Over the last few months, NHS Providers has engaged with leaders in trusts to understand how they are preparing for these developments and their analysis of the impact it may have for their patients, services, and organisations, recognising that these are likely to vary between systems and trusts depending on populations, geographies and service delivery arrangements.
Overall, trusts see a rationale for moving to more locally led models of commissioning for some specialised services. They are fully committed to system working to join up care to better meet patients' needs, and see bringing some specialised services together with other aspects of care as part of that process.
However, trust leaders also recognise that asking ICBs to play a greater leadership role in specialised commissioning marks a significant change of approach which brings risks as well as opportunities. This change process is happening at a time when ICBs are recently established and managing an unusually challenging set of operational pressures.
Below we briefly outline some headline opportunities and risks articulated by trust leaders, spanning both joint working arrangements and delegated models. While these two arrangements will present some slightly different questions and challenges, here we analyse them together pointing to the key issues that policymakers and systems will need to consider as they move into implementation.
Scope to better join up pathways of care in some clinical areas. The division in commissioning responsibilities between local commissioners and NHSE meant that in some specialities – for example cancer and neurological care – many patients' pathways of care included services commissioned by both ICBs and NHSE. Transitions between these services can lead to poorly coordinated care for patients (an issue which can be compounded when patients are also accessing social care services commissioned by local authorities). By localising more commissioning responsibilities, ICBs and partners will, in theory, be in a position to take a more end-to-end view of some pathways of care which could support a more coordinated experience for patients and a more sensible operating context for health professionals.
Incentivise preventative and early interventions. One consequence of the division of responsibility and budgets between local commissioners and NHSE for different aspects of the same care pathways has been that local commissioners have a limited financial incentive to invest in early intervention or preventative measures that save money elsewhere in the pathway. By joining up financial planning locally and given the significant proportion of NHS resources devoted to specialised services, ICBs will have a stronger incentive to seek opportunities to identify early disease, develop more cost-effective models of care, and/ or invest in preventative interventions and models of support (in disease areas which are amenable to preventative interventions).
Scope for trusts' and collaboratives' expertise to shape the design and development of specialised services. NHSE has sought to engage a range of stakeholders in discharging its role as commissioner for specialised services. But moves to localise decision-making present new opportunities for trusts and ICBs to work together more closely in shaping and improving these services, including bringing trusts' clinicians and operational teams more fully into discussions about planning and improving specialised services. One mechanism to enable this, which some trusts are exploring, are provider collaboratives. Over the last few years, NHS-led mental health provider collaboratives have been taking on some planning, improvement and monitoring functions which previously sat with NHSE, often via lead provider models. Other collaboratives are exploring related models based on taking on delegated functions from ICBs in the future with a view to more flexibly deploying the combined capabilities of commissioners and providers. As specialised service planning is localised, collaboratives could be vehicles through which trusts work with commissioners in new ways and play a leading role in driving better care and value.
Clinical and patient voice in commissioning decisions. NHSE has been the central point for clinical and service user input into specialised commissioning decisions over the last decade. Patient charities and service users, along with interested clinicians, have helped to shape national policy through patient and partner groups, clinical reference groups and national programmes of care. NHSE plans to maintain a national infrastructure for patient and clinical voices to inform and oversee delegated arrangements, including through national groups such as the patient and public voice assurance group. Alongside that continuing national infrastructure, there will be an important task for ICBs and providers to ensure joint committees or delegated models embed arrangements which ensure local decisions on specialised services are informed by high-quality input from patients and clinicians.
Provider voice. The prospect of meaningfully improving specialised services will be substantially aided if trusts' expertise is brought to bear early in planning discussions, alongside other valuable perspectives from clinical and health professionals, service users and the voluntary sector. Trusts can contribute an understanding of education and workforce considerations as well as links to research and innovation programmes. The design of localised arrangements – be it joint committees or delegations to ICBs – will naturally bring together NHSE and ICBs as commissioners of services. Trust leaders are keen to ensure that these approaches build on existing links between providers and specialised commissioning teams in NHSE regions so that discussions are informed by the range of insights that providers can bring. Ways of working will need to be established which allow trusts' clinical and operational insights and views to be expressed in local decision-making processes. This will include in 2023/24 as joint committees of NHSE and ICBs lead commissioning decisions; they will need to find ways to embed provider voice in local deliberations around specialised services.
Geographical variations in care. The move to national commissioning of specialised services a decade ago was partly informed by a recognition that specialised services varied around the country, both in access and quality. Over the last decade NHSE has sought to bring greater uniformity to specialised services, including through setting national standards and service specifications. Much of this national architecture will remain in place as ICSs play a greater leadership role, so scope for divergences in care should be partly limited. But the move to localised decision-making, via joint committee or full delegations, could see variations in service offers emerge incrementally as partners respond to local priorities and challenges.
Fragmentation of commissioning relationships. Many trusts delivering specialised services treat patients from large geographical footprints spanning multiple ICBs under a single commissioning relationship with NHSE (facilitated by the regional teams). Moving from centrally held contracts to ICBs leading commissioning of services may result in trusts needing to develop contracting, relationship management and reporting infrastructure across several systems to discharge the same responsibilities. Even where ICBs group together to jointly commission some services, this could see an increase in administrative burden and costs for providers (and commissioners). It will be important that ICBs and trusts develop ways of working which enable providers to devote maximum management bandwidth to service delivery, improvement and transformation and minimise low-value bureaucracy.
ICBs' capabilities and expertise. ICBs are relatively young organisations whose staff have expertise in commissioning locally delivered acute, community, mental health and in many cases general practice services. They are in the process of facilitating system planning processes to develop joint forward plans and defining their ways of working with local partners to address operational priorities. Taking on a leadership role for specialised services represents an expansion of their remit and will call for a knowledge base and skill set which many ICBs may not yet have in-house. Joint committee arrangements should support NHSE regional teams to help with this transition given their established role in operational commissioning for specialised services. Looking ahead, it will be important that ICBs can access constructive support to discharge these responsibilities effectively, particularly from the point at which delegated commissioning arrangements go live.
Access to capital. ICBs and system partners will determine how to deploy capital allocations made to systems based on their local priorities and population needs (this is in addition to some national capital programmes led by NHSE). Specialised services, which are often comparatively capital intensive due to requiring specific technologies, equipment and facilities, will be one of many priorities for systems to weigh up. Some trust leaders expressed concern that under a more localised model of leadership, specialised services may struggle to secure appropriate capital investment within systems given their service portfolio, the relatively small number of patients who access these services, and the range of other priorities that systems will be seeking to progress. The national context of constrained capital envelopes and substantial backlog maintenance needs could exacerbate this risk.
Revenue prioritisation. ICBs have emerged in statutory form at a challenging time for the NHS in the wake of a long slowdown in NHS funding growth, and when demand for care is outstripping resource growth. They will face a real challenge to meet population health needs effectively within available resources. At the same time, ICBs will be looking to make a demonstrable impact on high-profile operational priorities such as urgent and emergency care, addressing care backlogs and bolstering access to primary care services. In this context, there may be a risk that specialised services are gradually deprioritised to free up resources for other service areas. The fact that specialised services are likely to contribute in a relatively marginal way to some of ICSs' core objectives – population health, inequalities, productivity – may heighten this risk.
Long-term sustainability of centres of clinical and research excellence. Some trusts are centres of clinical expertise for particular conditions or population groups and serve several systems spanning large geographies. Organisational configurations vary, but in some cases, trusts have built up a community of clinical expertise, research infrastructure, industry partnerships, equipment and organisational capabilities over time. Moves to delegate commissioning will not inherently alter this, with ICBs being free to continue commissioning care based on existing delivery models. However, over time the quality of these centres may decline if ICBs respond to unintended incentives – particularly at a time when system finances are under pressure – to commission services at local providers within their footprints and reduce flows of patients to out-of-system regional centres. As well as shoring up local financial performance, developments of this type may have some real benefits in supporting more accessible care for some patients and supporting joint working within systems. However, there is a risk these improvements come at the expense of centres of clinical excellence and incrementally curtail their capacity to drive clinical innovation.