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1. 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

2. What we will cover/learning outcomes
• Background to specialised servicesand 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

3. 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 resourcesin 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?

4. 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.

5. Healthcare economics – making the most of
the money
• What is health care need?
• What is demand / want
• What is supply?
• What is opportunity cost?

6. 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

7. 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

8. 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.

9. Inconsistency – is all around us
• Cancer drugs fund
• NICE and end of life criteria
• Resourceallocation within the NHS
• Historic service differences
• Political priorities (e.g. mental health vs sexual health)
Fundamentally, our role is to ensure consistency, fairness andequity:
• Pragmatic and not compound inconsistencies
• Adhere to ethical principles and duties

10. Developing a prioritisation
framework

14. “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 -

15. • Ran for three months from January – April 2015
• Set out the proposed principles and process we will use when making
decisions on which specialisedservices 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

16. 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.

17. 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.

18. Four orders of prioritisation
1. Non-discretionary investments. Theseinclude service investment for National Institute for
Health and Care Excellence (NICE) TechnologyAppraisals 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.

19. Any questions?

20. 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?

21. 1. Provide a new drug for a very rare and serious inherited condition; it
costs £250kper 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 outreachspecialised 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.

22. Thank you