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

NHS England’s specialised services strategy can only be described as absent.

For years I’ve been hearing that a vision, strategy, or long-term plan on specialised commissioning would be forthcoming to only repeatedly fail to materialise. The latest planning guidance from NHS England and NHS Improvement even dropped the dedicated appendix on specialised, which had featured in the prior iteration.

So, it’s not surprising the very brief mention given to specialised commissioning in the guidance is far from clear in its intent.

The document appeared to say sustainability and transformation partnerships/integrated care systems must align their expected spec com income with the budget that is available for spec com in that area, although NHSE does not publicly break its budget down in this way.

The document said: “Systems should work with NHS England and NHS Improvement regional colleagues to develop narratives that demonstrate a clear path from assumptions made in the NHS long-term plan submissions on specialised income to an agreed set of assumptions that form the basis of a deliverable and affordable set of plans for systems and specialised commissioning.”

The guidance goes on to suggest that to deliver the financial efficiencies which may be needed because of this alignment, STPs must focus on “unlocking the potential of transformation schemes and service change across specialised services”. It added STP/ICS leaders will be responsible for collating and submitting specialised commissioning plans for all organisations within the system.

Nigel Edwards, chief executive of the Nuffield Trust, who has been looking into specialised commissioning lately, said this latest guidance on specialised commissioning was “completely impenetrable… it really is most extraordinary”.

He said it may be “related to several things” including: reducing the number of centres that do “really small volumes” of specialist surgery; improving the transition between services that are commissioned locally, regionally and nationally (so, for example, someone needing neurosurgery can easily transition to local rehabilitation); or opening “opportunities for more local commissioning of some specialised services”.

In February 2018, HSJ reported the spread of specialised services spend across English hospital trusts remained relatively unchanged over the last four years, despite Sir Simon Stevens having previously called for the “long tail of providers” which do very few surgeries to be curbed. Three months later, we reported NHSE’s system of “gold standard” quality requirements for specialised services had effectively been scrapped and replaced by a “quality surveillance processes”.  

We are yet to hear of either the previous gold standard system of derogations, in which services could continue as long as a remedial plan was in place to meet agreed quality standards, or the new surveillance system resulting in any significant change to specialised commissioning. Nor to see any signs of the latter bringing any new transparency on quality.

It seems on the face of it, therefore, that local systems are being tasked with doing what NHSE has failed to achieve since it took on specialised commissioning in 2012, namely closing those specialised services that are unaffordable and aren’t delivering on quality.

It may well be that NHSE thinks STPs/ICSs are a better vehicle to finally start to achieve local reconfigurations, but I’ve spoken to numerous commissioners within STPs and ICSs and the same concerns have consistently been raised.

First, they said their overview of spec com within their area dramatically dropped after NHSE took over commissioning in 2013, with one saying reports on specialised services never cross their desk anymore.

Second, they aren’t willing to take on specialised commissioning without some form of financial risk share with NHSE. A “review of the underpinning financial architecture for specialised commissioning” was also promised in the planning guidance, but whether this refers to a new risk share system is opaque. 

NHSE has confirmed its model for devolving mental health specialised commissioning, through a lead provider model, may be used in the future to “develop more integrated arrangements in other acute specialities”. But no quick movement is anticipated.

One commissioner said they had just begun discussions about spec com delegation with their regional NHSE/I team but expects them to last at least 12 months as they wanted to be very clear what the expectation was. They said: “We [CCGs] have been around now for eight years, we are wise to the games of NHS England.” Nearly all STPs/ICSs have a patch too small to plan the majority of specialised services, anyway.

If anything can be said to be clear within the vagueness surrounding spec com, it’s that NHSE intends to hold the line on the budget, which infamously went completely out of control shortly after NHSE first took over.

One source told me: “The planning guidance is a symptom of the lack of clarity around what they are doing.

”Potentially it means that NHSE might devolve spec com but say they have to stick to a rigid framework on spend assumptions. Not blowing the budget has always been the guiding principle.”

In summary — perhaps the strategy remains to not have a strategy.

Additional reporting by Katherine Hignett, procurement and specialised services correspondent at HSJ