Commissioning through Exclusion

30 billion black hole. Contract battles with junior doctors. An ageing and increasingly ill population. Increasing prevalence of long-term conditions.

The challenges facing the NHS are well versed and well-articulated by health commentators. The solutions are less easy to identify and agree upon. What is clear is that doing things the same as before without a serious injection of extra funding will not deliver the results needed.

Changing how the NHS operates will mean changing the tools and technologies that support healthcare delivery. This will mean more than new purchasing arrangements – it will require changes to commissioning practices and different ways of structuring the NHS. It is difficult to identify areas where the NHS is doing this on a systematic basis.

A clear example of this is the ‘Commissioning through Evalutation’ (CtE) process established in 2011. CtE was developed to give patients access to innovative treatments at the same time as developing the appropriate evidence in relation to their clinical and cost effectiveness.

Commissioners set a target for the number of procedures that would be carried out in a limited number of locations. Based on the outcomes of these procedures a permanent commissioning decision is to be developed. Following a long and difficult development phase, six treatments started the CtE process and will soon hit the target number of procedures.

As we move to the crucial point in the process – the decision on whether or not to routinely commission – NHS England appear to be prevaricating and delaying the decision. The decision making process has not bee clearly set out and timelines of several years have been mooted.

For patients this will mean huge delays in life saving treatments – for patients with arrhythmia problems they will now be denied an innovative treatment that can help them avoid strokes in the future.

For children with cerebral palsy there is an operation that can help them get back some of their motor skills and help them remain mobile in later life. This operation can only take place up to the age of 12 years old.

The treatment is going through the CtE process and is likely to be paused while a formal decision is made. This could see children currently waiting for an operation growing too old to receive treatment by the time a permanent commissioning policy is in place.

The failure of CtE paints a grim picture. The NHS hasn’t routinely commissioned a new cardiac treatment since guidance was developed on transcatheter aortic valve implantation in 2013. If the system is to change and deliver care differently it will have to be more responsive to new treatments and new ways of working.

Delaying decision on the future of CtE and the status of current treatments sends a clear message that the NHS is closed for business.

Alongside the experience of CtE we have data that shows that more and more patients are waiting for longer than ever to get treatment. For the first time since they were introduced the NHS failed to meet the standard that at least 92 percent of patients should wait for less than 18 weeks.

History shows us that during difficult times the NHS reverts to type – knuckle down, keep doing what you’ve always done but work a bit harder. This attitude has helped the NHS through difficult times.

All evidence suggests however, that this approach won’t work this time – the scale of the problem is just too large. In order to address the challenges faced the NHS needs to revolutionise healthcare delivery – both in terms of the locations that it takes place to the treatment that is offered. The NHS will need to change delivery and develop new ways of doing things.

Failing to complete initiatives such as CtE does not show an NHS that is looking for new ways to work and new solutions. The challenge for NHS leaders is to address this and start to forge a twentieth century healthcare system that embraces change.