Specialised services are the crown jewel of the NHS. Across the provider sector, world class clinicians and experts deliver leading edge treatments. From CAR-T therapy to forensic mental health services for young people, around 17% of the total NHS budget is committed to funding treatments for patients with conditions defined as rare or complex.
As the NHS landscape continues to evolve quickly with emphasis on delivering the aspirations of the long term plan, providers of specialised services are well placed to lead significant improvements in patient care.
We recently asked healthcare leaders for their views on the future of specialised services and its contribution to the long term plan. All our contributors reflected a strong desire to deliver excellent outcomes, support pioneering treatments and deliver improvements for patients. But many were clear that we also need to address a number of challenges if the full potential of specialised services is to be unlocked.
Getting the footprint right
The interplay between emerging integrated care systems (ICSs) and specialised services presents an immediate challenge for providers of specialised services, and their national commissioner, NHS England. For many of these services, a sustainability and transformation partnership (STP)/ ICS footprint isn't appropriate as the patient cohort is drawn from a much larger geography. Some specialised services are rightly concentrated in national or regional centres (that require a national or regional approach).
Providers are supportive of the move to system working but keen to flag the importance of thinking differently about what this means for commissioning and delivering different specialised services sustainably and to a high quality. According to one of our interviewees, there is a danger in "retro-fitting" specialised care into the new world of system working.
Providers are supportive of the move to system working but keen to flag the importance of thinking differently about what this means for commissioning and delivering different specialised services sustainably and to a high quality.
Managing complexity
The challenge of specialised commissioning has always been: how do you plan and commission a wide range of complex services within a limited budget? In recent years, the approach to specialised commissioning has felt particularly transactional to many providers. However the long term plan may prompt helpful conversations nationally, regionally and at system and local levels to change this.
Across the country, some systems are beginning to adopt different arrangements for specialised commissioning. In some, ICS planning boards are being set up to give providers, but also local CCGs, a greater say in NHS England's commissioning decisions. The hope is this will lead to true end to end commissioning for local populations. Other providers are looking to the seven new NHS England and Improvement regional teams to agree a strategic approach to specialised commissioning across a larger footprint.
It is a long term plan ambition for all appropriate specialised mental health, learning disability and autism services to be managed through provider collaboratives over the next five years. A number of trusts have already entered into these provider collaboratives and are commissioning and coordinating certain services. One of our interviewees felt that bringing senior clinicians and senior operational managers into commissioning discussions had helpfully "turned commissioning on its head" and put clinical drivers at the forefront of service redesign.
One of our interviewees felt that bringing senior clinicians and senior operational managers into commissioning discussions had helpfully "turned commissioning on its head" and put clinical drivers at the forefront of service redesign.
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Delivering the ambitions of the long term plan
It is clear that change is afoot across specialised services, but system's structures and commissioning arrangements are only a means to an end. If we can get it right, the prize is huge: delivering improvements in patient care through improving experience, investing in capacity and utilising new technologies and treatments. All of which supports the ambitions of the long term plan.
Patient experience
There are good examples of specialised services involving patients and service users in decisions about their treatment and the way services are delivered. But as one interviewee pointed out, this is far from universal and there is much more work to do. Some trusts are also increasingly engaging staff to drive improvements in care, creating a positive environment in which they can work and giving them the flexibility and freedom to innovate.
Investing in capacity
In the new world of system working, specialised providers can look to invest in capacity in other parts of their local health and care system to allow them to meet the growth in demand for their services. In mental health specialised service provision, some providers now have the power to invest in community provision as an alternative to their inpatient services. The caveat, of course, is that you need the money available to invest.
In the new world of system working, specialised providers can look to invest in capacity in other parts of their local health and care system to allow them to meet the growth in demand for their services.
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Research and innovation
Providers of specialised services can sometimes access additional funding via the strong links they have with academic and research centres. The new technologies and treatments that are developed within specialised services, although requiring upfront investment, can help solve many of the challenges facing the entire sector as well as ensure the NHS remains at the forefront of pioneering research and innovation. Providers delivering specialised services also play a key role in diffusing innovation throughout the rest of the sector.
Where next for specialised services
Many of the leaders we spoke to work in trusts that are global brands. One interviewee described specialised services as a "national asset" because of their international status. There is an opportunity and desire within the provider sector to drive innovation and transform delivery of these services. They have a leading role to play in delivering on the ambitions of the long term plan. But we must always keep the patient perspective front of mind. As one interviewee pointed out, 99% of patients would have no language to describe specialised services. For them it's simply their health and their health care.
This was published in the HSJ.