What are they?
CSUs are bodies that support clinical commissioning groups by providing business intelligence, health and clinical procurement services - as well as back-office administrative functions, including contract management. The 19 CSUs currently in existence across England are ‘hosted’ by NHS England.
As envisaged in the first draft of the health reforms in the 2010 White Paper, commissioning support was originally - and controversially - intended to be one of the key market places in the new NHS, attracting a variety of providers from the private and voluntary sectors as well as from within the NHS. NHS England estimates the potential size of the market as more than £1 billion but despite commissioning support´s potentially lucrative nature, the private sector has so far shied away from involvement.
Why were CSUs introduced?
As public bodies, CCGs are required to procure their support in the open market in line with the EU rules that govern the public sector.
The expected interest from private sector providers never materialised - in fact the giant US private health insurer Humana pulled out of the UK last year, reportedly because they saw no financial future in providing commissioning support to CCGs. There were also rumours that CCGs were discouraged from outsourcing commissioning support because of the potential redundancy bills the NHS would face.
Last year, with the deadline for fledgling CCGs to be authorised fast approaching - and with assurance of suitable commissioning support itself part of the authorisation criteria - the then NHS Commissioning Board recognised the risk involved in expecting all CCGs to make their own arrangements by April 2013.
The board was forced to agree late in 2011 to agree to host commissioning support until a market became established. The hosting role is not part of the board´s core functions, so a time limit - 2016 - has been set when commissioning support will be ‘externalised’.
In practice, CSUs have morphed out of the remnants of HSAs and PCTs. Much of this change has taken place behind closed doors in the former offices of SHAs and PCTs - the only change visible to the outside world, a new sign above the door.
Service level agreements with CCGs have been signed and CSUs are being run as break-even business as from April this year. Currently, they are legally part of NHS England and have no independent legal status until they are externalised. Until then, they also have to comply with the NHS England´s policies and processes.
They are big. The total commissioning support staff - employed by the NHS Business Service Authority - is around 9,000. Which equates to an average of nearly 500 staff each across the 19 units.
What do CSUs do?
Not all CSUs are doing the same thing. Commissioning support falls into six - or seven - categories and CSUs offer all or some of the following:
* health needs assessment - including developing Joint Strategic Needs Assessments
* business intelligence - including information collection and analysis (patient activity, clinical outcomes, patient experience), risk stratification, segmentation and referral assessment software
* support for redesign - developing clinical specifications and pathway design, service reviews, including involving patients and carers in the co-design of local services finance, IT
* communications and PPE - communicating and engaging with all stakeholders, managing the reputation of the NHS, media/press and FOI handling, briefing, campaigns and consultations
* procurement and market management - identifying best value providers to respond to service needs. Formal contract management, tendering and negotiation
* provider management - good practice provider management tools and techniques to ensure fulfilment of agreed contracts, service level standards and key performance indicators
In addition, all CSUs offer the back office support - including finance, IT, legal services and human resources.
The commissioning board has identified four of these categories as suitable for large scale delivery and appointed a subset of CSUs to offer these at scale.
The North West collaborative, Greater East Midlands, Central Southern, Best West and Birmingham, Black Country and Solihull are providing business intelligence and healthcare (clinical) procurement at scale.
North East and North Yorkshire and Humber collaborative, the South and West Yorkshire collaborative, the London collaborative and the South collaborative are providing business intelligence only.
And the North East, South Yorkshire and Bassetlaw, Norfolk and Waveney, Essex, North Central and East London, North West London, Surrey and Sussex and Commissioning Support South are providing healthcare (clinical) procurement only.
In September last year, after plans for a national communications and engagement service collapsed, it was announced that West Yorkshire CSU will lead on communications for the north of England, Birmingham, Black Country CSU for the Midlands and east of England, NW London CSU for London and Commissioning Support South for the south of England.
Future
Earlier this month, NHS England announced its ‘roadmap’ for creating a market for commissioning support - as was originally envisaged. This has been prepared with assistance from consultants Price Waterhouse Cooper and was launched by Bob Ricketts, NHS England’s director of commissioning support strategy and market development.
As part of the hosting arrangements, CSUs are currently being run ‘in a way that maximises their ability to provide services which are sustainable in a competitive marketplace’.
‘Towards commissioning excellence: a strategy for commissioning support services’ sets out the building blocks for developing a ‘vibrant market’ that enables CCGs and other commissioners to choose from best-in-class providers from the public, voluntary and independent sector.
The report says: ‘The approximate size of the CCG-related market (derived from CCG running costs) is just over £1bn. CSUs currently have half of this market, with CCGs expecting to spend £570m on CSU services. The remainder is provided in-house or by the independent and voluntary sectors.’
There are three key elements to the strategy for externalising CSUs:
1. Enabling CCGs to exercise informed choice of how they source their commissioning support and from whom. The first step towards this was the recent launch of a choice ‘app’ for CCGs.
2. Building up the cohort of commissioning support providers. This involves the current cohort of CSUs being autonomous by no later than 2016.
3. A partnership agreement between the Association of Chief Executives of Voluntary Organisations and CSUs to strengthen collaboration between CSUs and the voluntary sector so that CCGs benefit from a wider range of support.
Lessons from the education sector suggest among other things that it is difficult for private providers to enter a market unless they have a well-defined route to access customers. The report also warns that ‘CCGs have established relationships with CSUs and in some cases this may result in a lack of willingness to switch supplier even if significantly better services are available.’
These potential hurdles to commercialisation will be addressed when NHS England publishes an update on the strategy in the autumn along with the second stage of its plan for marketing commissioning support.
Further reading:
1. NHS England’s ‘roadmap’ for commissioning support units
2. Commissioning support units: is externalisation the right way to go? King’s Fund, Jun 2013
