CCG support vision will calm anger but spark controversy
Last week Sir David Nicholson summoned the 51 primary care trust cluster chief executives to a meeting at which he set out how they should address the challenges ahead. The audience listened dutifully, but the tension in the room was palpable.
Later, one very senior figure present told HSJ that Sir David was speaking with the knowledge “that half the people in the room don’t believe in the reforms they’re being asked to implement”.
The scepticism, and in some cases anger, means the need to set out a vision for the future of commissioning support is badly needed. This week HSJ was the first to reveal the draft version of that vision, the Department of Health’s Towards Service Excellence.
The document was immediately attacked as being a blueprint for the wholesale privatisation of the commissioning support sector – which is unlikely – or for reflecting the confused nature of the reforms – for which it can hardly be blamed.
In fact, the guidance is perhaps the first positive news those working in PCTs have received for years – setting out, as it does, a pathway to a potentially robust structure for a wide range of key functions. It states that commissioning support organisations will “work closely with commissioners” on a “day to day” and “long term” basis.
However, the guidance raises many questions. Perhaps the most significant is the role of the NHS Commissioning Board.
The guidance says: “The changes set in train are complex, involve a great many staff carrying out work that has a high monetary and operational value, yet must be implemented rapidly and with precision. This requires the commissioning board to set a very clear direction during the transition in order that these critical changes are delivered properly first time.”
In other words – “we didn’t create this mess, but we’ll make sure it doesn’t spiral out of control”. Sir David could have summed up the paragraph in one of his favourite words: “grip”.
A focus for that “grip” will be on ensuring that PCT redundancy costs are minimised along with the commissioning talent drain. Those two reasons, as well as allowing emergent clinical commissioning groups to “focus” on their apparent “strengths” of providing “clinical” and “community” insight, are the drivers behind the guidance.
The board will be in the unusual and conflicted position of being the biggest customer of commissioning support (it will, after all, be by far the biggest commissioner), the biggest supplier of support and the organisation responsible for developing the commissioning support market.
It is meant to exit the commissioning support space by “2016 at the latest”. That, of course, is a year after the next election, by which time health policy may be very different. Sir David, a man whose “wallet starts to itch” at the mention of private commissioning support, knows this and will make the appropriate judgements in what he believes are the interests of the NHS.
Private sector input can enhance commissioning support, but businesses are likely to need more certainty about the scale of the opportunity, the cash CCGs will have to spend and the procurement process before investing in capacity.
The guidance makes reference to “framework call-off arrangements” for some support areas. The underwhelming impact of 2007’s framework for procuring external support for commissioners suggests this will be easier said than delivered.
But perhaps the most present danger is set out on page 14 of the guidance. “PCT clusters and commissioning support organisations will continue to be under pressure to reduce operating costs.” Hardly an encouraging message to receive when embarking on a “complex”, “rapid” and “precise” change programme with a “high monetary and operational value”.
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Readers' comments (20)
Patrick Newman | 19-Oct-2011 2:24 pm
"“The changes set in train are complex, involve a great many staff carrying out work that has a high monetary and operational value, yet must be implemented rapidly and with precision...." Get real when many not only have the day job but are having to moonlight on QIPP. This is nothing more than a call for a tsunami of grand a day consultants.
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Anonymous | 19-Oct-2011 7:49 pm
and the grand a day consultants are ex PCT staff who took redundancy and fled. And still incompetent!
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Anonymous | 20-Oct-2011 9:21 am
To the person who posted at 7:49pm - do you think you could post constructive comments rather than just slagging off ex-colleagues? Your approach does nothing for staff currently going through the mill - it would cost you nothing to at least be considerate.
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Asimovhod | 20-Oct-2011 9:24 am
Why is it that everything I read seems to think that the only role carried out by PCTs is comissioning.
Those of us in PCTs in non-commisioning or provider roles would like to given a clue as to what is to happen to all those 'little' things like performers lists and suchlike.
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Clive Peedell | 20-Oct-2011 1:19 pm
The outsourcing of commissioning to private companies (FESC) programme was described by Frank Dobson as follows:
"If that wouldn't amount to privatisation, I don't know what would"
Guardian 2006
I agree, and it is clear that the Coalition is going to expand this New Labour policy
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Clive Peedell | 20-Oct-2011 1:20 pm
Here's the link to Dobson's article in the Guardian
http://www.guardian.co.uk/commentisfree/2006/jul/01/comment.publicservices
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Anonymous | 20-Oct-2011 3:27 pm
7:49
No they won't be. Political suicide to allow the revolving door approach that traditionally took place. And many senior people know this...
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Anonymous | 21-Oct-2011 10:14 am
Anon 3.27
Absolutely, apart from which you only have to look at the interim agencies, whose day rates have not only nearly halved but vacancies have dropped off a cliff too - although that market's picked up slightly over the last month. But although I don't agree with Patrick about the tsunami of expensive people (there isn't the money and what little there is, is probably earmarked for redundancies), I do agree with what he says about NHS staff having to do far more work with fewer people. In my SHA region, the view is very much "if you take the cheque, you're not coming back" so it's a very different place now. And yes, I do remember previous reorganisations where people did very well financially, only to pop up again in a different post a few months later, but I can't see it happening now on the same scale. There are some individuals who've been moved around the system in "unknown" ways, perhaps to preserve corporate memory or keep their experience within the NHS, but even they're on fixed term contracts - as is everybody's really.
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Anonymous | 21-Oct-2011 11:54 am
Steve Hodkin - I think the answer is on p14. Or if you mean performers lists for primary/ dental care, that'll go to the NHS Commissioning Board. What a muddle......
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Anonymous | 21-Oct-2011 12:48 pm
3:27PM & 10:14AM
I know of 2 people from PCTs who took redundancy (not MARS) and are now working for CCGs. CCGs are not controlled by the PCT and so can employ anyone they like - provided they have the money.
I wonder what am I doing staying where I am when I could take redundancy and jump ship thank you very much, but them I'm an old school public servant (or a mug!).
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Anonymous | 21-Oct-2011 2:00 pm
12:48
Suspect they'll be in a minority - and probably not at the "grand a day" level someone suggested.
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Anonymous | 21-Oct-2011 8:13 pm
2.00pm
Yes, spot on, and if you fiddle about with the CCG ready reckoner, they're not going to be able to take on armies of price-y Band 8s, it'll be mostly 5s as project managers or similar. And on fixed term contracts perhaps - GP employment contracts in practices seem rather different to PCTs/ SHAs!
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Georgina Craig | 22-Oct-2011 7:41 am
http://gcassociates.typepad.com/my-blog/2011/10/commissioning-support-how-will-innovators-thrive.html
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Georgina Craig | 22-Oct-2011 7:56 am
That link doesn't work - this one will take any one interested to a blog on this issue www.experienceledcare.co.uk
I really do see both sides of this argument. I just don't see the innovation needed to reduce operating costs from £88 a head to £25 per head being conceived with the same level of thinking as we have applied until now - and it is really hard for people who have always worked one way to invent the new way.
As for FESC 2.0 idea, didn't Einstein say, continuing to do the same thing and expecting a different result means its time to seek professional help? I think he mentioned madness - you get the point.
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Anonymous | 22-Oct-2011 10:47 am
Interesting website Georgina......
No, I agree, you can't "regulate" for innovation any more than you can mandate quality, unless you change behaviour - and hence culture.
Which is never easy in a centrally led NHS - managers are often too busy trying to survive constant upheaval, second guess the next change and cope with complex workloads in ever changing offices....
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phil kenmore | 24-Oct-2011 11:36 am
The debate about commissioning support is valid but to me not the most crucial. After all whatever support is needed is for the process - it is very unlikely to help set genuinely innovative commissioning strategy.
The real issue is de-commissioning. Commissioners fool themselves if they think their influence has been significant - the budgets may appear huge but the effect has all been at the margins and thus has had little widespread impact across the service. The only way to make real change is to get into the bulk of spend and free up some funds from those already allocated to existing services. Painful and politically dangerous!
Thats what CCGs will have to concentrate on to drive innovation - not getting caught up in what commissioning support they do or do not buy.
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phil kenmore | 24-Oct-2011 2:39 pm
The debate about commissioning support is valid but to me not the most crucial. After all whatever support is needed is for the process - it is very unlikely to help set genuinely innovative commissioning strategy.
The real issue is de-commissioning. Commissioners fool themselves if they think their influence has been significant - the budgets may appear huge but the effect has all been at the margins and thus has had little widespread impact across the service. The only way to make real change is to get into the bulk of spend and free up some funds from those already allocated to existing services. Painful and politically dangerous!
Thats what CCGs will have to concentrate on to drive innovation - not getting caught up in what commissioning support they do or do not buy.
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Anonymous | 24-Oct-2011 3:23 pm
Phil - hear, hear. CSOs are the icing on the cake, it's the ingredients that matter. I'm sure CCGs know they'll need audit, accountants, benchmarking data, information on demongraphics, epidemiology and so on. It's how they use that surfeit of information to deliver unprecedented savings targets. SJ Burnell makes some interesting posts elsewhere about bringing waiting times down from 18 to 8 weeks.... But wherever you sit, these are huge challenges, especially in the middle of such a turbulent reorganisation....
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Anonymous | 26-Oct-2011 10:36 am
The real challenge, which the DH document is trying to address, is that David has asked the architects of the old order (PCT cluster CEOs) to be the kingmakers of the new one (Commissioning support on a wider or non-geographic basis)
The inside knowledge and subject expertise of people in the current system is vital, but it will be a monumental act of leadership by the exisitng players to cede control and allow design freedom to the innovators, so we get a blend of the best of the current with the genuinely new and different.
Few PCTs genuinely operated key functions at scale, and even fewer were open to and willing to invest in FESC, because the forces for doing things your own way and in-house are seductive and powerful, not least because the NHS track record on shared services is at best mixed.
If the gamble fails and CSOs end up looking like (and behaving like) PCTs there will be 300 or so unhappy customers. But when history looks back, David's decision to put their fate in the hands of the barons of the old order will be seen as the critical one
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Anonymous | 26-Oct-2011 12:37 pm
Anon 10.36 - a sincere question - are there enough old barons left in the NHS where you work? Where I'm sitting, they've either gone to providers, the private sector or are in some sort of "holding" fixed term role with development in the title. We've got lots of people "acting up" or on secondments or as interims. It's genuinely difficult to know who's setting the vision for what, because trying to do the day job in this environment is difficult enough.....
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