The Pathfinder seeks to test elements of the delegated model for specialised services during 2023/24 in a safe and managed way to support the design and national implementation from 2024/25.

There are three main workstreams: Contracting, Finance, and Data / transactional BI.

Quality is out of scope for the Pathfinder programme.

Pathfinder is NOT full delegation. Pathfinder is testing the finance, BI and contracting processes in advance of delegation in a safe and managed way.

All financial risk remains with NHS England as the accountable commissioner of these services. The intention is for Pathfinder to be cost neutral to ICBs and providers.

Pathfinder is a collaboration between South London ICBs and providers, together with NHS England national and regional teams. Further details / members are listed within the governance diagram on FutureNHS platform within the Specialised Services Future Commissioning Model workspace (login required): https://future.nhs.uk/NationalSpecialisedCommissioning/groupHome

There are 157 prescribed specialised services in latest version of the NHS England prescribed services manual. However, many of these services have multiple service lines within them for a total of 285 service lines:

• Red (not suitable for delegation, and will remain nationally commissioned) – 105 service lines
• Amber (suitable, but not yet ready, for greater ICB leadership) – 57 service lines
• Green (suitable and ready for greater ICB leadership) – 109 service lines
• Blue (hosted / networks) – 14 service lines

Some prescribed services contain service lines with different classifications. For example, the service Adult specialist renal services has two green service lines, one amber, one red, and one blue.

The list of delegated services can be found in the NHS prescribed services manual.

Services deemed suitable and ready (“green”) for greater ICB leadership / delegation account for approximately 80-85% of specialised spend.

• High cost drugs and devices
• Non-NHS and independent sector providers
• Nationally retained services, those not yet ready for delegation, mental health (those deemed suitable not yet ready / “amber” and not suitable, not ready / “red”)
• Clinical networks
• Transformation spend

The three workstreams — Contracting, Finance, and Data / BI — report up to a Programme Board. The Board consists of representatives from South East London ICB, South West London ICB, specialist providers (Guy’s and St Thomas’, King’s College Hospital), along with national and regional NHS England colleagues. A diagram is available on FutureNHS platform within the Specialised Services Future Commissioning Model workspace (login required): https://future.nhs.uk/NationalSpecialisedCommissioning/groupHome.

Since we’ve begun, teams working within Pathfinder have unblocked obstacles and recorded learnings which we hope will be helpful to colleagues ahead of national delegation from April 2024. We are developing a playbook that aims to demystify delegation, to include:

• Learnings (Phase 1: pre launch; Phase 2: post launch)
• Recommendations (for NHS England, ICBs, providers)
• Resources (templates, flow charts, glossary)

Information is continuously update on the FutureNHS platform, within the Specialised Services Future Commissioning Model Workspace workspace (login required): https://future.nhs.uk/NationalSpecialisedCommissioning/groupHome

• Lucie Waters, Director, South London Office of Specialised Services – lucie.waters@swlondon.nhs.uk
• Jen Gospel, Programme Manager, South London Pathfinder programme – jen. gospel@nhs.net
• Andrea Marlow, Business Development Manager, South London Office of Specialised Services –andrea.marlow@gstt.nhs.uk

• Planning and safe transition to ICB allocation on ledger
• Testing of accounting, cashflow and other national SOPs.
• Testing attribution of financial flows to populations
• Development of specialised finance matrix team approach (ICB and hub)
• Aligning finance and contracting approaches
• Risk management – including understanding impact of allocation formula change
• Preparing ground for transformation opportunities (including whole pathway costing)
• In depth work across NHSE, ICBs and providers to test comparability of service line reporting and costing (‘like for like’) – feedback to NHSE re impact on rebasing
• Preparation for and management of impact of EPIC implementation in three tertiary trusts in 23/24
• Development of lessons learned document to inform 24/25 planning across regions and ICBs

It is expected that Pathfinder will be cost neutral to ICBs and providers. All financial accountability remains with NHS England.

ERF was previously funding by the seven NHS England regions on a host basis. Payments were made to trusts by each NHS England region to providers within their region for the full England population. Under Pathfinder, SEL ICB and SWL ICB will pay ERF to their host providers. SEL and SWL will pay over/ under-performance on ERF and API elements of their hosted provider contracts. They will be reimbursed for this by the London Region.

Previously all specialised services were funded by NHS England regions on a host basis (ie, payments made by NHS England to provider trusts within their region for the full England population). Under Pathfinder, delegated (suitable and ready “green”) services will be paid by each South London ICB (SEL, SWL) to all providers for their populations (unless low volume flow, or LVF, arrangements apply). Note: Mental health services are excluded.

LVFs are new arrangements that aim to reduce contractual relationships and associated payments for region / provider relationships valued at £1m or less:

• Regions will transfer LVFs between them, so that LVFs will flow to regions hosting a trust.
• LVFs will then be paid by regions to trusts on a host basis.
• A region will therefore only pay a trust outside of its region if the value is more than £1m.

Note: LVF arrangements are different to those for ICBs. For ICBs, the need for contractual relationships with smaller flows are handled through Low Volume Agreements (LVAs), which are for historical flows between an ICB and an NHS trust of £500K or under. Values are set and mandated nationally, and payments made by each ICB to providers once during the year, usually in September, rather than monthly.

Low volume agreements (LVAs) designate historical flows between an ICB and an NHS trust of £500K or less. Values are set and mandated nationally, and payments made by each ICB to providers once during the year, usually in September, rather than monthly.

Aligned payment and incentive (API) is a type of blended payment, comprising a fixed element, based on funding an agreed level of activity and a variable element, which increases or reduces payment based on the actual activity and quality of care delivered. Within Pathfinder, all SEL ICB and SWL ICB contracts include start funding for other variable elements of API contracts. The ICBs will pay over / under performance on API elements of hosted provider contracts, and will be reimbursed for these by NHS England (London region).

• Developing and testing data access
• Alignment of specialised data with ICB data sources to create single data set
• Triangulation with spend data and provider data sets
• Application and monitoring of identification rules (IR) and correct allocation of ICB & service lines
• Modelling actual ICB spend in relation to planned ICB budget
• Calculating impact of future changes in allocations (i.e. shift to needs-based)
• Liaising with Trust colleagues to validate assumptions from a data perspective
• Designing reports and modelling tools as required
• Supporting financial intelligence colleagues with in-depth data quality analysis
• Development of specialised BI matrix team approach (ICB and hub)
• Development of lessons learned document to inform 24/25 planning

There are no changes to provider data recording and reporting requirements during Pathfinder. Providers should continue to follow national guidance relating to the reporting of specialised services in commissioning datasets (contract monitoring and SUS).

To identify activity relating to pathfinder, ICBs will use the following fields within contract monitoring datasets:

• Service code
• Organisation identifier (GP practice responsibility)
• Organisation identifier (residence responsibility)
• Organisation identifier (code of commissioner)

It is therefore particularly important that providers continue to complete these fields accurately and comprehensively.

• Agreed ways of working across organisations with accountable leads and workstream forums/ sub groups where required
• Agreement of contract form, with defined schedules and legal Assignment
• Engagement with key stakeholders and workstream interdependencies (especially Finance, Bi and Data workstreams)
• Working with NHSE London Region contracting team to align seven regional associate contracts to SEL and SWL led host arrangements and co-designing contract models and CCA.
• Establish process and implementation of testing phase.
• Production of lessons learned document OR contribute findings to lessons learnt - agreement of measurements / milestones/ indicator that demonstrates success.

General Condition 12 (GC12) of the NHS Standard Contract enables to commissioning body (NHS England) to assign some or all of their responsibilities to another organisation without the need to formally agree with the provider or the requirement for a separate contract with providers.