The Shelford Group of tertiary trusts is concerned that moving commissioning of specialised services to ICSs risks creating a postcode lottery and a drop in quality of provision
“Delegating certain specialised services will provide more joined-up care for patients, improve their experiences and speed up treatment. Services will only be delegated where ICBs are ready, with NHSE remaining ultimately accountable, including setting national policies and standards." John Stewart, national director for specialised commissioning, NHS England
Moving specialised services commissioning from NHS England to integrated care systems (ICSs) could result in fragmented provision and a dilution of quality and experts, a group of trusts has warned.
The Shelford Group is made up of 10 of the largest tertiary trusts in England, including Guy’s and St Thomas’ NHS Foundation Trust and Manchester University NHS Foundation Trust. It wrote to NHS England in March outlining its concerns about the plans to move some responsibilities to ICSs from next April. The group told HSJ that it had been “engaging very constructively with NHSE and other partners.” A leaked letter to the publication, however, provided a list of significant risks “in terms of quality, equity, value and system complexity that we do not yet see being fully taken into account”.
According to the letter, the Shelford Group “welcomes the policy intention to improve the co-ordination of patient pathways” and the “focus on early intervention, prevention and health promotion.” It also agrees that “there are now some services where delegation of commissioning to ICS level makes sense”. It identifies renal dialysis and HIV screening in emergency departments as examples of the latter.
It then issues a warning about the risks: “We do not see, however, that these examples justify the wholesale move of commissioning of 80-90 per cent of specialised services to an ICS footprint, particularly those services where the numbers and evidence base supports the planning and provision of care being done at a population size larger than a typical ICS footprint.” The letter warns that there may be “a risk of derogation” from the standards, “leading to increased variation by postcode, unless governance mechanisms and resources required to audit compliance are in place”.
It adds that there is a risk that ICSs “will focus on high volume services for their local population, leading to de-prioritisation of specialised services, and/or an inclination to support development of services within that ICS’s footprint as opposed to at the optimal level for ensuring clinical quality.”
In the past, the NHS has aggregated the provision of some specialised services, enabling a smaller number of units to perform rare procedures at sufficient volume to maintain clinical expertise. The Group’s letter warns that fragmenting the provider landscape would put this approach in danger.
The NHS allocated £19.3bn to specialised services in 2020-21, according to the latest NHS England annual accounts, about 15% of total NHS revenue. Currently all those services are commissioned by NHS England.
NHS England has said it will evaluate each specialist service later this year to see if it is eligible to be delegated or moved to ICSs, now or at some point in the future. It added that it will remain accountable for services and will set national standards.
John Stewart, NHS England’s national director for specialised commissioning, told HSJ: “Delegating certain specialised services will provide more joined-up care for patients, improve their experiences and speed up treatment. Services will only be delegated where ICBs are ready, with NHSE remaining ultimately accountable, including setting national policies and standards.
He added: “It is understandable that the biggest specialised providers have a strong interest in the future provision of services, and it is important they work with commissioners to better meet the needs of all specialised patients, including those outside their immediate local area.”
Lou Patten, NHS Confederation ICS Network director, said that the organisation welcomed the opportunity to devolve some specialised services to ICSs. She added: “This may involve reclassifying some of those services classed as specialised and delegating some specialised services. Local flexibility gives ICSs greater scope to innovate to improve services for patients.
The introduction of integrated care systems represents yet another major reorganisation of the way NHS commissions services. There is always a risk in such a reorganisation that the change will have unintended consequences, but for hospitals to make such stark warnings about the potential fragmentation of provision is concerning. The Shelford Group’s warning of a potential drop in the quality of specialised services, as well as a postcode lottery, in which not all areas are able to offer tertiary care, should be heeded.