Abstract:
Background: Neonatal medicine is a highly specialised field providing critical and developmental care to infants with complex medical needs. Within the NHS, commissioning determines how such services are planned, funded and monitored to deliver equitable, high-quality care. Historically, neonatal critical care (NCC) has been centrally commissioned by NHS England (NHSE) to ensure national consistency. However, recent reforms under the Health and Care Act 2022 and NHSE’s Roadmap for Integrating Specialised Services are redistributing responsibility to Integrated Care Boards (ICBs). This shift aims to improve local integration and flexibility while maintaining national standards.
Aim: To review and evaluate the current specialised commissioning process for neonatal services in England, assessing its structure, mechanisms of accountability, funding models and implications of the ongoing delegation to ICBs.
Objectives:
1. To outline the organisational and financial framework governing neonatal commissioning.
2. To compare centrally and locally commissioned neonatal services.
3. To evaluate the benefits and challenges associated with specialised commissioning reforms.
4. To identify opportunities for greater integration and equitable resource allocation.
Methods: A structured desk-based review was conducted using NHS England policy documents, statutory legislation, The King’s Fund analyses, and NHS Improvement reports. The commissioning of two contrasting neonatal services was compared: (1) the centrally commissioned Neonatal Critical Care (NCC) service, and (2) the locally commissioned Neonatal Home Care Team at the Rosie Hospital, Cambridge. Framework analysis was applied to examine three key commissioning components - planning, procurement, and monitoring, as defined by NHS England.
Results: The review found that specialised commissioning in neonatal medicine operates across a multi-tiered structure involving national, regional and local organisations. NHSE retains responsibility for defining service specifications and outcome frameworks, while ICBs increasingly influence local delivery through LMNS (Local Maternity and Neonatal Systems) and Operational Delivery Networks. Funding under the 2023 NHS Payment Scheme now combines fixed and variable elements via the Aligned Payment and Incentive Model, balancing predictability with responsiveness to clinical complexity.
Centrally commissioned NCC services ensure equitable access, high clinical standards and consistent monitoring through the National Neonatal Audit Programme. However, centralisation may limit adaptability to regional needs and innovation in service delivery. Conversely, locally commissioned neonatal outreach services, though more flexible and family-centred, face challenges related to variable funding, workforce pressures and uneven service quality across ICBs.
Conclusion: The ongoing transition of specialised commissioning responsibilities from NHSE to ICBs represents a pivotal opportunity to redefine the balance between national consistency and local autonomy. While localisation can enhance integration and responsiveness, it also risks regional inequities without robust oversight and data-driven governance. Strengthened collaboration between NHSE, ICBs and ODNs is vital to ensure that quality, safety and equity remain central to neonatal care delivery.
Importantly, the NHS model of specialised commissioning, particularly its evolution towards integrated, outcomes-based and locally adaptable structures, offers valuable insights for global health systems. By analysing its mechanisms for resource allocation, quality assurance and cross-sector coordination, this framework can inform international strategic commissioning approaches, supporting other nations to design neonatal and paediatric care systems that are both equitable and efficient. The lessons from England’s neonatal commissioning reforms can therefore supplement worldwide decision-making on developing or refining integrated care and funding structures in specialised health services.
