The delegation of specialised services: What now?

More than three years on from the release of the roadmap for integrating specialised services within integrated care systems (ICSs), and with 70 specialised services now delegated, the future of specialised commissioning is still up in the air. 

The impending abolition of NHS England and consolidation of ICSs has necessitated a rethink within NHSE’s transition leadership team and the Department of Health and Social Care (DHSC). Indeed, in Sir Jim Mackey’s first interview as interim CEO he signalled a potential change in direction, stating “the right level of commissioning for different specialised services would have to be reconsidered”. 

Sir Jim’s attention on specialised commissioning is no surprise given his experience running Newcastle Hospitals Foundation Trust, one of the most financially stable Trusts in the country which draws around two thirds of its income from specialised commissioning.  

Three months later, and ahead of any formal announcements, here’s what we might expect: 

1. Local responsibilities 

A key concern with the delegation of specialised services has been the capacity of individual ICBs to take on additional commissioning responsibilities. To overcome this, ICBs are likely to group together on a regional basis, allowing them to commission on a pan-ICB basis, supporting commissioning and population management at scale.  

To ensure this approach is truly joined up, we expect to see the emergence of an ‘Office for Pan ICB Commissioning’, hosted by a lead ICB, but supporting the whole region. 

It’s unclear what criteria might be used to decide on these lead ICBs, but they are likely to be those closely aligned to Foundation Trusts where skillsets exist.  

2. What will be commissioned and where? 

With a new structure in place, ICBs will be expected to quickly determine which services they want to commission individually vs collectively through pan-ICB commissioning. While they will have the autonomy to do this, their decisions are likely to be sense checked by NHS regions.  

Regions are unlikely to veto any decisions but will play an important role in ensuring a standardised approach, making ICBs pool budgets and adhere to service specifications.  

Nationally, an Office for Specialised Commissioning is likely to be established in the DHSC. This will commission highly specialised services and set national standards. While it is possible that the DHSC will claw back commissioning responsibility for some already delegated services, this new arrangement is unlikely to result in a full reversal of specialised commissioning delegation – especially as it is widely accepted that some specialised services are not, in practice, particularly specialised as a whole or in part.  

3. How can these changes be implemented successfully? 

As with much of recent NHS policy development, these changes may sound familiar to those who have been around for a while. For Offices for Pan ICB Commissioning – see Strategic Health Authorities (SHAs), abolished in 2013, they provided strategic direction and performance management at a regional level with some leading on specific Specialised commissioning across large populations via centralised expert teams of commissioners, finance staff and pharmacists.  

SHAs were largely successful and learnings from their success should be used to implement the future of specialised commissioning. Other key considerations for ICBs and the DHSC are: 

• Funding: The level of funding for specialised services has risen more rapidly compared to other parts of the NHS, however budgets are not ringfenced and ICB allocations per capita are unequal with a 34.32% variance from target between the least resourced and most resourced. There will inevitably be a temptation for some cash strapped ICBs to move resources from specialist providers to other parts of the system, which could put services under increasing pressure. 

• Service specifications: Following service specifications will be essential. For too long specifications have been seen as necessary guidance to manage growing system pressures. This has meant people requiring specialised care – particularly those with long term conditions – are unable to receive the support they require. The key challenge in delivering against service specifications has been the lack of a skilled workforce, often due to a combination of stretched finances, a lack of prioritisation, an ageing workforce and a lack of specialisms and opportunities to train replacements. With this in mind, the DHSC should audit adherence to service specifications to support workforce planning, influencing updates to the Workforce Plan.  

• Care closer to home: If done well, the delegation of specialised commissioning can support one of the key aims in the 10-Year Health Plan – shifting care from hospitals to community settings. However, the ICBs most likely to lead on behalf of regions will be those aligned to large acute Trusts. At the new Office for Specialised Commissioning takes shape, it will need to keep a watchful eye on where care is taking place, including what patient groups are better off being supported in tertiary centres, and what care should be taking place in the community. This cannot be a one size fits all approach.   

• Pathways: As responsibilities and places of care shift, the importance of care pathways becomes even greater. For the first time since SHAs, commissioners will have oversight of entire care pathways. The new Integrated Healthcare Organisations and the move to a proposed system of Year of Care contracts will facilitate end to end pathway financial arrangements that combine tertiary, secondary and community NHS spending. To grasp the opportunity this provides, commissioners must lean on Clinical Reference Groups (CRGs) to drive new pathways while updating those already launched with the shifts in the 10-Year Health Plan at the forefront. CRGs must be provided with the resource and impetus to do this at pace. 

While the road to delegating Specialised Services has been rocky, the clear direction coming down the line provides the certainty and frameworks required to provide specialist care for all. It’s now up to the DHSC, in their position of power, to provide stronger foundations to make a success of the new model.