NHS England (NHSE) set out a path to delegate commissioning of primary care and some specialised services to Integrated Care Boards (ICBs), beginning with pharmacy, optometry and dentistry (POD) from 1 April 2023.
The aim is for decisions about healthcare to be made at a more local level, and to enable a more joined-up approach to service delivery. POD delegation is generally regarded as the most straightforward given the knowledge and understanding of primary care at system level. But transferring this commissioning responsibility to ICBs is not without its challenges, and there are lessons we can and should learn to inform the next phase of delegated commissioning in April 2024.
While common requirements run across all delegated commissioning projects, the scale and complexity of systems inevitably impacts the approach Arden & GEM has taken in supporting systems through this change. This case study draws together experience from supporting a network of 11 ICBs in the NHSE Midlands region as well as the three ICB region in the North West.
The challenge
Delegating commissioning responsibilities for POD services included the services themselves as well as the supporting services such as finance and complaint handling. Together these required staff, processes and systems to be transferred, and new arrangements to be set up to govern these services locally.
Despite delegation, NHSE remains accountable for the functions under the Health and Care Act 2022. ICBs therefore must meet requirements set out by NHSE to provide assurance that the delegated services will be delivered safely in line with statutory guidance.
Our approach
With services being delegated at regional level, ICBs needed to develop new ways of working to enable these services to be commissioned effectively. This requires effective programme management to manage multiple workstreams and meet the assurance requirements set out by NHSE, as well as extensive stakeholder engagement to build relationships, support staff and integrate new responsibilities into existing activities.
In both regions, robust programme governance and continuous communication were key. Regular programme meetings and reporting provided the necessary structure and programme governance to keep the workstreams on track and ensure continuous engagement with different stakeholders.
With 12 organisations involved (NHSE and 11 ICBs) in the Midlands region, two ‘host’ ICBs were selected to represent the east and west of the region for this programme team and host the staff moving across from NHSE.
In the North West, the ICBs began work early on to develop a shared understanding and vision for delegated commissioning as a whole, albeit prioritising POD services. This was managed through a combination of fortnightly working group meetings, weekly catch ups and regular workshops.
Corporate governance
Good governance is essential to enable these delegated services to be commissioned effectively. Each region needed to establish structures that were in keeping with the delegation agreement and legislation, while also reflecting local needs. Developing a detailed understanding of existing processes and engaging with stakeholders in each region allowed the programme teams to develop appropriate structures to enable clinical and managerial input, and maintain a collaborative approach across ICBs.
The Midlands region has established a three tier Clinical Commissioning Committee, with tier one made up of chief executives and chairs, and tier two led by senior ICB directors. Most decisions are made at tier two, with monthly meetings in place to review finances, performance etc. The committee is supported by clinical experts and approving specialists, in tier three, to take delegation arrangements into business as usual. Crucially, every ICB retains equal responsibility for the POD services – the arrangements in place to host staff do not affect governance arrangements or responsibilities.
Transfer of staff
Delegation of POD services includes the transfer of affected staff from NHSE to the appropriate regional teams under TUPE (Transfer of Undertakings Protection of Employment) arrangements. While the approach differs according to local requirements, both the North West and Midlands regions implemented comprehensive staff engagement programmes to support teams through the change.
ICBs and NHSE engaged fully with regular staff engagement events, to understand current work practices, identify any concerns and work collaboratively to support seamless transfer. This included providing staff with new equipment and accounts to enable access to different systems and platforms.
Systems, processes and assurance
Alongside transfer of staff, the programme teams brought across supporting systems and processes which have been integrated into new regional arrangements. This included finance ledgers, central data files and outstanding POD complaints and required a review of user access permissions to the millions of files included in the transfers.
To meet NHSE assurance requirements, we also completed the documentation set out in the pre-delegation assessment frameworks (PDAFs) which ICBs must meet before commissioning functions can be transferred.
Outcomes
In both regions, POD services have been successfully transferred and service decisions are now being made closer to the local level with the aim of improving patient care and experience.
The ICBs in each region have developed close working relationships, both among themselves and with NHSE, which is not only supporting the successful delivery of POD services, but also lays strong foundations for future phases of delegated commissioning, beginning with some elements of specialised commissioning in April 2024.
By Iain Stewart, Programme Director and Ayesha Janjua, Associate Director, NHS Arden & GEM CSU
