Transfer of multi-billion pound fund to ICSs delayed until 2024

NHS England guidance issued in the spring set an expectation that responsibility for 65 out of 154 specialised services lines would be devolved to most integrated care systems in April next year. The services included major trauma, congenital heart disease, and radiotherapy. 

The value of the funds due to be transferred was not specified, but total annual spend on specialised services is around £23bn.

The guidance said the change would lead to fairer distribution of resources, and enable systems to “design care that joins up around patient needs, and invest resources where they can have best effect on outcomes”. It added the move would allow ICSs to “make decisions about investing upstream in interventions that will reduce demand for… more interventionist approaches”.

However, several senior sources have told HSJ that NHSE will delay the delegation of the large majority of specialised services, initially to April 2024. Instead, ICSs are expected to be encouraged to step-up closer working with regional commissioners in 2023-24, commissioning more services through joint ICS/NHSE committees.  

The move has not yet been formally announced but several ICS and trust leaders said they had been informed of it.

It comes after concerns were raised about the risks of going ahead with the transfer.

Specialist providers are worried cash-strapped ICSs may reduce spending on services based outside their area, potentially destabilising them, and/or making it hard to secure capital for developments. 

The Shelford Group, which represents the largest teaching hospital trusts, wrote to NHSE strongly opposing a transfer of many services in May, shortly before NHSE published its “roadmap” guidance.

There is also considerable concern about financial control of such significant sums in a time of major budget pressures.

Most systems are considered too small to take on responsibility for specialised commissioning alone. They were expected to commission jointly with their neighbours, in partnerships similar to those formed by primary care trusts prior to 2013. However, ICSs’ capability, and progress in forming these regional groups, is highly variable, some leading NHSE figures believe.

Meanwhile, some ICS finance leads fear NHSE cannot give them a clear picture of the allocations, risk and responsibilities they would be taking on, or which services would benefit from co-commissioning.

NHSE had also proposed to move at some stage from allocating specialised funding based on provider income to population need.

Nuffield Trust chief executive Nigel Edwards has previously warned of the risks of the delegation. Speaking to HSJ last week, he said: “Given the complexities and risks involved, and the unresolved and potentially unwise decision to move to a new method of resource allocation, a pause makes sense.”

However, some ICSs and some in NHSE support delegation, with the NHS Confederation ICS Network saying that systems “in a position to do [so], this handover should go ahead as planned from next April” (see below).

Those who support delegation fear responsibility for most services will remain with NHSE beyond 2024, preventing systems from developing their role. The government earlier this month said it wanted more power devolved to ICSs, and the current health and social care secretary, Steve Barclay, has made clear he thinks NHSE is too big.

Meetings were due to take place next month to decide, for each ICS, how ready it was to take on specialised budgets. It is unclear if they will still go ahead.

An NHSE spokesperson said: ”Our plans remain unchanged from our roadmap published in May, and in 2023-24, responsibility for these services will either be delegated in full to integrated care boards or to joint committees of NHSE and ICBs depending on an assessment of system readiness.

“Final decisions on the list of services that will be included within these delegation arrangements and the form of delegation, will be taken by the Board next year following an ongoing assessment process.”

NHS Providers director of policy and strategy Miriam Deakin said: ”Changes to the way these services are commissioned or planned should be done in close collaboration with the people who know those services best, ensuring that, as now, expert clinicians and patients are heard. It has always been important to ensure proposals to give integrated care boards more responsibility in commissioning specialised services are thought through carefully.

”It will be important to consider the capacity and capability at ICB level, mindful that these are new organisations being given a range of complex and important functions. We need to ensure too that specialised services retain due priority in funding discussions. Trust leaders believe that the proposed move to a formula based on local population needs may lead to significant changes to available funding over time and the impact of this needs to be understood.

“The reported delay gives trusts and local systems a fuller opportunity to consider and address some of the risks of delegating specialised services. Clear, early communication by NHS England of expectations for the next two financial years will help effective planning by trusts and their partners.”

NHS Confederation ICS Network director Sarah Walter said: ”The delegation of specialised NHS services provides an opportunity to better integrate services and improve the quality of care for patients.

”While ICSs will want to have as much time as possible to thoroughly prepare before taking over these functions in full, for those systems already in a position to do [so], this handover should go ahead as planned from next April.”

Updated at 9.35am on 28 November to include comments from NHS England and NHS Providers, and at 5.15pm to include NHSC comment.