A quiet revolution?

The relative paucity of debate over this reform belies its significance. Approximately one in every seven pounds spent within the NHS, a total of £20.5 billion a year, goes on Specialised Services. Around 20 per cent of this is medicines spend – further bolstered by the Cancer Drugs Fund and the new Innovative Medicines Fund, which together guarantee nearly £700 million in ring-fenced funding for high-cost, novel medicines.

Specialised Commissioning facilitates many extraordinary aspects of NHS care, from proton beam therapy for rare cancers, to next-generation treatments for multiple sclerosis and cystic fibrosis. It also supports some of our institutional crown jewels, such as Great Ormond Street Hospital in London and The Christie in Manchester, both of which are heavily dependent on specialised commissioning funding.

From an industry perspective too, it represents an important repository of commercial potential: the average per patient drug costs within a specialised service often exceed £100,000 a year.

But Specialised Commissioning has also been facing its moment of reckoning. Costs have soared in recent years – its budget has grown by more than 50% between 2013 and 2020 – while a 2016 National Audit Office report roundly criticised a lack of data on costs, access to services and patient outcomes.

Across the six national programmes of care, there are stark inequalities between different types of disease, with some of the more high-profile disease areas achieving much better outcomes than others.

Patient groups, meanwhile, have criticised the flexibility and timeliness of service specifications, and across many pathways there is a tension between the specialised provision of services (organised nationally) and the supporting generalist care that patients need (organised locally), which can lead to fragmentation and a frustrating patient experience.

Despite all of this, there has actually been comparatively little explicit commentary from NHS England on the rationale for change, though the Health Minister Earl Howe described it as “an enabler for integrating care and improving population health” during a parliamentary debate earlier this year.

Certainly, as the Policy Exchange’s recent (and excellent) Devolve to evolve? report argues, there is a surface logic to asking ICSs – the integrators-in-chief of the new NHS – to solve the challenge of bringing together what can often be a disparate patient experience for those on specialised pathways.

Yet some big questions remain about how the new arrangement will work in practice – particularly in terms of governance and financial sustainability. And there is a pretty big spectre at the feast: a potential return to the bad old days of ‘postcode lotteries’ in drug access, which could arise if financially straitened ICSs begin setting different eligibility criteria for patients with the same condition.

This is precisely what happened before 2013 when the ten Strategic Health Authorities had responsibility. For patients, the stakes couldn’t be higher.

What we do know is that process of devolving responsibility will begin from April 2023, and there will be a set of criteria – known as a pre-delegation assessment framework – that ICSs will need to meet before they take on budgetary control. At the time of writing, this framework had not been published, but is due to land before the 1 July, the point at which ICSs assume statutory form.

NHS England is also expected to remain ultimately accountable for all Specialised Services, and there is likely to be a period of double-running, probably involving NHS England regional offices jointly commissioning services in conjunction with any Integrated Care Systems that are ready on their patch.

We don’t yet know how many of the 149 services will be up for delegation or how quickly this will happen, although a 2018 policy paper unearthed by the Policy Exchange gives us a clue. It suggests that services may be segmented.

The most highly specialised, low volume ones, such as proton beam therapy, would continue to be commissioned on a national scale by NHS England, and others with high capital costs, such as radiotherapy, being done at a regional level with planning boards drawing in input from systems. This would leave about 20 services, including chemotherapy, specialist cardiac services and kidney dialysis, to be commissioned at ICS level.

If such a segmented approach happens, it would make sense to prioritise the relatively high-volume specialised services. As the Policy Exchange puts it, these are areas where “there is a high degree of interface with other parts of the system and a low level of justification for retaining central commissioning responsibility in an era of population-health”.

We may not have to wait much longer to find out, as a strategic ‘roadmap’ is expected shortly. Until then, what we can conclude is that, as a direction of travel, the abiding principle seems to be that planning and decision-making for Specialised Services should happen as close to systems as possible. This alone is a considerable break from the past.

How, then, should pharma prepare? Despite the unknowns, there are a few things we can say with confidence.

The first is that provider collaboratives – formal arrangements bringing together relevant providers to enable shared planning and delivery of services – will be essential to how things work in practice. Anticipating the connections between specialised providers and how they will work together to scale up service plans will be crucial.

The second is that addressing health inequalities remains a totemic aim. The ability to root out any disparities and ensure patients across the country can access services equitably will be an essential success measure for any ICS taking on delegated responsibility. Pharma can be part of that conversation – for example, by harvesting relevant data and working with a provider collaborative on optimising diagnostics and referral networks within the pathway.

The third is that clinical leadership is likely to be positioned at the forefront of any reform. In the current centralised system, the six national programmes are supported by Clinical Reference Groups which provide advice and strategic direction. Expect these to continue to be influential for as long as NHS England has a place at the table, and keep an eye out for similar clinical networks that will almost certainly emerge at system level as delegation happens.

Most importantly, watch out for forthcoming communications from NHS England. The clock is ticking before the scheduled April 2023 start date. We expect a lot more detail to emerge in the months ahead.

Oli Hudson is Content Director at Wilmington Healthcare.
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