS England to provide one or more specialised services, although in 2014–2015, 28 acute teaching trusts and 20 specialist acute trusts accounted for 58% of specialised services activity by cost.4 For many trusts, NHS England represents over 50% of their income and, in the case of specialist acute trusts, up to 95% of their income.
NHS England publishes commissioning intentions7 outlining changes and planned developments in the commissioning and delivery of prescribed specialised services. This includes proposals for future devolution of some commissioning responsibilities for specialised services from NHS England to CCGs including renal dialysis and surgery for morbid obesity.
The NHS Five Year Forward View8 confirmed the intention to offer CCGs progressively greater influence over the total NHS budget for their local populations, including specialised services. As of April 2017, 197 out of 207 CCGs had some form of co‑commissioning agreement with NHS England.9
A House of Commons briefing paper10 provides a useful summary of specialised services commissioning in England and the devolved administrations of Scotland, Wales, and Northern Ireland.
Priorities for 2017–2018
The priorities for 2017–2018, which were identified in the NHS England strategic framework for specialised services,11 will be implemented through:
- improving patient care, particularly for mental health, learning disabilities, and cancer
- financial control and achieving financial savings for 2016–2017 to 2020–2021
- place-based commissioning where appropriate
- improving use of data and information, including implementation of NHS RightCare12 for specialised commissioning
- determining which new treatments will be routinely commissioned by NHS England
- identifying opportunities to maximise value from medicines.
Annual prioritisation process
NHS England assesses treatments—with the exception of those under a National Institute for Health and Care Excellence (NICE) technology appraisal or highly specialised technology (HST) evaluation—through its routine commissioning processes based on their cost effectiveness.
Treatments assessed as cost neutral or cost saving for the NHS are processed as in-year service developments, while treatments with an associated cost to the NHS are considered through NHS England’s annual prioritisation process (APP) (Box 1).
Box 1: Annual prioritisation process
- Clinical priorities advisory group (CPAG) submits commissioning recommendations to specialised commissioning oversight group (SCOG) on the clinical and cost effectiveness of treatments
- SCOG assesses the impact of any decisions to commission new treatments in light of the financial resources available
- Based on SCOG’s assessment, the specialised services commissioning committee (SSCC) ranks treatments in terms of cost benefit and decides which will be routinely commissioned
- Treatments not routinely commissioned may still be commissioned on an exceptional basis through individual funding requests.
Future APP decisions will be informed by NICE, which will provide a summary of available clinical evidence, together with the financial impact of new treatments.
In 2016, reports by the National Audit Office4 and the Public Accounts Committee13 criticised the specialised commissioning process, including a lack of transparency about decision-making and its financial management. NHS England has since published details of the roles and functions of specialised services advisory committees, for example, CPAG14 and decision-making bodies and guidance15 on how new clinical policy is initiated, developed, evaluated, and decisions made.
Where there is insufficient evidence to refer a treatment through either NICE’s HST evaluations or NHS England’s commissioning processes, patients may potentially access treatments under the Commissioning through Evaluation (CtE) programme.16 The CtE programme generates new data for evaluation by NICE and to inform the APP.
Cancer drugs fund
The CDF was set up in 2010 to allow people access to drugs that were not otherwise routinely available on the NHS. It was significantly revised in 2016 after criticism about its effectiveness and financial management.10 A national list of drugs that can be funded by the CDF is maintained by NHS England.17 For 2017–2018, the fund is worth £340 million.10
All new systemic cancer treatments expected to receive market authorisation are assessed by NICE with a final appraisal published within 90 days of authorisation. This appraisal results in one of three outcomes:
- Recommended for routine commissioning (‘yes’)
- Not recommended for routine commissioning (‘no’)
- Recommended for use in the CDF.
Where the recommendation is ‘yes’, the CDF can be used to make the drug immediately available, rather than the usual 90-day wait to implement NICE recommendations. After 90 days, the drug is funded from NHS England commissioning budgets rather than from the CDF. Where NICE recommends ‘no’, treatments can still be accessed on an exceptional basis through individual funding requests.10
NICE recommendations ‘for use in the CDF’ apply when there is potential for a drug to be considered for routine commissioning but more evidence is required about its clinical effectiveness. This allows the drug to be funded for a fixed period of time, usually no more than 2 years, to gather more data on clinical effectiveness. After this period it will be reappraised and a ‘yes’ or ‘no’ decision made. The CDF can also be used to fund off-label treatments where the clinician wishes to use the drug outside of its marketing authorisation.10
- NHS England. Specialised services. www.england.nhs.uk/commissioning/spec-services (accessed 12 October 2017).
- NHS England. National programmes of care and clinical reference groups. www.england.nhs.uk/commissioning/spec-services/npc-crg (accessed 12 October 2017).
- NHS England. Manual for prescribed specialised services 2017/18. Redditch: NHS England, 2017. Available at: www.england.nhs.uk/wp-content/uploads/2017/10/prescribed-specialised-services-manual-2.pdf
- National Audit Office. The commissioning of specialised services in the NHS. London: NAO, 2016. Available at: www.nao.org.uk/wp-content/uploads/2016/04/The-commissioning-of-specialised-services-in-the-NHS.pdf
- NHS England. NHS England regional teams. www.england.nhs.uk/about/regional-area-teams (accessed 12 October 2017).
- Department of Health. The UK strategy for rare diseases. London: DH, 2013. Available at: www.raredisease.org.uk/uk-strategy-for-rare-diseases
- NHS England. Commissioning intentions 2017/2018 and 2018/2019 for prescribed specialised services. Redditch: NHS England, 2016. Available at: www.england.nhs.uk/wp-content/uploads/2015/12/spec-comm-intent.pdf
- NHS England. NHS five year forward view. Redditch: NHS England, 2014. Available at: www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf
- NHS England. About primary care co‑commissioning. www.england.nhs.uk/commissioning/pc-co-comms/pc-comms (accessed 12 October 2017).
- Bate A. NHS commissioning of specialised services. Briefing paper number 7970, 9 June 2017. London: House of Commons Library, 2017. Available at: researchbriefings.files.parliament.uk/documents/CBP-7970/CBP-7970.pdf
- NHS England. Strategic framework for specialised services. Redditch: NHS England, 2016. Available at: www.england.nhs.uk/wp-content/uploads/2016/05/item5-26-05-16.pdf
- NHS England. What is NHS RightCare? www.england.nhs.uk/rightcare/what-is-nhs-rightcare (accessed 12 October 2017).
- Public Accounts Committee. NHS specialised services. London: PAC, 2016. Available at: publications.parliament.uk/pa/cm201617/cmselect/cmpubacc/387/38702.htm
- NHS England. Clinical priorities advisory group (CPAG). www.england.nhs.uk/commissioning/cpag (accessed 12 October 2017).
- NHS England. Developing a method to assist investment decisions in specialised commissioning: NHS England’s response to consultation. Redditch: NHS England, 2016. Available at: www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/06/prioritisation-method-cons-response.pdf
- NHS England. Methods: commissioning through evaluation. Redditch: NHS England, 2017. Available at: www.england.nhs.uk/wp-content/uploads/2017/06/methods-commissioning-through-evaluation.pdf
- NHS England. National cancer drugs fund list. Redditch: NHS England, 2017. Available at: www.england.nhs.uk/wp-content/uploads/2017/04/national-cdf-list-v1-45.pdf