What is specialised commissioning?

Updated April 2024.

NHS England is the accountable commissioner for 154 ‘prescribed specialised services’. This portfolio of services includes many services for people affected by neurological conditions.

Through the new legislation set out in the Health and Care Act 2022, integrated care boards (ICBs) will take on delegated responsibility for 59 of these services, within a framework of continued national accountability, national standards, national service specifications and national clinical policies.

NHS England has conducted an ‘pre-delegation’ assessment to inform which services can be appropriately delegated. This takes into account:

• There is a clear understanding of how receiving each new responsibility will benefit population health outcomes.
• There is a shared understanding across all ICS partners of the benefits of delegation.
• Governance enables safe, high quality delivery.
• Clinical leadership combines the specialist expertise to lead and scrutinise individual functions, and the collaborative working necessary to identify, enable and oversee clinical improvements.
• Major financial risk factors and issues are clearly understood and mitigated, and there is a track record of delivering a balanced budget.
• There is an understanding of the workforce, capability and capacity requirements, with any major risks understood and processed for mitigation.
• There is a clear understanding of the level of digital maturity required, with any gaps identified and prioritised for improvement.
• There is a meaningful geographical footprint which takes into account key patient flows, with clear plans in place to manage and mitigate against any risks

See section 4 of the NHS England Roadmap for specialised services for further information.

The NHS England roadmap for specialised services

NHS England set out the direction of travel in its Roadmap for specialised services in 2022.

According to the roadmap, responsibility for some key services will be delegated to ICBs. These include:

• Adult neurology
• Adult neurophysiology
• Adult rare brain and central nervous cancers
• Paediatric and adult neuropsychiatry Paediatric neuroscience
• Paediatric neurorehabilitation
• Neurosurgery
• Neuroradiology
• Complex rehabilitation for ‘patients with highly complex needs’ (likely to include neurorehabilitation for adults)

Low volume neurosurgery procedures, transcranial magnetic resonance guided focused ultrasound, adult ataxia telangiectasia services, diagnostic services for rare neuromuscular disorders, neurofibromatosis services, hyperbaric oxygen and services for neuromyelitis optica, are not deemed suitable for ICS leadership.

Importantly, NHS England retains accountability for the entire portfolio of specialised services throughout England, no matter where responsibility for commissioning lies.

In addition, all specialised services will continue to be subject to national service specifications and clinical policies. These are likely to continue to be developed with the advice of appropriate clinical reference groups (CRGs) within specialised commissioning. Our Chief Executive, Georgina Carr, is currently patient and public voice representative for the neurology CRG.

These policies will outline what components services should include. However, with greater responsibility for provision, ICBs will have flexibility to determine how services are delivered. Money for specialised services will not be ringfenced. 

Timeframe for delegation of commissioning

The NHS England Board confirmed in December 2023 that only three of the seven ICB regions are to go ahead with full delegation.

ICBs in the East of England, Midlands and the North West regions of England will receive full delegated responsibility for specialised services from April 2024 (covering 20 ICBs).

Statutory joint commissioning arrangements between NHSE and ICBs in the South West, South East, London and the North East and Yorkshire regions of England will remain in place until April 2025.

Most ICBs will need to execute their responsibilities through nine multi-ICB groups to reflect patient flow and appropriate population footprints.

Legal duties to involve the public in commissioning will continue. The public involvement and consultation duties of commissioners are set out in s.13Q NHS Act 2006 (as amended by the Health and Social Care Act 2022).   

As you can see in the map above, there are 24 neuroscience centres, and not every ICS has a neuroscience centre. As such, multi-ICS arrangements to ensure access to specialised services is critical.

The majority of ICBs are ready for “joint commissioning” rather than full delegation – a ‘stepping together’ approach has been proposed – whereby all ICBs across the country will establish formal joint working arrangements with NHS England via nine statutory joint committees in 2023/24, with a view to moving to delegated commissioning arrangements from 2024/25, subject to a further assessment of system readiness ahead of April 2024. Further information about this process was set out in Item 7 of NHS England Board papers, February 2023.

The neuroscience transformation programme was set up to assess the current commissioning model for neuroscience (in practice this means neurology and neurosurgery specifically), and how this might need to change in future.

At a glance: key milestones in specialised commissioning

• May 2022: NHSE Roadmap for specialised services published.
• Aug 2022 – Nov 2022: Assessment of system readiness.
• Dec 2022: NHSE panel to agree scope, system readiness and commissioning arrangements (i.e. joint committee or full delegation).
• Feb 2023: Final decision from NHSE Board on delegation of services and to which systems.
• Apr 2023: Joint committees established between ICBs and NHS England
• 2023/2024 Further testing of new model (including in neurology and neurosurgery), and support for systems.
• April 2024: Services allocated for delegated responsibility will be delegated to three regions in England (a total of 20 ICBs).
• April 2025: Delegation to the remaining ICBs.

Further reading

NHS England and Improvement (2017) Prescribed specialised services manual.

NHS England Board meeting minutes, item 8 (2023)