Choice of commissioning support – promised to GPs as long ago as last summer – has become a key point of tension between emerging clinical commissioning groups and the Government. Many GP commissioners want choice because they believe competition will benefit patients by driving costs down, leaving more money for patient care.
Yet draft guidance from the Department of Health put out for consultation last month suggests CCGs will be unable to secure alternative commissioning support until at least 2014. The draft guidance proposes to allow elements of commissioning support currently provided by the NHS to be ‘hosted' by the NHS Commissioning Board from 2013, and makes clear that ministers are taking a long-term view and that effective choice may not even be available until 2016 – blaming the ‘complexity' of establishing a market.
The Clinical Commissioning Coalition first raised the alarm about commissioning support over a month ago, when a survey revealed CCG chairs were being offered all or nothing by their PCT clusters and that the promised choice had failed to materialise. It called for CCGs to at least be able to switch PCTs to access commissioning support.
NAPC chair Dr Johnny Marshall told last month's NAPC annual conference: ‘This cannot be left undeveloped until April 2013.'
Dr Marshall's interpretation of the draft guidance is that CCGs will not be able to begin securing commissioning support until April 2013 and that a six to 12-month procurement process means that 2014 ‘is the reality'.
There are a number of reasons why the much-envisaged scenario of provider choice – with hawkish private-sector companies circling for a piece of the action – has not yet materialised.
Firstly, CCGs have been bogged down in structural issues, not knowing what their management allowance will be and the recently announced threat that if they seek commissioning support outside the NHS, they'll be saddled with paying the redundancies of affected PCT staff.
Neither PCTs nor their overworked staff have had time to morph into the predicted fleet-footed competitive bodies undercutting PCT-based commissioning support units and creating a new market for their expertise. It has led to a frustrating situation for go-ahead CCGs. Dr David Rooke, chair of Somerset CCG, said they were looking for ‘large-scale, value-for-money offers', but that there was currently no choice available: ‘We've got fairly advanced plans, but don't yet know what's going to be available.'
Dr Rooke says he's had lots of unsolicited offers of free support from private companies, but that a ‘menu' of organisations growing out of PCTs has yet to materialise.
But not all GPs want choice. Dr Sam Everington, chair of Tower Hamlets CCG, is happy with what's on offer in London and says he hasn't got time to shop around.
Tower Hamlets will share commissioning support provided by one of London's four putative commissioning support units with two – and possibly five – neighbouring CCGs.
‘I'm a clinician and I need good managers around me,' he says. ‘Our attitude is that we want our commissioning support unit to do everything for us. Expanding provision of commissioning support makes me worried. Where does the corporate memory go? The idea this is just like managing Tesco's is too simple. We're happy with what we know.'
Dr Richard Vautrey, GPC deputy chair, is particularly worried about opening commissioning support up to providers from outside the NHS – or even from outside the CCG: ‘The real risk of a market for external commissioning support is that you'll end up with a small number of large companies dominating it, and it could quickly get into a position where these few companies are telling CCGs what to do.'
The hosting function of the board will be wound down by 2016, by which time the DH ‘expects the commissioning support market to be sufficiently established'.
The DH draft guidance says: ‘This ensures CCGs have ongoing access to the capacity and capability they need to carry out their functions during their transition towards authorisation.'
Yet it's these noises emanating from Richmond House that ambitious commissioners find particularly worrying. The Clinical Commissioning Coalition is clear that without choice from the start, one of the main benefits of the reforms could be strangled at birth. It plans to continue to press ministers until the tension is resolved.
Alisdair Stirling and Emma Wilkinson are freelance journalists.
