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An Update on NHS Specialised Services: The Clinical Advisory Group's Report and the Issue of Commissioning Boundaries

21 September 2012 Cameron Lockwood

The dust rarely has time to settle in the NHS; currently in the midst of major reforms, England's health service has undergone a variety of transformations over recent decades, with the evolution of commissioning structures proving particularly interesting.

This week there was some news on the future of commissioning for specialised services - an area of the NHS which has been no stranger to change in recent years - as the Clinical Advisory Group (CAG) for Prescribed Services made its recommendations on which specialised services ought to be commissioned nationally.

A Brief History of Specialised Services
Major attention was first drawn to the landscape for specialised services back in 2007, following Sir David Carter's review of commissioning arrangements for this area of the NHS. It was this review which gave rise to the National Specialised Commissioning Group/National Commissioning Group/Specialised Commissioning Groups configuration.

The short-lived Advisory Group for National Specialised Services (AGNSS) came about as a result of a Department of Health consultation on ways to strengthen the national commissioning system, specifically with regards to review of high-cost, specialist technologies. However, as a result of the major and ongoing NHS reforms, from April 2013, AGNSS will be dissolved and NICE will take over this framework.

Commissioning "Boundaries"
Interestingly, the CAG report identifies the potential for three different types of service configurations, as a result of the current intention to split specialised-services commissioning between the new NHS Commissioning Board and the local Clinical Commissioning Groups:

  • Services where the entire patient pathway is prescribed (i.e. under the remit of the NHS Commissioning Board);
  • Services where only specialist and highly-specialist care is prescribed; and
  • Services where only procedures/facilities are prescribed (e.g., radiotherapy).

As a result of the fact that elements of the same patient pathway may thus be split across budgets, the CAG highlighted the potential risk of "commissioning boundaries" being created.

Ensuring Nothing Slips through the Cracks...
The issue of commissioning boundaries has been broached before-indeed, in a 2009 Health Select Committee investigation into commissioning, a then current chair of one of the regional Specialised Commissioning Groups alleged that proposals to allocate funds to different commissioning groups could "cut across" patient pathways and potentially compromise the quality of care.

As pointed out by the CAG using Morbid Obesity Services as an example, the national commissioning of some services divorces the "prevention" from the "outcome" - i.e., the entity in charge of commissioning this service will not have responsibility for preventative weight management policy and services, which instead reside with Local Authorities and the Clinical Commissioning Groups.

Clearly some pretty savvy, linked-up joint working between commissioners will be required to make this arrangement work, as pointed out by the CAG.

It remains to be seen how evolving NHS structures impact patient care and access to treatment at large-and specifically in the area of specialised services.



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