The introduction of integrated care systems (ICSs) this summer, triggering a major overhaul of commissioning responsibilities, could have a negative impact on the delivery of specialised services – which range from chemotherapy, radiotherapy and kidney dialysis to treatment trials such as mitochondrial donation – across England, according to a group of major hospital trusts.
In a letter, leaked last week to HSJ, the Shelford Group of teaching and research trusts warned NHS England (NHSE) two months ago that the provision and quality of these services risked being diluted by “the wholesale [transfer] of commissioning of 80-90 per cent of specialised services to an ICS footprint”.
The group – which includes University College London, Imperial College Healthcare and Guy’s and St Thomas’ Trusts among its membership – suggested the changes could lead to a postcode lottery in provision. It highlighted the risk that ICSs will now “focus on high-volume services for their local population, leading to de-prioritisation of [such] services, and/or an inclination to support development of services within that ICS’ footprint, as opposed to at the optimal level for ensuring clinical quality”.
Seemingly of less concern to the group, however, was the spiraling cost of specialised services provision. That cost reached £19.3bn in 2020-21 (equivalent to 17 per cent of the NHS’ entire budget), and is predicted to rise to £25bn by 2025.
This level of funding has allowed NHSE to directly commission all 149 ‘prescribed’ specialised services, the provision of which is determined by four factors:
– the number of patients requiring the service
– the cost of providing the service
– the number of trusts or clinical commissioning groups (CCGs – the bodies set to be replaced by ICSs) able to provide the service
– the financial implications for CCGs or trusts if they had to arrange for provision of the service themselves
But according to a recent government policy paper outlining the implications of the recently passed 2022 Health and Care Act, NHSE will now gradually transfer direct commissioning responsibilities to “other NHS bodies, individually or jointly”, and instead assume an “assurance” role, overseeing the commissioning activity of those bodies, while continuing “to have responsibility for developing and setting standards nationally, which local healthcare providers will be expected to follow”.
The national body will, however, retain direct responsibility for ‘highly specialised services’ – services such as liver transplants, and enzyme replacement and proton beam therapies, rarely made available to more than 500 patients each year – which are currently delivered nationally through “centres of excellence”.
In a follow-up policy paper, the government dodged the funding implications of the changes to how specialised services are commissioned, and instead positioned the Health and Care Act as an essentially positive outcome for patients as well as clinicians, by allowing NHSE to introduce ‘integration measures’ that will “ensure services are designed (and investment is made) with the whole patient pathway in mind”.
This argument is tentatively supported by the Nuffield Trust, which recently argued that putting some specialised services into ICSs could help align incentives and lead to better service integration or investment decisions – suggesting, for example, that combining the commissioning of both transplantation and dialysis would align the incentives to increase the former in order to control the costs of the latter.
The Trust adds, however, that the theoretical advantages of joining up one set of services could potentially be outweighed by the risk of creating new fragmentation with others.
Historically, specialised services have been prey to the same structural and financial constraints and reorganisations as the rest of the NHS over the decades. National level planning was formalised in 1983, when the Supra regional services advisory group was set up. Responsibilities were later devolved, first to primary care trusts in 2002, and then to national and regional specialist commissioning groups in 2006. Six years later commissioning was further fragmented following the 2012 Lansley reforms, which led to the creation of clinical commissioning groups.
How the latest changes, ushered in by the 2022 Health and Care Act, pan out only time will tell. The Shelford Group told HSJ it was generally supportive of the ICS reforms despite its misgivings over commissioning but, given the size of the NHS budget allocated to specialised services, the sector is bound to remain the focus of Tory ire.
With the ink barely dry on the new legislation, only last week the Telegraph decided to run a story on what it called “an explosive report” from Policy Exchange. The right-leaning thinktank’s publication called for particular scrutiny of how specialised services were commissioned, suggesting the sector had “largely evaded political scrutiny”.
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