An official review of specialised services has highlighted the risks in having three separate commissioners for the NHS and public health, warning of a potential threat to integration of some care pathways.

The Clinical Advisory Group for Prescribed Service’s final recommendations were published this morning.

Prescribed services, or specialised services, are for rare conditions and are provided at specialist centres on a regional or national scale. In the current NHS structure many of these are provided at strategic health authority level, and will in future be the responsibility of the NHS Commissioning Board.

Kathy McLean, who led the review, emphasised that for many services some elements will be specialised and others will remain the responsibility of clinical commissioning groups.

“We were struck by the difficulties which arise when an attempt is made to translate the consensus definition into contractual terms.”

Her report said: “[Group] members were struck by the need for commissioners to work together where a patient pathway crossed between the CCG and commissioning board responsibility.

“There were potential risks in creating a commissioning ‘boundary’ – especially where separate budgets will apply.

“For instance, our proposals recommend that general nephrology should be commissioned by CCGs but that specialist assessment for renal replacement therapy should be commissioned by the board.

“There is an identifiable risk that activity could migrate towards one or the other if the criteria for referral to such a clinical were not clearly laid out.”

Meanwhile leaving morbid obesity services to be commissioned by the board “separates prevention from the outcome,” she said.

“Local authorities and CCGs will be responsible for weight management policy and weight management services. A successful programme to reduce the number of people requiring surgery would lead to a reduced cost to the board based on expenditure by CCGs and councils… the absence of a weight management programme could lead to increased cost to the board but the investment required would sit within a different budget.”

However, these risks should not prevent a service from being prescribed, she concluded, but the commissioning board “will need to develop systems to ‘join-up’ commissioning for these services.”

The review was asked to consider the existing list of specialised services against the following four criteria: the number of patients who need the service; the cost of providing the service; the number of people able to provide the service; the financial implications for CCGs if they were required to commission the service.

The group recommends that “virtually all” existing designated specialised services should be prescribed in the new system.