Hot on the heels of pharmacy, optometry and dentistry (POD) services, ICBs are expected to take on responsibility for commissioning many specialised services from 1 April 2024. This brings a host of new challenges due to the complexity of the services and the phased way in which responsibilities will be transferred. We look at the key tasks facing ICBs in the weeks ahead.
Delegating the commissioning of specialised services is more complex than the process we’ve already been through with POD. As a result, responsibilities will be transferred in stages, and some highly specialised services will be retained by NHS England. Furthermore, while the first tranche of specialised commissioning will be delegated to ICBs from April, the NHS England staff responsible for managing these services will not transfer until a year later. ICBs will need to consider how to bridge that gap, ensuring staff feel engaged with the new processes being developed regionally, despite being rooted in the existing set up for a further 12 months.
Establishing a framework
Different regions are working through their own structures for managing specialised commissioning. In our experience, a good place to start is by mapping all the existing procedures, processes, decisions and governance that are currently in place to develop a detailed understanding of how specialised commissioning currently works in practice. This is not about replicating the existing model but about understanding the starting point to inform the basis of the target operating model. To gain benefits from this change, system leaders need to consider how specialised commissioning will work in an ICB environment and take time to question existing approaches so that improvements can be identified.
In some systems, specialised commissioning is expected to run as a business unit within an ICB, acting as a self-contained department. Unlike POD services, where there is benefit in integration with other teams, the distinct nature of this work lends itself to a more independent approach. But even with setups like this, ICBs will need to support staff in understanding changes in governance. Effectively, these teams will have multiple ‘customers’, reporting to NHS England, individual ICBs and multiple ICBs across a region, depending on the project. ICBs will benefit from clarifying how that workload will be managed and decisions made early on.
The delayed transfer of staff does present challenges but also allows for thorough staff engagement and planning. Building relationships with those affected, understanding current working relationships, and having the time to understand and address potential barriers to effective transfer will be crucial in building staff confidence and minimising any impact on service delivery.
Underpinning all these considerations is the need for a system-wide governance and assurance framework that enables appropriate decision-making at this more local level. What this looks like can be determined by each region in accordance with the guidance set out by NHS England and any conditions applied as part of meeting the requirements in the pre-delegation assessment framework (PDAF).
Benefits
The objective of delegating commissioning is to enable population based, end-to-end commissioning of services with decisions made closer to communities, and care provision is better joined up for the benefit of the local population. This requires ICBs to consider how specialised commissioning will dock into existing governance, planning and financial arrangements. For example, if there is only one specialised commissioning hub in your region, how will that hub seek clinical input, and how will individual ICBs provide appropriate input from their boards? Clarifying these decision-making and assurance processes and how they fit into existing structures in good time will make for a smoother transition.
Funding
The way funding is allocated for specialised commissioning is also changing to support this delegated approach. Instead of funding being structured based on the location of providers, from 1 April 2024 this will move to a population model. Initially this funding will be based on historic use of services but over time, budgets for specialised commissioning will be based on population needs giving ICBs more flexibility in tackling health inequalities.
These changes will rightly influence how specialised commissioning can become more joined up with other services. ICBs will want to consider how they can link their Joint Strategic Needs Assessment (JSNA) and public health priorities with the specialist care likely to be needed within their communities. For example, linking together alcohol use in the community with anticipated requirements for liver transplants.
This integration of needs, early intervention and specialist support will enable ICBs to deliver end-to-end pathways of care designed based on population needs. Taking on these additional commissioning responsibilities adds to a long list of demands for ICBs. However, once the new arrangements are in place, they will enable a further step forward for ICBs in delivering integrated, sustainable care for their communities.
By Ayesha Janjua, Associate Director of Leadership and OD, and Iain Stewart, Programme Director, at NHS Arden & GEM CSU
