Funding for cleft services in the UK
Cleft Lip and Palate is categorised as a 'Specialised Service' which is defined as a healthcare service that supports people with rare and complex conditions. Here we explore the way in which cleft care is funded in the United Kingdom.
At the time of UK cleft centralisation into hub and spoke services in 2000, contracts for the 12 newly formed Cleft Service Networks were negotiated on an individual service basis, influenced by regional cleft births. Cleft Service Networks have subsequently been commissioned nationally and have retained similar annual contracts that were originally negotiated from the outset in 2000. The 2013 NHS Standard Contract for Cleft Lip and Palate Services identifies aspects of cleft care that need to be delivered with associated key performance indicators, which are reported for each network. The 12 centralised cleft networks use their allocated annual budget to deliver the service specification. Discrepancies may arise for spoke services, which are delivered in the community, including speech therapy, dentistry and audiology. These services are under immense pressure and there is reported geographical variability in accessibility and delivery of services.
The differences in the way in which funding is allocated to cleft networks in each of the four devolved nations is described below:
England (9 Cleft Networks)
In England in 2000, NHS Primary Care Trusts (PCTs) delegated funding responsibility to Specialised Commissioning Groups (SCGs), but following the 2012 Health and Social Care Act, PCTs were replaced by Clinical Commissioning Groups (CCGs). In this new system, ‘Specialised Services’ (There are currently 154 Specialised Services identified by NHS England, of which Cleft Services are one) benefitted from funding at a national level, overseen by NHS England and NHS Improvement (NHSE/I).
The Health and Care Act 2022 introduced Integrated Care Systems (ICSs) into the legislature. This reorganisation saw 42 ICSs in England replace over 100 CCGs, with the aim of maximising cohesive high quality and equal care, which is more responsive to local health needs (see figure). Each of the 42 ICSs has an Integrated Care Board (ICB) responsible for budget allocation and an Integrated Care Partnership (ICP) responsible for strategy. The key change is that funding will move to regional population-based allocations for healthcare services via delegation to ICBs.
Cleft Lip and Palate Services are one of 59 specialised services assessed via a pre-delegation assessment framework as being ready to transition to ICB commissioning from April 2023. The framework assessed readiness to transition according to six key domains: health and care geography, transformation, governance and leadership, finance, workforce capacity and data reporting structure. During 2023, NHSE/I will continue to commission nationally according to the historical arrangements already in place. From April 2024, nine geographical footprints in England, formed from multi-ICB collaborations, will determine future allocations via a needs-weighted population-based funding formula. These nine geographical footprints bear resemblance to, but are not the same as, the geographical distribution of the nine cleft networks in England.
There have been reassurances that NHSE/I, through the Advisory Committee on Resource Allocation (ACRA), will put safeguards in place to ensure the pace of change for funding transitions are appropriate, with the aim of avoiding any dramatic changes. Furthermore, NHSE/I, together with the Care Quality Commission (CQC), have pledged to retain national accountability for specialised services and determine what they need to deliver, giving ICBs the freedom to determine how they deliver it. From April 2023, NHSE/I will establish a Delegated Commissioning Group (DCG) for the specialised services deemed appropriate for ICB commissioning, which will manage approval of national standards, approve gateways for national transformation programs and guide support to the nine regional multi-ICB collaborations.
Find more informtaion via this open access publication in the Bristish Dental Journal 2024: https://rdcu.be/dB7a6
Wales (1 Cleft Network)
NHS services were devolved in Wales in 2001 which means that the Welsh Minister for Health and Social Services is directly responsible for the delivery of health services in Wales. Since the Health Act in 2014, 22 health boards were reduced to 7 Local Health Boards (LHBs). These plan and provide health services for their resident population and are regulated by Community Health Councils (CHCs) and the Healthcare Inspectorate Wales.
The Welsh Health Specialised Services Committee (WHSSC) commissions specialised services in Wales, and Cleft Lip and Palate Services are included in their portfolio. WHSSC published the Cleft Lip and Palate Specialised Services Specification for Wales in July 2023. This bears close resemblance to the Cleft NHS Standard Contract and WHSSC have a commitment to commission cleft services to meet these specifications. Whilst WHSSC specialist services commissioning is separate from the proposals for Integrated Care Systems in England, it will be necessary for WHSSC to work closely with NHS England at a national level during these changes to facilitate cross-border healthcare services.
Scotland (1 Cleft Network)
NHS services were devolved in Scotland since 1999. In Scotland, Integration Joint Boards (IJBs) manage its integration of health and social care services. Following the Public Bodies Act in Scotland 2014, 31 IJBs were created to correlate with the 32 local authority areas.
The National Services Division (NSD) commissions more than 60 national designated specialist services in Scotland, and cleft care falls under this portfolio.
Northern Ireland (1 Cleft Network)
NHS Services were devolved to Northern Ireland in 1999 and services are delivered by Health And Social Care (HSC) Northern Ireland. Specialist services are commissioned nationally in line with the principles of NHS England’s commissioning strategy.
Resources
NHS: Roadmap for integrating specialised services within Integrated Care Systems
NHS England: Revenue finance and contracting guidance for 2023/24
The King's Fund: Integrated Care Hub
UK Gov: The Hewitt Review April 2023: An independent review of Integrated Care Systems
RCSLT: What you need to know about Integrated Care Systems
Policy Exchange: Devolve to evolve? The future of specialised services within integrated care
NHS England public board meeting – agenda and papers – 2 February 2023
NHS England public board meeting - 7 December 2023