The must-read stories and debate in health policy and leadership.

Whose spec com budget is it anyway?

Simon Stevens is ignoring the Health Act! The NHS is working around the law! Such exclamations are now a common (and accurate) feature of debate among senior NHS leaders and policy wonks.

Looking at what this means in practice is a much less popular pursuit. But if you’re into that, a little-noticed recent NHS England publication is a classic example of the management and governance nightmares the services is grappling with.

The specialised commissioning integration annex to the planning guidance talks about the current outlook for joining up the funding and coordination of these services, which was massively centralised in 2013 – slicing up patient pathways, adding to spiralling costs, and perverting incentives.

For some years now, the NHS has been seeking to join national and local decision-making back together, but it’s jolly slow going.

Like many of the legal workarounds (Greater Manchester is another great example), it features a heck of a lot of “delegation” – delegation within NHS England, delegation to new committees, delegation to other organisations – sometimes even multiple delegations at once.

The new publication identifies “three options which are possible within the current legislative framework” for making it happen. These are: pooled budgets between NHS England and clinical commissioning groups; joint appointments between the two; and internal delegation of NHS England’s statutory responsibilities. 

Meanwhile, in 2019-20, NHS England expects every area (and an area is not easily defined, BTW) to have an “NHS England-led specialised services planning board” to start making decisions together.

Another option discussed is delegating responsility direct to providers, and letting them make sense of the whole mess.

If you’re hoping the NHS long-term plan will end all this delegation delight: don’t.

Hub hassle

Most areas are planning to reorganise pathology services in line with the 29 networks proposed by NHS Improvement. But the process in Kent and Medway is looking particularly painful.

Unite has already expressed concern about the initial options, which include carrying out less urgent work at one, two or three hubs and potentially outsourcing or private sector involvement. Decisions on the final shape of services and how they will be delivered will be made later this year but are likely to take years to implement.

The waters are muddied by a past history of attempts to reconfigure services which, in some cases, led nowhere. Where a hub has been established to serve a wider area  – for example, in Dartford which now processes non-urgent work from the Medway area – the implementation has proved more difficult than expected, leading to around 2,500 tests having to be repeated. Those leading the pathology shake-up are well aware of the past problems and are determined not to repeat them.

The four Kent trusts have signed up to work together to create a single service. But there remains much work to be done – not least to deal with the logistics of moving samples a considerable distance on congested roads.

Making decisions on hubs with a no-deal Brexit looming – which many believe could lead to gridlock on some roads in the county – should concentrate minds wonderfully.  In the report which is going before trust boards at the moment, there is just a hint that different solutions to standard road transport will be needed and drones could be one way to transport samples in the future.