Organisation objective
- NHS Mandate from government
Working with people and communities
What approaches have been used to ensure people and communities have informed this programme of work?
- recruited patient and public voice (PPV) partners
- consultation/engagement
- partnership working with voluntary, community and social enterprise organisation
Action required
The NHS England Board is asked to
a. Consider and reaffirm the ambition, intent and opportunities offered by the delegation of commissioning responsibility for suitable and ready specialised services to integrated care boards (ICBs), including through:
i. enabling the planning, commissioning and provision of better and more integrated services for patients across whole and linked pathways of care
ii. supporting key aims of the government’s forthcoming 10-Year Plan to bring about a shift from sickness to prevention; and from hospital to community
iii. strengthening the hand of ICBs to act as strategic commissioners and lead on population health, with providers of specialised services increasingly reaching out and into neighbourhood health and care systems
b. Note that the list of services suitable and ready for delegation to ICBs has now been finalised with 70 services in scope (annex a). 11 services have been added to the 59 services that were delegated to ICBs across 3 out of 7 NHS regions since April 2024 (North West, Midlands and East of England).
c. Approve the delegation of commissioning responsibility for these 70 specialised services to all ICBs in the North East and Yorkshire, London, South East and South West regions from April 2025 (and the additional 11 services to those ICBs in the Midlands, North West and East of England regions that took on full delegated commissioning responsibilities this year).
d. Support the recommendation from the NHS England Executive to apply a consistent condition on delegation to all ICBs falling within the segments 3 and 4 of the NHS Oversight Framework (NOF) that requires any decision that impacts on the overall spend of the specialised service allocation to have NHS England regional approval before the commissioning change is made or any change process is begun.
e. Approve the template delegation agreement for signature ahead of 2025/26, at annex b.
f. Give delegated authority to regional directors to sign the final delegation agreements on behalf of NHS England
Context
1. Plans to delegate suitable specialised services were first set out in the May 2022 roadmap for integrating specialised services within integrated care systems and enabled by the legislative provisions in the Health and Social Care Act 2022.
2. This important commissioning reform agenda will significantly strengthen the hand of integrated care boards (ICBs) in acting as strategic commissioners for the system and leading on population health management, consistent with the evolving NHS operating model.
3. .A final list of 70 specialised services (annex a) has been identified as being suitable for delegation following a comprehensive analysis of the entire specialised portfolio and careful consideration of whether the current split in commissioning responsibilities between NHS England and ICBs is hindering opportunities to plan, commission and provide services in a more strategic and integrated way.
4. This analysis also included consideration of where a greater focus on upstream intervention (‘left shift’) could significantly reduce demand for certain specialised services. Lord Darzi, in his recent report, noted how specialised services account for a growing share of NHS expenditure and whilst this is the result of being able to treat more diseases and conditions than ever before, it creates an inexorable pressure on costs. In this respect, the delegation of specialised services is intended to facilitate the realisation of secondary and tertiary prevention across pathways of care.
5. To illustrate again the case for change across a few example service areas:
- Renal – ICBs hold the responsibility for commissioning chronic kidney disease and acute kidney injury services, while renal replacement therapy, including dialysis and transplantation, have been the responsibility of NHS England. This has led to there being weak incentives for investment up front in the pathway to reduce incidence and exacerbation of these conditions as the cost of treating patients as their disease progresses falls elsewhere. Delegation will enable a whole pathway approach across primary, community, secondary and specialist care.
- Adult critical care– ~50% of patients in ICUs at any one time are being funded by NHS England as part of a specialised pathway while the other ~50% are funded by ICBs, eg as part of an emergency admission. This fragmentation has made it difficult for commissioners and providers to take strategic long-term decisions about the overall design and delivery of care across their whole network, including transport, levels 1-3 of care, and rehabilitation and support for patients back into the community.
- Mental Health– whilst mental health lead provider collaboratives are successfully driving improved planning and delivery of specialist inpatient services across a geography, the budget and commissioning responsibility continues to sit with NHS England and separate from ICB commissioned community and acute services. This separation is again leading to misaligned incentives that have not encouraged the design of pathways that keep people out of hospital and supported within their local communities. Delegation will put the funding and responsibility for the majority of mental health services with ICBs, giving the opportunity to deliver earlier intervention, and care closer to home.
- Liver– the opportunities for improving outcomes from liver conditions sit predominantly in upstream preventative action and early diagnosis, such as action on alcohol and obesity, which are the responsibility of ICBs working with their local partners. Yet the treatment for later stage liver disease is the responsibility of NHS England. We need to ensure that the whole pathway, the opportunities for intervention and the resulting benefits, are within the remit of commissioners locally through ICBs so that they can optimise the use of resources and outcomes.
6. Although commissioning responsibility for all 70 services is being delegated to ICBs, commissioning accountability will continue to rest with NHS England. In this role, NHS England will continue to set consistent national standards, services specifications and clinical commissioning policies; develop metrics and quality dashboards to support improvement, oversight and assurance; and provide national clinical leadership, expert advice and support to ICBs through our Clinical Reference Group infrastructure.
7. Approximately 100 specialised services, including all highly specialised services, will not be delegated to ICBs and will continue to be the direct commissioning responsibility and accountability of NHS England. The Board is asked to:
a. Consider and reaffirm the ambition, intent and opportunities offered by the delegation of commissioning responsibility for suitable and ready specialised services to integrated care boards (ICBs), including through:
i. enabling the planning, commissioning and provision of better and more integrated services for patients across whole and linked pathways of care
ii. supporting key aims of the government’s forthcoming 10-Year Plan to bring about a shift from sickness to prevention, and from hospital to community
iii. strengthening the hand of ICBs to act as strategic commissioners and lead on population health, with providers of specialised services increasingly reaching out and into neighbourhood health and care systems
b. Note that the list of services suitable and ready for delegation to ICBs has now been finalised with 70 services in scope (annex a).
Progress in 2024/25
8. Since April 2024, and following NHS England Board approval, all ICBs in the East of England, Midlands and the North West regions have taken on full delegated commissioning responsibility for all suitable and ready specialised services (59 services at that point).
9. The transition in commissioning responsibility and budgets across these regions has been carefully managed. From the start of 2024/25, cashflow to providers has been timely and appropriate. Data is being submitted utilising the new data flow arrangements, following revised information rules and data submission processes being published. Contracts have been signed following the new contracting procedures. Where commissioning change has been effected, it has taken place in line with established rules. All relevant standard operating procedures and business rules guidance has been applied, but also with an eye to refining and improving this into 2025/26 to ensure the immediate operational and practical aspects of commissioning are being managed most effectively
10. Although still early days, ICBs in these regions are already identifying opportunities and taking forward plans to improve pathways of care. For example:
- In the North West, work to join up the renal pathway, supported by the Renal Specialised Clinical Network is underway. The aim of this work is to identify and implement interventions which better manage patients with acute and chronic kidney disease to reduce the likelihood of them from needing dialysis or transplantation. Work is also underway to consider how best to streamline the patient journey for ischaemic stroke to ensure that greater numbers of patients can benefit from thrombectomy procedures within the window of effectiveness.
- The 11 ICB’s in the Midlands continue to work collectively and collaboratively with NHS England to jointly plan and set priorities for specialised services and enhance the ICBs’ oversight and responsibility for the quality of services commissioned for patients (eg neonatal services in context of the wider perinatal pathway). In preparation for the next phase of delegation a focused piece of work to transform mental health services for women is underway to reduce the need for tier 4 services. Work on cancer pathways has begun to transform oncology services, through the vertical integration of services (place, system and specialised) aimed at reducing fragmentation and improving patient experience.
- In the East of England region, delegation is supporting ICBs to adopt collaborative ways of working, processes and behaviours. For example, all 6 ICBs across the region are working together in partnership to ensure specialised services are planned on an appropriate footprint whilst at the same time meeting the needs of individual ICB populations. Current areas of focus include the reprovision of Mount Vernon Cancer Centre services and the further development of mechanical thrombectomy and major trauma services. Work to improve aseptic services has also united all 6 ICBs and system partners behind a single vision and delivery model which seeks to integrate patient pathways and ensure the provision of sustainable and consistent services.
11. ICB’s in the South West, South East, London and the North East and Yorkshire regions of England continued statutory joint commissioning arrangements with NHS England in 2024/25. NHS England regional and national teams have worked with ICBs across these regions to ensure that they are ready to take on full delegated responsibility for specialised services from April 2025.
Delegation recommendations from April 2025
12. A National Moderation Panel (NMP) was convened on 16 October 2024 to moderate the arrangements for the delegation of all suitable and ready specialised services to all ICBs in April 2025. The NMP was asked to:
a. Review progress on resolution and mitigation of any outstanding readiness actions and risks for the regions not yet delegated (North East and Yorkshire, London, South West and South East).
b. Confirm the strategic intent of all regions to delegate all suitable and ready specialised services to all ICBs.
c. Consider and moderate any proposed local developmental arrangements (conditions placed on delegation).
13. The NMP were assured that all regions, in partnership with their ICBs, had clear and robust plans in place for the delegation of all 70 specialised services in scope from April 2025, and were taking appropriate steps to mitigate any risks to a smooth transition. A programme board, the Future Commissioning Model Programme Oversight Group for Specialised Services, will continue to oversee delivery.
14. The NMP supported a number of locally appropriate developmental arrangements being included within relevant ICB delegation agreements. However, the NMP identified a variable approach to the application of developmental arrangements or ‘conditions’ to financially challenged systems. This was considered by the NHS England Executive who concluded the need for a consistent approach and recommend the adoption of the following condition where applicable:
- for all ICBS in NOF3 or NOF4, any decision that impacts on the overall spend of the specialised service allocation must have NHS England regional approval before the commissioning change is made or any change process is begun
15. This condition should not act as barrier to innovation and change but is considered appropriate given NHS England’s continued accountability for delegated services, our broader oversight and assurance role and our need to work together to support those systems facing the greatest challenges. The Board is asked to:
a. Approve the delegation of 70 specialised services to ICBs in North East and Yorkshire, London, South East and South West regions (and the additional 11 services to those ICBs in the Midlands, North West and East of England regions).
b. Support the recommendation to apply a standard condition on delegation to all ICBs in NOF3 or NOF4.
Delegation agreement
16. An amended template delegation agreement for specialised services has been prepared for implementation in 2025/26 and is attached at annex b. This agreement will formally delegate to ICBs the 70 specialised services deemed suitable and ready for greater ICB leadership. The agreement uses powers given to NHS England under section 65Z5 of the NHS Act 2006 (delegation and joint working), as amended by the Health and Care Act 2022.
17. The delegation agreement for specialised services builds on the agreements put in place for primary care services but amends the agreement to the specific needs of specialised services. This includes key risk mitigations:
a. Introducing ‘developmental arrangements’ that allow NHS England to tailor the agreement in line with the local circumstances and readiness of the specific ICB.
b. ICBs must follow the national standards for specialised services which are set by NHS England. These include clinical commissioning policies and service specifications. Additionally, ICBs will need to follow guidance and standard operating procedures issued by NHS England.
c. Requiring ICBs to establish a collaboration arrangement across neighbouring ICBs to ensure planning and commissioning of services is always undertaken at an appropriate scale.
The Board is asked to:
a. Approve the template delegation agreement for signature ahead of 2025/26, at annex b.
b. Give delegated authority to regional directors to sign the final delegation agreements Don behalf of NHS England
Publication reference: Public Board paper (BM/24/45(Pu)