Organisation objective

• NHS Long Term Plan
• NHS Mandate from Government
• Statutory item
• Governance

Action required

The NHS England Board is asked to:

• note the process that has been undertaken to review the list of services that were deemed suitable but not yet ready for delegation from April 2024; and
• approve the recommendation on which of these services should be delegated (as they are both suitable and will be ready for delegation), and which should be retained by NHS England (as, either they remain unsuitable for delegation, or they may be suitable, but they are not ready to be delegated) from April 2025.

Background

1. NHS England is the accountable commissioner for a portfolio of ~150 specialised services. The list of services is set by the Secretary of State for Health and Social Care through regulations.

2. NHS England has been working towards more integrated commissioning of specialised services for some time, and with the establishment of integrated care boards (ICBs), has been able to take practical steps to put this on a more formal footing. These changes aim to improve patient care and outcomes by enabling the joined-up planning and commissioning of services at a population level across whole pathways of care, ie across specialised and non-specialised services.

3. As part of determining how integrated commissioning can achieve these aims, NHS England conducted an analysis of the portfolio of specialised services that it commissions across a range of criteria, considering both suitability and readiness. The recommendations from this analysis formed part of the recommendations to the Board on 2 February 2023 on how we should proceed.

4. Since April 2023, commissioning responsibility for 59 specialised services has been delegated to 9 statutory joint committees formed between ICBs and NHS England regions which cover the entire population of England.

5. The Board agreed in December to move forward in 2024/25 with the following careful and considered approach:

• support full delegation to ICBs in the East of England, Midlands and the North West regions of England; and
• support one more year of statutory joint commissioning arrangements between NHS England and ICBs in the South West, South East, London and the North East regions of England, before moving to full delegation in April 2025.

6. Regardless of delegation status, NHS England will remain the accountable commissioner for the entire portfolio of specialised services and maintain responsibility for setting consistent national standards, service specifications and clinical access policies.

Service portfolio analysis

7. An analysis of the entire specialised services portfolio was conducted in 2022/23 to determine which services were suitable and ready for greater ICB leadership, using methodology co-developed by regional and national commissioning teams, with input from finance and clinical colleagues. Patient and public voice representatives had the opportunity to input via the clinical reference groups.

8. Following the completion of an initial internal analysis, 3 categories of services were identified ahead of potential delegation in April 2023.

• services that were suitable and ready for greater ICB leadership
• services that were suitable but not yet ready for greater ICB leadership; and
• services that should remain nationally commissioned.

9. The initial service list was published as part of the Roadmap for integrating specialised services within integrated care systems in May 2022 and stakeholders were invited to provide feedback. Subsequently – in a process underpinned by a service appropriateness panel and a clinical panel – national, regional and clinical leaders reviewed this feedback and considered where the position of any services needed to be adjusted, or whether the original decision remained appropriate based on the evidence provided.

10. The Board approved in February 2023 the initial set of recommendations that 59 services were suitable and ready for joint commissioning from April 2023, and to be delegated to ICBs from April 2024. The remaining services would be retained by NHS England, either permanently, or until they were ready for delegation. 

Further update to the service portfolio analysis (SPA)

11. In August 2023, the NHS Executive concluded that from April 2025, there should be clarity for all prescribed specialised services as to whether they would be delegated or retained. This was to ensure that there was clarity for services, clinicians and patients, as well as to inform the future operating model of NHS England, and how commissioning teams should best be integrated with ICBs.

12. Between September and October 2023, National Programme of Care leads reviewed the list of services that were deemed to be suitable but not yet ready for delegation with their clinical reference groups, finance, legal, and commissioning colleagues to assess service readiness for greater ICB leadership and provide an initial assessment on whether the service should be retained or will be ready for delegation by April 2025. The process also identified the work required during 2024/25 to ensure the service would be ready for delegation.

13. The recommendation on each service was then reviewed by both a Service Appropriateness Panel (chaired by the Director of Strategy, Transformation and Quality in Specialised Commissioning, and included representation from regions) and a Clinical Panel (chaired by the Medical Director for Specialised Commissioning) between November 2023 and January 2024.

14. A final set of recommendations from these panels went to the Future Commissioning Model Programme Oversight Group in February 2024 and the NHS Executive in February and March 2024.

15. Annex A sets out the recommendations from the panels. Following the panels’ review, the suggested breakdown of the services (which equate to 57 separate service lines in total) that were previously deemed suitable but not yet ready is:

• Delegate – 25 service lines – representing £2,732 million total expenditure
• Retain – 32 service lines – representing £863.1 million total expenditure

Engagement with NHS Executive

16. The paper was presented to the NHS Executive in March 2024 and the contents were agreed by the Executive.

Annex A

Services suitable and ready for delegation from April 2025

Services to be retained by NHS England