Context:
With the announcement of NHS England’s planned abolition and the accelerated delegation of responsibilities to Integrated Care Boards (ICBs), specialised commissioning in England stands at a crossroads. Ravi — a pharmacist and system leader with experience across commissioning, NICE, and frontline practice — offered a sobering yet pragmatic view of what this upheaval means for the NHS, patients, and the pharmaceutical industry.

1. Structural Reform Without Strategic Clarity

While the headlines suggest a bold streamlining of NHS bureaucracy, Ravi urged caution: major structural changes — such as the dismantling of NHS England and the potential consolidation of ICBs — cannot happen overnight. Legislation, governance, and operational planning cycles will all delay meaningful change by at least 12–24 months.

“Functions will remain — they’ll just wear different hats. The work still needs to be done.”

In the meantime, uncertainty dominates. Organisations are in limbo, staff face redundancy, and leadership capacity is being lost at the exact moment the system needs strategic oversight most.

2. Specialised Services: From Central to Local — But Not Always Better

Delegation of specialised services to ICBs was intended to bring decision-making closer to the patient, reduce variation, and enable more responsive care. But Ravi highlighted a key tension: delegation has occurred without the matching of resources, infrastructure, or clarity.

• Service specifications are being refreshed, but vary in quality and interpretation.

• Funding is only being delegated for the drug, not the diagnostics or wraparound care required to deliver it.

• There is growing risk of post-code variation in access to specialist drugs and services — particularly where budget pressures dominate over clinical need.

3. The System Can’t Afford Business as Usual

Ravi’s presentation reinforced the fiscal reality: NHS finances are stretched beyond capacity. With every ICB reporting deficits, NICE implementation is no longer guaranteed, and some drugs — even those with positive Technology Appraisals — are not making it onto formularies.

“The gap between NICE guidance and local delivery is widening. In some cases, it’s become a quality standard with no operational plan behind it.”

Legal risk, public expectation, and clinical pressure all collide in this space. But without aligned funding, service specifications, and workforce, implementation simply can’t happen.

4. The Role of Industry in the Next Phase

Ravi offered a constructive call to action for pharmaceutical companies:

• Think in pathways, not products — Where does your therapy sit in the real-world care model? What needs to change to enable its adoption?

• Support the enablers — Diagnostics, workforce training, digital infrastructure, and patient identification must be part of the solution.

• Build shared evidence — Co-develop real-world data to support commissioning decisions, and use it to demonstrate population health impact, not just clinical efficacy.

• Engage early in the planning cycle — Business cases must be aligned with April–March commissioning timelines, or they risk being deferred for another year.

Ravi also emphasised the importance of real-world studies, including working with NICE through Early Value Assessments to strengthen evidence for medicines with limited affordability at launch.

5. Opportunities Amid the Challenge

Despite the current instability, Ravi urged attendees not to lose sight of the opportunity. Delegation of specialised commissioning — if implemented with care — could unlock more equitable, joined-up models of care. It could:

• Empower more centres to prescribe, easing patient access

• Build capability in primary care

• Standardise fragmented pathways

• Reduce workforce siloes and inequality

“This is a chance to move from ivory tower prescribing to truly integrated care — if we do it right.”

Conclusion: Collaborating for the Future of Specialised Care

The outlook for specialised commissioning is undeniably uncertain. But one thing is clear: the burden of delivery is shifting to the local level. Success will depend on partnership — between NHS leaders, clinical teams, and industry.

Pharmaceutical companies must be prepared to engage not just with the evidence, but with the infrastructure, the workforce, and the wider system challenges that surround adoption. That means showing how your therapy fits, enables, and elevates care across the full pathway.

At NeoNavitas, we work with our clients to navigate this complexity — shaping access strategies that reflect the new NHS landscape and deliver value where it matters.

If you want to understand how to position your offer in this next phase of specialised commissioning, get in touch.