Specialised commissioning for severe asthma: oxymoron or opportunity?

In the UK, almost 15% of the annual healthcare budget is set aside by the National Health Service (NHS) for specialised services . This significant resource (£14 billion last year) is directed towards a clearly defined pool of uncommon and complex conditions, and specifically supports small numbers of ‘centres of excellence’ with large catchment areas. In respiratory medicine, specialised commissioning has funded services for cystic fibrosis and pulmonary hypertension for some years. However, variations in commissioning arrangements for other complex conditions have led to variable service provision. In 2013, NHS England (NHSE) produced service specifications for an additional set of respiratory conditions, including severe asthma1 (figure 1), and these have fuelled a good deal of debate.Figure 1 Under specialised commissioning, patients fitting the criteria would be referred to their most geographically convenient regional specialist unit from either primary, secondary or tertiary care. The specialist units, based at an unspecified number of pre-existing centres, would act as concentrated centres of excellence located around the UK, with all other severe asthma services decommissioned in their existing form. To be commissioned as a specialist unit, centres must have access to all facilities outlined in the specification4 required to deliver full multidisciplinary team assessments over 2-day case visits and must be led by at least two consultant respiratory physicians with a special interest in severe asthma.We all recognise asthma to be a major source of physical and psychological morbidity and of indirect and healthcare expenditure. Indeed, preventative inhaler therapy is the largest drug cost faced by the NHS. It came as little surprise to us that the recent National Review of Asthma Deaths revealed failings across the whole spectrum of asthma care,2 with this report and other publications (such as the NHS Atlas of Variation3) also highlighting disparities in outcomes …