Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by commissioning correspondent, Sharon Brennan.

In the long-term plan, NHS England declared it would dramatically increase the number of people diagnosed with cancer in the early stages – with those discovered at stages one and two to rise “from around half to three-quarters of cancer” patients by 2028.

Speaking at HSJ’s first cancer forum earlier this month, David Fitzgerald, NHS England’s national cancer programme director, said the “sheer scale of the ambition [of the 75 per cent goal], was always intended to be challenging” and warned the audience that meeting it is “going to be tough”.

Mr Fitzgerald confidently said that planning guidance makes it “absolutely clear” integrated care systems and sustainability and transformation programmes should be working with their regional cancer alliances to achieve these targets. Yet forum attendees were far from clear what that will actually look like on the ground.

One leading figure in regional cancer care bluntly said to me, “If you work it out, let me know.”

There are three clear problems that need to be quickly overcome to help solve this commissioning conundrum and ensure the targets have a chance of being met.

Firstly, the integration of the alliances and the current STPs do not neatly fit together. There are 19 CAs and 42 STPs. HSJ understands that at least one subregion of an STP recently asked NHS England to change geographical patch and was refused.

Changing boundaries is not easy – in part because of concerns that it would start a domino effect that could force nearby STPs to absorb neighbouring populations. Nor am I hearing serious talk of cancer alliances changing size.

In some areas this does not matter – Kent and Medway, for example, have a single CA that fits the same STP patch. Glenn Douglas is accountable officer for all the region’s eight CCGs, plus its STP and its cancer alliance. The Greater Manchester alliance is similarly aligned.

Contrast this with the East of England cancer alliance which supports five different STPs over a large geography, the Northern alliance which is spread across three STPs, and the Thames Valley Cancer alliance which spans two STPs in which sit three ICS.

While this lack of symmetry may not have hindered the work of alliances until now – as they used their yearly transformation funds to tackle small, specific projects – it is likely to cause problems in the future, as the role of cancer alliances beefs up.

Secondly, the fragile nature of ICS could also slow down progress.

The latest planning guidance for CCGs said the alliances should be “bringing together their constituent commissioners and providers, on behalf of their STPs/ICSs” and the latter should help facilitate this. However, without any legislation underpinning their status, ICS will often find it difficult to collaborate with cancer alliances.

Finally, the way the alliances and STPs operate conflicts with each other. Alliances are assigned transformation money on a year by year basis, meaning that projects have to be short term or providers and CCGs must be on board to continue funding a project once the alliance money has been used. While Mr Fitzgerald said at the forum that NHS England is considering confirming alliance funding for more than a single year, the timing will be out of sync with the STPs who have to file five-year regional plans this summer on how they will meet national targets.

I’ve also been told that single providers compete strongly for the annual cancer alliance transformation funding as the pot is shared across the regions each year. This is the antithesis of an ICS which requires all providers and commissioners to come together to resolve regional problems without the spectre of competition hovering over them.

The NHS would have been off to a much stronger start if these governance issues, and commissioning decisions that stem from them, had been addressed before the long-term plan was launched. As it stands, it seems unavoidable that the system will end up with significant variation across STPs in how these early diagnosis goals are addressed.