The white paper that kick-started the latest round of reforms in the NHS was published two years ago.
‘Equity and Excellence: Liberating the NHS’ mentions the word ‘commissioning’ 124 times; but the term ‘commissioning support service’ does not appear once.
Pros and cons of the CSS model
The white paper said that primary care trusts would be scrapped, NHS management costs cut by 45%, and power devolved to GP consortia.
It said consortia would have the freedom to decide what commissioning activities they wanted to undertake and what activities “they may choose to buy in support from external organisations, including local authorities, private and voluntary sector bodies.”
It did not talk about buying support from former PCT-bodies. Yet, in the past 12 months, the creation of CSSs has been the focus of much time and attention for life-limited PCTs.
And by next month, around 24 CSSs are likely to have their existence confirmed by the NHS Commissioning Board. Clinical commissioning groups have also been heavily encouraged to use these services.
Paul Fitzsimmons, managing director of MedeAnalytics, believes CSSs were an “instant invention” by the executive at the NHS CB when it realised that the NHS could not afford the cost of redundancy payments for the thousands of staff working in PCTs.
But aside from the savings in redundancy costs, CSSs appear to offer the clear benefit of providing CCGs with easy access to the considerable expertise that has been built up over many years by PCT staff. They also provide a relatively straightforward way for CCGs to access the support they need.
Less positively, organisations such as the NHS Alliance have voiced fears that CSSs are limiting CCGs’ choices on commissioning support and that former PCT staff may be keen to maintain business as usual behind the doors of a new shop front, instead of acting innovatively.
Fitzsimmons says his experience has been that some emerging CSSs are ready to move quickly and satisfy the demands their CCG clients; but others are not.
He adds: “Some of them are thinking about being ready in 12 months’ time, which will be too late. If they are not able to respond pretty quickly CCGs will challenge the status quo.”
Long term challenges
CSSs undoubtedly face a challenge in winning and keeping all their CCGs as customers in the long term, which is perhaps why there is a reported shortage of candidates for the managing director posts that the NHS CB is in the process of trying to fill.
The NHS CB is also in the process of authorising CSSs through a three stage ‘checkpoint’ process that will see successful services hosted by it for a maximum of four years. After that time, CSSs are expected to establish themselves as independent organisations.
The checkpoint process is due to be completed in August and September this year, with the final decisions about hosting services due in October. This will be followed by the transfer of NHS staff from PCTs and strategic health authorities to CSSs. Staff employed by CSSs will remain on NHS terms and conditions.
Focused on customers
It is highly likely that all CSSs will offer IT services to CCGs, including primary care IT services alongside other commissioning functions such as finance, provider management and service redesign.
Business intelligence is one of a small number of commissioning support functions that the NHS CB wants to see delivered over a bigger geography; last month, plans were outlined for eight to ten data management integration centres.
All CSSs have been asked if they would like to become one of the DMICs – an offer which is likely to appeal to the larger emerging CSSs.
In the first instance, most CSSs are likely to be looking for business from their CCGs. But CSSs will also be looking to get business from the NHS CB, from local authorities (which will soon be hosting public health) and, in the longer term, from more distant CCGs.
Inevitably, this will put them in competition with each other. And it is quite possible that some will move into the private sector once the NHS CB hosting arrangements end.
Andrew Fenton, chief information officer for NHS Buckinghamshire and Oxfordshire, says the Central Southern CSS will potentially provide commissioning support for 14 local CCGs covering 3.6m patients.
He adds: “We are developing quite a significant informatics and IT programme, including infrastructure requirements, business and communication systems, and web-based collaboration. We have also applied to provide business intelligence services at scale.”
Like many others Central Southern, is in the process of agreeing with CCGs what services they would like to buy from it. The CSS will then analyse those sometimes varied needs and aim to deliver them from within its technology portfolio.
The outline business plan for the North Central and East London CSS, which aims to cover 12 CCGs and 3.3m patients, shows that its core offer to its CCGs will include desktop, infrastructure and networking services, data management and access to online performance management data and BI support.
Looking for ‘something different’
The decision about whether to ‘do or buy’ individual commissioning support services is being considered by CCGs around the country.
For example, Doncaster CCG developed criteria for deciding which way to go. It will buy services from a CSS if it improves quality, improves resilience, is more cost effective, and allows the CCG to concentrate on transformational commissioning rather than transactional responsibilities.
This has led it to conclude that services it should buy from the South Yorkshire and Bassetlaw CSS include the data warehousing aspects of business intelligence. But the interpretation of that data will remain within the CCG.
Nigel Slone, managing director of Sollis, believes the kind of tools that CSSs will need for their CCGs will extend beyond contract and performance management systems to systems that provide population and disease profiling, resource management and linked patient data in support of integrated care.
He adds: “By their nature clinicians will demand evidence based information upon which they base commissioning decisions.”
Slone says CSSs cannot be seen to be operating as PCTs previously operated. He adds: “When I go out on the road and talk to senior members of CCGs, they are looking for something very different from that which has gone before.”
Slone also argues that while using CSSs has been “the easiest thing to do” while CCGs undergo authorisation, many will look to the market from 2013 onwards.
The NHS CB’s hope is that CSSs will become a vibrant part of that market, so that by 2016 there will be a range of different models and options for CCGs to choose from.
These will include NHS staff-led social enterprises and partnership arrangements with other independent, local government or voluntary sector bodies.
How that market develops, and how many CSSs prove both commercially viable and an essential part any future government’s plans for the NHS, are currently unknowns.
This feature ran as part of EHI’s latest special report, on business intelligence for commissioning.