Investing in specialised services - the

prioritisation framework Dr David Black, Deputy National Clinical Director for

Specialised Services, NHS England

Ann Jarvis, Head of Acute Programmes, Specialised

Services, NHS England

What we will cover/learning outcomes • Background to specialised services and the challenges we face

• The concepts of need, want, supply and opportunity cost

• Ethics of prioritisation and the role of clinicians in this

• The challenge of scarcity in health service provision

• How NHS England makes decisions around which specialised

services to prioritise for investment

• What would you do? – an exercise in applying the prioritisation

principles

Dealing with scarcity – what do you think? • Question 1: Rationing health care because of a shortage of money is

unethical?

• Question 2: Clinicians should lobby for more government spending on

health Care?

• Question 3: I should lobby for resources in the clinical areas for which I

have specific responsibility or a particular interest?

• Question 4: I will take a pay cut to help the NHS?

Specialised services – some background • NHS England commissions 145 specialised services within a budget of

c£14bn a year

• Usually these services are accessed by relatively small numbers of people, in

a small number of providers but where the costs of the service are very high.

• Examples include - renal dialysis, secure inpatient mental health services,

treatments for rare cancers and life threatening genetic disorders.

• Many of the services operate at the cutting edge of science and

innovation with new treatments and procedures being developed and

introduced all the time. These offer real benefits for patients,

but put significant pressure on NHS resources.

Healthcare economics – making the most of

the money

• What is health care need?

• What is demand / want

• What is supply?

• What is opportunity cost?

What is need? • Need is the ability to benefit from an intervention

• Demand / want is what people ask for

• Supply is what we actually provide

• We may supply what is demanded but not needed and not supply what is

needed but not demanded.

• Opportunity cost – what then can’t be afforded

What is need? The ability to benefit from an intervention Difficult when: • Scarce (e.g. organs) • V expensive (e.g. some drugs/devices/services) • Costly (e.g. HIV - many patients at moderate cost) • Effectiveness/cost–effectiveness uncertain Remember:

– Illness is not need – An ineffective treatment cannot meet need

Ethics: What does the GMC say? • Provide the best service possible within the resources available, taking account

of your responsibilities towards your patients and the wider population.

• Be familiar with any local and national policies that set out agreed criteria for

access to a particular treatment.

• You should be open and honest with patients when resource constraints may

affect the treatment options available

• If you have a management role or responsibility, you will often have to make

judgements about competing demands on available resources.

When making these decisions, you must consider your primary

duty for the care and safety of patients.

Inconsistency – is all around us • Cancer drugs fund

• NICE and end of life criteria

• Resource allocation within the NHS

• Historic service differences

• Political priorities (e.g. mental health vs sexual health)

Fundamentally, our role is to ensure consistency, fairness and equity:

• Pragmatic and not compound inconsistencies

• Adhere to ethical principles and duties

Developing a prioritisation

framework

“Strengthening our capability to make fair and timely decisions

about what will be commissioned and for whom whilst engaging

with NICE and others to find better ways to both introduce cost effective new treatments within available budgets and stop the

commissioning of less effective treatments.”

We will achieve this by -

• Ran for three months from January – April 2015

• Set out the proposed principles and process we will use when making

decisions on which specialised services and treatments to invest in.

• Consultation response published in June setting out the principles that

would be used to inform the decision making in 2015 and the further

work to be done in advance of the 2016/17 investment round.

• Further opportunity to engage with this work in 2015/16

Investing in specialised services

consultation

Prioritisation Principles – 2015/16 I. General principles:

a. Follow normal good practice in making prioritisation decisions in a transparent way, documenting

the outcomes at all stages of the process.

b. Involve the diversity of stakeholders including the public and patients in the development of

proposals and take appropriate account of their views; and,

c. Take into account all relevant guidance.

II. Clinical effectiveness principles:

a. There must be adequate and clinically reliable evidence to demonstrate clinical effectiveness.

b. There must be a measurable benefit to patients.

c. The intervention should offer equal or greater benefit than other forms of care routinely

commissioned by the NHS.

d. While considering the benefit of stimulating innovation, NHS England will not confer

higher priority to a treatment or intervention solely on the basis it is the only one

available.

III. Fairness and equity principles:

a. NHS England may agree to fund interventions for rare conditions where there is limited

published evidence on clinical effectiveness.

b. The intervention must be available to all patients within the same patient group (other than

for clinical contra-indication).

c. The intervention should be likely to reduce health inequalities, and NHS England will have

regard to any relevant broader equality issues.

d. The intervention should benefit the wider health and care system.

e. The intervention should advance parity between mental and physical health.

IV. Financial principles:

a. The intervention should demonstrate value for money.

b. We will then apply the principle of affordability and only commission those treatments

and interventions that are affordable within the annual allocation to specialised

commissioning and those that enable resources to be released for reinvestment.

Four orders of prioritisation 1. Non-discretionary investments. These include service investment for National Institute for

Health and Care Excellence (NICE) Technology Appraisals and the appraisals undertaken as part of the Highly Specialised Technologies Programme, where we are legally required to do so.

2. For discretionary investment, the first priority will be funding services that support the delivery of the NHS Constitution Standards. These include for example the 18-week wait referral to treatment time, and the cancer and mental health targets.

3. The next priority for discretionary investment will be developments to support our strategies and priorities. These may be pre-existing, such as increasing access to transplantation, or nationally / locally defined strategic change.

4. All other developments will then be considered.

Any questions?

Exercise – Deciding how to use

limited resources

Consider the following three examples.

How would you decide if these are good ideas?

If only one can be funded, which one?

1. Provide a new drug for a very rare and serious inherited condition; it costs £250k per year for life and outcomes up till age 2 are very good. The drug is so new there is no evidence beyond this. 10 new cases per year

2. Provide a new drug for a sub group of patients with a common and serious condition. 85% of cases occur in people over 75. It costs £50k per year for life and appears to provide normal life expectancy and eliminates most symptoms. 250 new cases per year. Research underway may indicate it may be equally effective for a further 4000 patients per year.

3. Provide an outreach specialised neuro-rehabilitation service to people with LD, stroke, brain injury and progressive neurological conditions because evidence shows these often disadvantaged people don’t make full use of current services. 10,000 patients per year at £2500 per person per year.

Thank you