Over the next few months, its looks as though more than 20 commissioning support services will emerge from the ashes of primary care trusts.
The process by which the CSSs are being formed and authorised is attracting a lot of interest but mixed amounts of enthusiasm from potential users, if the results of EHI Primary Care’s exclusive survey are anything to go by.
The survey of more than 90 GPs, emerging clinical commissioning group chairs, board members, IM&T leads and others involved in commissioning found that only 18% were ‘very satisfied’ with commissioning support so far, with 46% quite satisfied and 35% not satisfied.
Shifting views
The breadth of feeling reflects, to some extent, the relationship that GP practices had with PCTs before the reorganisation.
While some worked closely with their PCTs over many years, others have enjoyed a less collaborative relationship – and may be less keen to work with another NHS support organisation in the future.
David Cripps, a practice manager and board member of West Suffolk CCG, says that while much of the day-to-day support from his local PCT has been good, practices have faced pressure to move to the local service provider GP IT system, and faced obstacles when wanting to upgrade their existing systems.
He wants to see commissioning support responding to local needs from practices, rather than working to a national agenda. For this, he argues that a culture change will be required.
He adds: “Over the last few years, quite a few PCTs have become quite aggressive with practices. But you can’t have a command and control structure with 30,000 independent contractors. It just does not work.”
Choice of GP IT system has been a long-standing bone of contention for GPs, while choice of CSS is a new source of controversy.
In the early days of the ‘Liberating the NHS’ reforms, a number of emerging CCGs complained they were being encouraged to use NHS services – not least because of the redundancy costs of not doing so – when they would rather bring in private sector support.
Meanwhile, the BMA has been fretting that because the NHS CB wants CSSs to become stand-alone organisations, they could all be privatised eventually; leading to the “outsourcing of commissioning.”
While the BMA renewed its concerns at the Local Medical Committee conference in Liverpool last week, Elizabeth Wade, head of commissioning policy and membership at the NHS Confederation, says she is seeing a change in mood on the ground.
She adds: “There is a sense that things have shifted in the last couple of months. There was a bit of tension in the very early stages with CCGs feeling ‘done to’ on this question of choice.
“But the latest series of checks on CSSs showed that while not every CCG was happy about everything relationships are developing quite well.”
Passing through the checkpoints
The checks Wade refers to were called Checkpoint 2; the second part of a three stage process of approval for commissioning support services run by the NHS Commissioning Board’s Business Support Unit.
Emerging services are required to prove that they have both the expertise to deliver commissioning support and CCG customers who want to buy it.
Checkpoint 2 included a survey of CCGs’ views on their potential commissioning support suppliers and, while the full results have not yet been published, Wade says it was clear that nearly all CCGs planned to use their local CSS, but not for all services.
She suggests a CCG might spend 50% of its £25 per head management allowance with a regional CSS, and then spend the rest on funding in-house commissioning support services and buying support from others, such as the local authority or third sector and private sector suppliers.
Even so, Checkpoint 2 saw two out of 25 proposed regional services scrapped and a further nine warned they had issues requiring ‘rapid management’ if they were to survive in the new regime.
Working together – but not always for good reasons
The EHI Primary Care survey found that around two-thirds of CCGs were already planning to work with their local CSS. Almost half of the respondents (44%) said they were doing so because of previous good working relationships with PCT staff, while 20% felt they had no choice.
Roz Foad, chair of the British Computer Society’s Primary Healthcare Specialist Group, says her personal view was that CCGs might feel they had no choice if they were concerned about carrying the cost of redundancy payments if local staff were not used.
She adds: “Do you keep the dead wood because it is too expensive to replace it, and you are worried about managing the cuts required?”
If CCGs do decide to choose an alternative to their local CSS, it is as yet unclear what the financial impact will be on the CCG and on staff currently in commissioning functions with a PCT.
In the cases of the two CSSs scrapped by the NHS CB, the board says strategic health authorities will be working closely with the CCGs and PCT staff involved.
It adds: “In these cases it is clear that there will still be a significant need for locally-based staff to deliver support services to CCGs and that the main impact will be to senior management arrangements and organisation shape rather than to the roles that are available to NHS staff.”
More change ahead
All CSSs must prove they have a “robust plan to build the new business as a distinct separate entity from the existing PCT cluster” so that they can meet the NHS CB’s timescale for becoming stand-alone organisations by 2015-16.
It may be that CCGs opt to use their local CSS in the first instance, and then review the kind of service they are receiving as both sides start to find their feet in the new NHS.
For the moment, the authorisation process is a huge task consuming 100% of time and energy in most CCGs. The EHI Primary Care survey found that 96% hope to be authorised by April next year.
Only once that milestone has been achieved, may the real business of commissioning and providing support for that commissioning get underway.