NHS England is drawing up plans to bring in private sector consultants under a "no saving, no payment" arrangement to reduce expenditure on all-age continuing care, a budget that has grown to £7.5 billion and become one of the most significant financial pressures facing the health service.

The initiative targets spending on continuing healthcare packages, which cover NHS-funded support provided outside hospital settings for patients with complex, long-term primary health needs. These packages are commissioned by Integrated Care Boards across England and can include care delivered in residential homes, nursing facilities, or within a patient's own home. Unlike social care, which is jointly funded, all-age continuing care is met entirely by the NHS.

Regional ICBs have faced mounting pressure to bring their finances into order following a period of significant deficit accumulation across the system. Continuing care budgets have proved particularly difficult to control, driven in part by an ageing population and by increasing clinical complexity among those assessed as eligible. The all-age continuing care budget now accounts for a substantial share of the money flowing through regional health systems, and NHS England regards it as an area where costs can be meaningfully reduced without changes to eligibility policy.

The contingency fee model is central to the proposed approach. Under such arrangements, consultancies are paid only when they demonstrate measurable reductions in expenditure, transferring financial risk away from public funds and onto the firms engaged to deliver savings. This structure has been used in other areas of public sector procurement but represents a significant shift in how NHS England approaches the use of external management expertise.

Consultants brought in under the scheme are expected to audit existing care packages, scrutinise assessment processes and identify cases where packages may no longer reflect a patient's current needs. They may also be tasked with reviewing contracts held with local care providers and examining commissioning practices that vary considerably between boards. The scope of the work is likely to extend across a wide range of ICBs, though the precise terms of engagement are still being developed.

The plans have renewed questions about the relationship between NHS England's central authority and the autonomy of regional boards. Integrated Care Boards were introduced in 2022 partly to devolve commissioning decisions to local level, on the basis that regional bodies would be better placed to understand local needs and manage resources accordingly. The imposition of centrally procured consultants tasked with reducing locally commissioned care raises questions about how far that principle extends in practice when boards face sustained deficits.

The use of private management consultants in decisions about clinical and social care funding is also likely to attract scrutiny from trade unions, patient groups and some parliamentarians. Critics of such arrangements have previously argued that commercial firms brought in to reduce costs may not adequately account for patient welfare, and that savings achieved through tighter assessment can result in individuals losing packages of care they continue to need.

NHS England has not yet confirmed the scope, timeline, or value of the contracts it intends to offer. The continuing care budget has been subject to repeated review in recent years, and previous attempts to standardise assessment processes across ICBs have produced inconsistent results. Whether an externally led intervention structured around commercial incentives produces durable reductions in spending remains to be established.

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