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With diagnostics being the big bottleneck for cancer and many other elective treatments, more work needs to get done.

And the people doing it are likely to be NHS staff anyway, so the question of how that extra work is arranged is important. Because whether the backlog is sent to one of the large outsourcing companies, insourced at a trust or put out to a limited liability partnership of consultants, it will need to get done if the government is to have any hope of pointing to falling waiting lists as an election approaches.

The Royal College of Radiologists puts the total amount of outsourced radiology work at £120m in 2021. The largest outsourcing firm in this field reported a £47m UK turnover in its accounts published in May 2021.

There are signs that the NHS might look to repatriate some of that work so that public money doesn’t leave the service as private profit. The staff doing the same work could be paid the same amount for their overtime as part of a national NHS subsidiary instead, some have suggested.

The existing outsourcing arrangements have grown up ad-hoc, but with workforce the limiting factor, the NHS may have to make itself more attractive for this extra work or continue to see money leave the system.

Delegation deceleration

A welter of uncertainties surrounding the viability of delegating commissioning budgets worth £23bn to integrated care systems has led to the plans being delayed.

NHS England is set to slow the process down, amid concerns about financial risk and the destabilisation of services, HSJ understands.

NHSE guidance issued in the spring set an expectation that responsibility for 65 out of 154 specialised services lines would be devolved to most integrated care systems in April next year. The services included major trauma, congenital heart disease, and radiotherapy.

But several senior sources have told HSJ that NHSE will delay the delegation of the large majority of specialised services, initially to April 2024. Instead, ICSs are expected to be encouraged to step up closer working with regional commissioners in 2023-24, commissioning more services through joint ICS/NHSE committees.

It comes after concerns were raised about the risks of going ahead with the transfer.

Specialist providers are worried cash-strapped ICSs may reduce spending on services based outside their area, potentially destabilising them, and/or making it hard to secure capital for developments.

There is also considerable concern about financial control of such significant sums in a time of major budget pressures.

Also on hsj.co.uk today

In news, we report that a judge has urged a foundation trust and the governor it has suspended to settle their differences outside the courts, and in our weekly round-up of health coverage, The Primer looks at how the media this week have handled stories about private healthcare, underfunding of the NHS and what a health service rescue plan might look like.