ALL CHANGE FOR SPECIALISED COMMISSIONING: FOUR THINGS INDUSTRY NEEDS TO KNOW ABOUT THE LATEST REFORMS

1. From April 2023, Specialised Commissioning decisions are set to be delegated to Integrated Care Systems (ICSs) in line with a new “roadmap” published by NHSEI. This will affect the way the NHS funds and delivers many high-cost medicines and technology in the years ahead.

Since 2013, around 150 Specialised Services – ranging from relatively high-volume interventions like kidney dialysis and chemotherapy, through to the treatment of rare conditions only affecting a handful of patients each year – have been planned and commissioned on a national or regional scale by NHS England.

Now, as a result of measures in the Health and Care Act, many of these responsibilities are set to be delegated down to the 42 new Integrated Care Systems, reversing the centralisation of spending decisions that took root since the Lansley reforms.

With approximately one in every seven pounds spent within the NHS, a total of £20.5 billion a year, going on Specialised Services (around 20 per cent of which is medicines spend), this is a shake-up that will have big implications for pharmaceutical companies, specialised providers and – most important of all – patients themselves.

2. The process of devolving responsibility for Specialised Services will be gradual, drawing on a number of criteria and conditions set out by NHSEI – and only a certain range of services will be delegated to ICSs from April 2023.

The basic principle of systems taking the lead on the commissioning of Specialised Services is intended to make them more integrated with other non-specialised services that patients also depend upon. But this process won’t happen all at once, and some Specialised Services won’t be delegated to ICSs at all.

NHSEI have divided the 150+ Specialised Services into three categories based on their suitability and readiness for delegation:

▶ those that are suitable and ready for delegation to ICBs in April 2023
▶ those that are suitable for delegation to ICBs at some point but not ready in April 2023
▶ those that are not suitable for delegation and will continue to be commissioned nationally

Only those in the first category will be considered for delegation next year – about 65 services in total. However, it's a significant range as far as industry is concerned, including all chemotherapy & dialysis services.

The guidance also makes clear that arrangements must reflect appropriate population footprints, meaning that in some place this will involve a number of ICBs jointly commissioning these services across a wider geography, creating further complexity and variation in how things work.

3. Stringent checks will also take place on ICSs to check on their readiness for assuming responsibility for Specialised Services. There is likely to be a patchwork of approaches across different localities, with NHS England remaining heavily involved in many areas.

While the process of devolving responsibility will begin from April 2023, there will be a set of criteria – known as a pre-delegation assessment framework – that ICSs will need to meet before they take on budgetary control.

To support transition, NHS England and NHS Improvement will run a series of developmental check-ins during 2022/23 and a formal system readiness assessment will be conducted later in the year which the NHS England and NHS Improvement Board will consider before making any final decision on delegation.

NHSEI will also continue to be accountable for all Specialised Services and will retain a strong core of commissioning expertise within its national and regional offices. It expects to work hand-in-hand with systems up to and beyond the April 2023 handover and will develop an assurance model based on a wider system oversight framework it is developing. Once again, pharma should therefore expect a patchwork of different arrangements, rather than a single, uniform way of working.

4. Understanding how clinical networks feed into decision-making, and also how services will ultimately be organised, funded and delivered in each locality, will be crucial for navigating the newly devolved commissioning landscape.

Under the new system, Provider Collaboratives – those formal arrangements that bring together relevant providers to enable shared planning – are likely to be at the forefront of delivery of specialised services. Industry should expect a wide variety of approaches to emerge depending on specific service and population needs. Understanding the connections between specialised service providers and how they will work together will therefore be vital.

Understanding the Clinical Networks driving decision-making is equally important. In the current centralised system, the six national programmes are supported by Clinical Reference Groups which provide advice and strategic direction. The guidance confirms a strong and continuing role for clinical networks and Cancer Alliances in supporting ICSs: these will remain important stakeholders for pharma and med tech companies.

Finally, in terms of funding, it is worth noting that Specialised Services commissioning will shift over time towards a population-based funding allocation methodology. Next year, funding for delegated services will be based on historic costs, but this will gradually move to reflect a needs-based methodology from April 2024. As this takes root, this will have significant implications in terms of allocation and prioritisation of spend and what the NHS will be looking for from commercial suppliers as a result.

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