Big hospitals warn NHSE of dangers of ICS takeover

The Shelford Group, made up of 10 of the largest teaching and research trusts in England, wrote to NHSE in March detailing its concerns about its plans to move some of the responsibilities to ICSs from next April. 

The group told HSJ it had in recent months been “engaging very constructively with NHSE and other partners” and was generally supportive of the ICS reforms.  

However, its letter – leaked to HSJ this week – set out a detailed list of significant risks “in terms of quality, equity, value and system complexity that we do not yet see being fully taken into account”.

It said it “welcomes the policy intention to improve the co-ordination of patient pathways” and the “focus on early intervention, prevention and health promotion”, and agrees “there are now some services where delegation of commissioning to ICS level makes sense”. It identifies renal dialysis and HIV screening in emergency departments as examples of the latter. 

But it said: “We do not see, however, that these examples justify the wholesale move of commissioning of 80-90 per cent of specialised services to an ICS footprint, particularly those services where the numbers and evidence base supports the planning and provision of care being done at a population size larger than a typical ICS footprint.”

The NHS allocated £19.3bn to specialised services in 2020-21, according to the latest NHSE annual accounts, about 15 per cent of total NHS revenue and currently all commissioned by NHSE.

When ICBs are ready

NHSE has said it will evaluate each specialist service later this year to see if it is eligible to be delegated or moved to ICSs, now or at some point in the future. It also told HSJ: “Services will only be delegated where [integrated care boards] are ready.”

NHSE has said it will remain accountable for services and will set national standards, but the Shelford Group letter said there remained “a risk of derogation” from the standards, “leading to increased variation by postcode, unless governance mechanisms and resources required to audit compliance are in place”.

There is also a risk ICSs “will focus on high volume services for their local population, leading to deprioritisation of specialised services, and/or an inclination to support development of services within that ICS’s footprint as opposed to at the optimal level for ensuring clinical quality”, it said.

The NHS in the past moved to aggregate up the provision of some specialised services so that a smaller number of units could perform relatively rare procedures at sufficient volume to generate and maintain clinical expertise, improving patient outcomes. 

The Shelford Group warned that the potential for fragmenting and diluting the provider landscape would imperil this. Having this “critical mass” for services “ensures the development of expert staff who treat sufficient numbers of patients to maintain safe, high-quality care, supports patient recruitment to the research trials essential to improving treatment and care, and maximises the use of scarce, expensive physical and human resources”, it said. It could also damage innovation, research and life sciences. 

Joined-up care

Asked about the letter, NHSE’s national director for specialised commissioning John Stewart told HSJ: “Delegating certain specialised services will provide more joined-up care for patients, improve their experiences and speed up treatment. Services will only be delegated where ICBs are ready, with NHSE remaining ultimately accountable, including setting national policies and standards.

“It is understandable that the biggest specialised providers have a strong interest in the future provision of services, and it is important they work with commissioners to better meet the needs of all specialised patients, including those outside their immediate local area.”

NHS Confederation ICS Network director Lou Patten said: “We welcome the opportunity to devolve some services, currently classified as specialised services, to [ICSs] in line with the broader ‘system by default’ approach [which has been set out by NHSE]. This may involve reclassifying some of those services classed as specialised and delegating some specialised services. Local flexibility gives ICSs greater scope to innovate to improve services for patients.

“However, ‘default’ does not mean ‘always’ and there may of course be some specialised services which are best continued to be commissioned centrally, alongside highly specialised services, or commissioned by a group of ICSs, reflecting on the size of the populations they serve. This requires close consideration by ICSs and providers and we look forward to having the opportunity to work with NHSE to find the approach which works best for patients.”

Shelford Group managing director Will Warburton told HSJ: “We recognise there are some really good opportunities to improve care, and we are engaging very constructively with NHSE and other partners.”