It´s odd to think that an emerging service industry, employing over 9,000 staff, was more-or-less an afterthought in Lansley’s health service reforms.
The 23 commissioning support units (CSUs) are now firmly on the commissioning map – but curiously were not mentioned in either the 2010 White Paper ‘Equity and Excellence’ or the Health and Social Care Bill.
’Commissioning for Patients’ – the detailed consultation paper on the original 2010 proposals – had only this to say about commissioning support: ‘We envisage that over time a more competitive market will develop for supplying some of these services.’
Back then, with the focus on GPs being handed vast budgets and forming exotic-sounding ‘consortia’, the riddle of who would supply commissioning support was very much part of the ‘It´ll be alright on the night’ flavour of the times.
The lacuna allowed critics to warn that the lack of detail hid a Conservative agenda to privatise the NHS, leaving a back door open where commerce could creep in.
But as the Bill´s lengthy progress through parliament focused minds on the details, it became apparent that there would be no immediate ‘gold rush’ for commissioning support. And in 2011 giant US healthcare firm Humana made a dramatic exit from the NHS commissioning support market.
The arranged marriage of CSUs and CCGs
Before Lansley’s NHS reforms, commissioning support was a job done by PCTs and in the transition phase was taken over by PCT clusters, mostly manned by NHS staff.
Commissioning support functions include:
· 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
· redesigning services support- developing clinical specifications, pathway design, service reviews, patient involvement
· communications /PR
· procurement and market management – contract management, service level standards and key performance indicators
· back office support, including finance, IT, legal services and human resources
The new CSUs vary in size and so CSUs offer all or some of the above, with the exception of back office support which all CSUs provide.
Initially many CCGs felt they would like to directly employ PCT staff themselves but the management allowance figure was unknown until November 2011, so most were unable to do this.
The pressure was on for CCGs. Not only did they have to make their commissioning support arrangements by April 2013 but they were also, under EU rules, required to procure their commissioning support in the open market.
The NHS Commissioning Board was forced to take action and came up with a ‘solution’.
It would ‘host’ CSUs until a market could be established in 2016 when the CSUs would then be ‘externalised’.
Behind closed doors
The result of this CSU hosting by the NHS Commissioning Board has been for a new system to quietly come into being in the past 12 months.
Out of the remnants of SHAs and PCTs, CSUs have slowly morphed into existence and service level agreements signed with CCGs who had the huge task of authorisation to get through. A new NHS structure has quietly come into being.
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.
David Stout, managing director of two CSUs in Hertfordshire and Essex: ‘Most CSUs have inherited existing buildings. If they wanted to move, they are probably not able to, as they have inherited PCTs´ long- term leases.’
A quirk of the transition is that many CSUs are actually sharing premises with the CCGs they serve: ‘Our Hertfordshire building contains the CSU, some of the CCGs and the Local Area Team (of the NHS Commissioning Board) all located together.’
All grist to the mill for critics who cast the reforms as simple desk-hopping, in which the same faces reappear, doing the same jobs, under new titles.
Mr Stout believes CSUs will gradually pull in more talent from outside the NHS family. However, as a former director of the NHS Confederation´s PCT network, Mr Stout is in a minority among his fellow CSU leaders who are mostly from within the NHS.
The CSU story so far
CSUs are a big part of the NHS family. The total staff – employed by the NHS Business Service Authority – is around 9,000, which equates to an average of nearly 400 staff each across the 23 units.
From April they will be providing chargeable services to CCGs and other customers and reinvesting any profit into the development of their business.
Legally, CSUs are part of the commissioning board and have to comply with the board’s policies and processes and will have no independent legal status until they are externalized in 2016.
Geographically, they vary a great deal. David Stout again: ‘Size varies quite a lot. GEM CSU covers 20-odd CCGs. Equally, some are much smaller – more locally based outfits.
’My staff across both CSUs totals around 750. That covers 11 CCGs and 3.5 million people. Within that we run quite a big Information and Communications Technology service to other healthcare providers.’
At the other end of the spectrum, the 101-practice Dorset CCG employs its own commissioning support staff – effectively an embedded CSU. The service is overseen by a steering group chaired by a CCG board member.
Part of the reason for the variation in size is that, as already touched upon, not all CSUs are offering the same thing.
And the commissioning board has identified three commissioning support functions – business intelligence, healthcare procurement and communications -as suitable for large scale delivery and appointed a subset of CSUs to offer these at scale.
So the North West collaborative, Greater East Midlands, Central Southern, Best West and Birmingham, Black Country and Solihull CSUs 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.
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.
Authorisation for CSUs
With half of CCGs now authorised by the commissioning board, CSUs are having to jump through series of hoops of their own referred to as ‘checkpoints’. Three proposed CSUs were stopped at the second of a series of ‘checkpoints’ in May.
CSUs are currently proceeding through checkpoint four and according to David Stout, failure at this stage could result in intervention from the board. ‘They´ve brought in an audit firm – RSM Tenon – to do an analysis of the financial model.
’At this stage it would be hard for a CSU that´s up and running not to proceed but there could be intervention of one kind or another that could take the form of extra support such as added management or management capacity added. Or they may conceivably need to be linked with another CSU’.
And as well as these checkpoints, CSUs are also having to plan for life outside the NHS after 2016, when ‘externalisation’ kicks in.
The NHS Commissioning Board has awarded a contract to consultants Price Waterhouse Cooper to help it ‘explore and appraise the potential externalisation options and examine ways of creating a successful market for commissioning support services’. A strategy will be produced shortly.
So with this somewhat forced marriage between CSUs and CCGs, how are relationships panning out on the ground?
The board has said from the outset that its intention is to manage CSUs ‘in a way that maximises their ability to provide services which are sustainable in a competitive marketplace’. That means that CSUs have to be market-facing from the start.
Dr Nigel Watson, chair of the GPC´s commissioning and service development subcommittee and a member of the commissioning board´s strategy working group says this has introduced a cultural challenge for CSU staff: ‘My observation is that there has been an awareness that if they are not careful, CSUs could end up doing exactly the same thing as PCTs. But I get a sense that CCGs are being more challenging with CSUs than they were with PCTs and that is forcing them to act.’
According to David Stout, the adaptation is from being public servants to being customer-focused: ‘Most are former PCT staff. Our local PCTs populated our staffing, certainly. I expect that will change as we progress, but CSUs are offering a range of functions and are open to competition. The customer relationship is a very big change for staff.
’In addition, my own staff are from four different PCT clusters – all of which had their own different cultures. Not all PCTs were the same.’
For Gerry McLean, chair of Consulting Associates UK which provides services to CCGs, the big question is whether CSUs will prove to have the entrepreneurial flair they need: ‘It´s hard for those NHS staff to get into the correct mindset. It´s a psychologically interesting test. Can they make that massive jump to understanding the customer?
’CSUs need to be developing their culture and understanding what the customer doesn´t know. And that involves understanding the market and knowing what the competition´s doing – a much more commercial outlook than they are used to.’
For David Stout, externalisation is very much on the horizon rather than a current preoccupation. Come 2016 he believes CSUs could be ‘bought, floated off as social enterprises or perhaps wholly owned by CCGs’.
’It´s even possible that some could stay within the NHS family if they were bought by a trust’ he adds. ‘As a last possibility, there could be an option for a CSU to partner with private provider or a consultancy to extend the organisation. Who you partner with would then delineate the sort of operation it is. If you buy in that service, the CCG can buy it from their CSU.
Dr Watson says his personal view is there should be a way should be a way for CSUs to stay within the NHS rather than being externalised.
‘You hear fears about the tail wagging the dog, but I don´t think that´s going to happen. If CSUs don´t come up to the mark they just won´t survive. In my area, Hampshire is providing services to Surrey CCGs and I think CCGs will generally go where they find the service they want.
’I am cautious about the private sector but I don´t think there´s going to be a bonanza. In that respect, I suspect the government has learned its lesson from G4S and the Olympics.’
For Gerry McLean, there will be other factors at play beyond externalisation: ‘We haven´t yet seen the full might of the private sector. I´m not sure the CSUs realise that the customer (CCGs) is not theirs as of right. If the CSUs don´t get it right, the private sector will want to fill those gaps. The question is under which flag they will do it. Under their own, or under the flag of a CSU?’
And he believes the future commissioning support landscape will be determined by how much knowledge of the market CSUs can develop in the next three years:
‘As Michael Portillo [former Conservative cabinet minister and broadcaster] said at the NAPC conference last year this is not so much about commissioning as about provision.
’The whole thing could become very provider-led if the providers have better market intelligence than the customers.
On the other hand, GPs could be the other key factor, adds Mr McLean: ‘GPs are used to running a business and must not be underestimated as customers. And what will happen as the customer becomes more sophisticated?
’They´ll have a different take on it all after they´ve been doing this for say 18 months. So the next wave of contracts for commissioning support could look very different.
’They´ll be much more savvy and the market will change.’
That point of view is echoed by Dr Watson, who practices as a GP in the New Forest. He believes GPs will ultimately determine the future commissioning support landscape: ‘In the end, the CSUs are going to win or lose on what difference they make to me when I´m sitting in my practice.’
Alisdair Stirling is a freelance journalist