This response includes the main points that CPAG members have brought to my attention.

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1 Richard Jeavons Director of Commissioning Specialised Services Quarry House Leeds West Yorkshire LS2 7UB Dear Richard, Specialised Commissioning Clinical Priorities Advisory Group Skipton House 80 London Road London SE1 6LH Date: 24 April 2015 Response to Investing in Specialised Services Consultation I am writing on behalf of the Clinical Priorities Advisory Group (CPAG) membership in response to the Investing in Specialised Services consultation. We welcome the consultation by NHS England, which encourages discussion about prioritisation to come alive in a very constructive way. The members of CPAG are deeply aware there a number of difficult decisions to be made and wider ownership of the basis for these decisions can only strengthen the position of NHS England in specialised services commissioning and going forward into collaborative commissioning. The consultation illustrates the commitment NHS England has to ensuring all patients have access to consistent high quality, effective and efficient services that represent value for money. At our last meeting, we received a clear and concise presentation from James Palmer outlining the scope of the consultation, the background to the proposals, the proposed principles that underpin decision-making, the proposed process for decision-making and the consultation questions. This response includes the main points that CPAG members have brought to my attention. Background The main aim of prioritisation in commissioning is to secure best value (effectiveness and efficiency) and the best return on investment. However, it was noted that cost effectiveness is not specifically covered in the principles. As there will be more potential areas for investment than available resources, the term economically sound is insufficiently precise. Similarly, the reference to investing only in services that are of equal or greater benefit than already offered could be made more clearly. I suggest that instead the phrases cost effective, representing good use of resources and investing only in services that deliver a clinical benefit at a cost that is comparable with the majority of other NHS services are used. High quality care for all, now and for future generations

2 The principles As a general comment on drafting and interpretation, the phrase will accord priority is applied against a number of the proposed principles. This is poor drafting and would pose a problem for NHS England and its advisory groups in terms of literal interpretation, because the current drafting is quite absolute in suggesting that a proposed intervention will be prioritised if compliance with one or more of the principles is demonstrated. Rather, the correct intent should be for the opening narrative to say something more general along the lines of NHS England will prioritise those treatments and interventions that most demonstrate the extent to which the following principles are met and then for the list of principles to remove the separate references to will accord priority. It needs to be made clear that the proposals cover all areas of specialised services resource allocation decision making. This should include clinical commissioning policy and service specifications. It must also be made clear that these principles will apply to decisions about existing services as well as to new ones and for example, will be used in the service review work programme (and in this regard we note with some concern that whilst the scope of consultation does not exclude existing services the proposed process for making investment decisions is limited to proposals for new investments). Under the Health and Social Act 2012, NHS England has a duty to improve outcomes, and in order to do so NHS England needs to proactively assess the needs of the population and develop a clinical strategy that best meets these needs and is consistent with the NHS Constitution, service strategies and NHS England Business Plan and Mandate. The general principles needs to include an additional statement NHS England will assess the specialised service health care needs of the population and identify priorities for improving health outcomes, reducing inequalities and making best use of resources. Otherwise, the principles will appear somewhat reactive and may lead to investment skewed into areas where there are innovations and new interventions rather than where there is the greatest opportunity to improve outcomes. It would be helpful to have a basis for NHS England to distribute resources in relation to need. We recommend that principle iii include a statement that NHS England will take into account the evidence of the impact on improving outcomes for the health of the population. We welcome the emphasis on reducing inequalities within the principles. Principle iii also makes reference to wider societal impact. Measuring social impact and differentiating between different social impacts is difficult. Assessing social impact may also lead to discrimination as valuing social impact is often subjective. Our view is that this reference to societal impact should be removed. Principle (iii)d should thus read will take into account evidence of the impact of any prioritisation decisions on the wider health and care system. Principle (ii)a should read there is adequate and clinically reliable evidence to demonstrate clinical effectiveness, taking account of patient related outcomes when these are available.

3 The statement that NHS England will only prioritise treatments or interventions where these can be offered to patients within the same patient group (other than for clinical contra-indication) needs to be clearer and should instead state will only prioritise treatments or interventions where these can be offered to all patients with the same severity of disease and clinical condition (other than for clinical contraindication). Principle 4a reads that NHS England will prioritise those treatments and interventions that demonstrate the greatest value for money. The inclusion of the word greatest effectively introduces a sub-prioritisation process (the weighting for which is not apparent) and it is unclear how the proposed process would enable NHS England and its advisory groups to reach a conclusion as to which intervention/s offer the greatest value for money. It may be helpful to amend this principle to read that proposed investments should demonstrate value for money. The process The decision making process for proposed new investments is presented logically and a rationale is provided, especially for the legal duties. It is rigorous and comprehensive, whilst recognising the need for the complete process to be as simple and straightforward as possible. While this is not specifically covered in the consultation, a number of CPAG members are concerned that the statutory nature of NICE Technology Appraisal guidance may lead to investment skewed towards a limited range of new technologies without taking account of the health needs of the population. Our view is that this effect could be minimised by ensuring that NHS England has a greater influence over the NICE Technology Appraisal programme driven by a specialised commissioning needs assessment. A greater emphasis by NICE on Multiple Technology (MTA) technology appraisal would also be helpful as these take into account the pathway of care rather than just individual interventions within a pathway. The proposed process that is described in the consultation document does not refer to the review of existing services in order to ensure best use of resources. NHS England needs to be able to evaluate and prioritise existing investments in parallel with new investment decision to ensure no in-built bias towards existing commissioned services. Our view is that NHS England needs to add to third order priorities the statement Development to support specialised commissioning service strategies in order to reflect the importance of service reviews and their potential to both release resources, but also their potential to identify unmet need and inequalities. It has been noted that the limited data and evidence of effectiveness available to support some commissioned services is a major challenge. Capacity within specialised commissioning and the availability of the expertise needed has also slowed progress. We understand that this is being addressed by NHS England through a review of staffing and the restructure of specialised commissioning support. This work is to be commended and ongoing review is needed to ensure that there is sufficient capacity and skills, and that there is an active programme of work force development.

4 The process described applies to specialised commissioning and this is only a subset of all NHS spending, and in this regard we note that principle 4b reads that NHS England will only commission for those prioritised treatments and interventions that are affordable within its relevant budget, which we interpret to mean the budget for specialised commissioning that is allocated by the Board of NHS England outside of the process described in the consultation document. Our challenge to NHS England is to demonstrate that it has developed and published a robust and transparent resource prioritisation process at board level to ensure equitable and needs driven resource allocation across the various directly commissioned services. Reducing inequalities Most specialised services are part of a pathway, and if only the specialised component elements are considered there will be a lack of attention to the upstream parts of the pathway. This includes prevention, primary care, secondary care and community services. Specialised commissioning should actively identify where there is a need to review and improve the pathway before and after specialised services and develop robust mechanisms to ensure these are taken account of by other commissioners such as CCGS and local authorities. NHS England should use its system oversight and CCG assurance and development role to make sure that this happens. Many interventions are differentially utilised by more advantaged populations. There are many reasons for this and the consultation notes the work by Public Health England and NHS Right Care to review variation in uptake of services to drive down variation. NHS England needs to state clearly that work to review variation in utilisation will continue. NHS England also needs to state that this work will be used to drive more equitable utilisation of services, in proportion to need, by ensuring that services are commissioned so as to be accessible and acceptable to disadvantaged groups. Members are also concerned about how this prioritisation process sits alongside decisions that are typically outside the proposed planning and prioritisation process. This includes Commissioning through Evaluation and the Cancer Drugs Fund. There needs to be clear statement regarding other programmes as the principles will not be appropriate. We welcome the acknowledgement that rare diseases require special consideration. The measures for clinical effectiveness may be limited and there needs to be an established process and criteria for assessing which products will be progressed to allow for concise and documented decision-making. Service reviews Public Health England has recently reviewed the whole pathway for five of the six top spend areas and identified the key areas where upstream changes could make a difference to downstream needs and patient outcomes. We recommend that service reviews should be prioritised taking into account of where there may be greatest potential to improve outcomes, reduce inequalities, improve consistency, increase efficiency and release resources.

5 Lay membership In addition to the response to the specific consultation questions, James Palmer asked if members could advise of the idea of CPAG consisting of lay members only. There was consensus that a mix of lay and professional membership was most helpful to ensure access to the necessary expertise, but with the challenge needed for good decision making. I trust the points above are helpful and I look forward to reviewing the report of the consultation findings outlining the key themes once published. With best wishes, Sir Nick Partridge Chair, CPAG