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Exclusive: commissioning board says CSSs 'on the cusp of failing'

“Too many” of the support services vital to the success of the new NHS clinical commissioning system are “on the cusp of failing”, according to leaked NHS Commissioning Board papers.

They also have “fragile” leadership, “lack respect” for clinical commissioning groups and display poor commercial acumen, the papers add.

The internal documents set out the validation process commissioning support services must navigate over the coming months, and emphasise the probability that not all will make it through.

CSSs are currently being set up by primary care trust clusters to provide support services such as contact management and data analysis functions to clinical commissioning groups. Between 20 and 25 are being established, with the intention of them becoming “freestanding enterprises”, independent of the NHS no later than 2016.

The commissioning groups have a restricted running cost allowance meaning that to achieve economies of scale much of the task of administering the £60bn commissioning budget is likely to be carried by CSSs.

However, no plans have been detailed for what will happen to CSS staff if their organisation fails, or to the CCGs they had been working with locally.

The documents relate to “checkpoint two” – the crucial second stage of CSS assurance. This begins at the end of March with the submission of “outline business plans” to strategic health authorities and culminates in a decision on whether to continue with the plan.

One of the documents says checkpoint two is “the most important part of the business planning and assurance process” for CSSs.

But the board’s business development unit is “concerned that too many CSS are on the cusp of failing checkpoint two”.

There is therefore an “urgent need” to ensure CSS leaders are in place with the freedom to develop their organisations, to ensure CSSs are communicating effectively with CCGs.

A summary of anecdotal evidence on CSS development since January reports some good engagement between CSSs and CCGs. But there are also “confused or fragile leadership arrangements”, and - with reference to CCGs - “customer coercion and lack of respect for customers”.

The document also criticises CSSs for “too much focus on glossy plans and not enough on fundamental business development”. This is thought to be a reference to the production of prospectus documents.

A separate commissioning board document emphasises the possibility that some CSSs will be abandoned if they cannot demonstrate the required standards of “leadership, customer focus and business awareness”.

It calls this “scenario one”, with the other two possible outcomes being further development work with either greater or lesser oversight from the business development unit.

Checkpoint two assessments will include an interview which the commissioning board says is more important than the outline business plan. CSS leads will be assessed by a four-person panel including representatives from the business development unit, the strategic health authorities, a non-local CCG, and an “independent expert” with business start-up experience.

CSSs will need to display “evidence of credible financial planning”, based on “the key parameters of financial success: turnover; margin (both cost base and income drivers); pricing and pricing strategies; costing and delivery management”.

The commissioning board notes that CSSs should be supporting their local CCGs as they prepare for authorisation, and CCGs must be able to demonstrate they can source support services in order to be authorised.

But the document makes no mention of what would happen if a CSS fails, leaving questions over the future of staff in a failed CSS, and how CCGs that had been working with it could be authorised.

It will be possible for CSSs to pass checkpoint two but fail later in the assurance process. A “binding development and improvement plan” will be agreed between the business development unit and each CSS. However, failure to stay on course as set out in the plan “will cause the BDU to reconsider support for the CSS”.

One PCT cluster official involved in CSS development told HSJ the documents “show the top-down control over the development of CSS”.

“But there is no explanation of what happens if a CSS fails. We need them up and running in less than 12 months because we need them for the 2013-14 commissioning round. They’re not thinking of what happens if this system falls over,” the source added.

One well-placed source told HSJ that the failure mechanism could effectively launch the planned market in commissioning support, as it would allow viable organisations to bid for work from CCGs whose local CSS had failed.

Charles Alessi, a senior figure in the Clinical Commissioning Coalition umbrella group, said CSSs were coming to realise they had to be responsive to CCGs’ demands.

“They’re going through a transition,” he said. “Inevitably it is messy. Some areas are doing well, and others are doing less well.”

A survey by the coalition published yesterday found that 71 per cent of CCG leads were dissatisfied with the commissioning support on offer to them.

A NHS Commissioning Board spokeswoman said: “This is a significant period of change. We are working to enable CSSs to be the best they can be and we know that there are already many strong, emerging CSSs who are doing a great job and making significant progress with CCGs.”

She said the “robust” development process would ensure CCGs had a choice of high quality support.

Readers' comments (24)

  • Thats no suprise. Most of them are being lead by a board of directors with lots of NHS experience and no commercial experience as they are PCT board members slotted in to keep them employed rather than the right people for the job. None of the senior roles in my patch have gone out to proper recruitment.

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  • I'd love to know from the "well-placed source" just who the potential entrants to this market are and how on earth they're going to make ends meet - in London CCGs are looking to keep in-house up to £12.50 per head leaving v little for any prospective commercial organisation to bid for - and presumably they'd have to take on PCT staff who'd be TUPE'd over..? even if they find a way of getting out of that there's simply not the money to make it a viable commercial proposition.

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  • Given the NHSCB has just published its guidance on getting past checkpoint two (a whole 4 weeks before detailed outline business plans are needed). It's hardly suprising they're concerned some might not pass.

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  • Anon 12.36, Your comments are unfair. The CSS has been asked an impossible question of which it is supposed to come up with an coherent answer yesterday. The reason it can't do so is because the central policy is all over the show. The HR issues alone are immense. CCG's who crticise should perhaps take a more mature approach and find out why customer service isn't top notch. Staff are being put through the ringer and then supposed to come out smiling and say "have a nice day". A reality check across the board is required here. Unless the secret agenda is to make CSS's look so bad in the eyes of the GP's that they go to the private sector.

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  • Richard Russell

    Every now and again I get asked by PCT staff what they should be doing to succeed as a support service. My advice always has been to think of the GP as the customer/client and so rather than doing things "to" the GP it is now "for" the GP.

    This means that whilst there may be one process the dealing of the consequences of that process needs to be tailored to the audience.

    I have met some GPs who want it all, some who like numbers, some who like words, most just want the material exceptions and so forth. Also some want it in paper, some by email (to their home email rather than practice email if important), verbally etc.

    If we don't tailor the message to the audience (i.e. the GP remembering that each GP/Practice is different) then we won't engage that audience and clinical commissioning will essentially be done by the few that like the process that is in place with the remainder either at worst disengaging (assuming they engaged in the first place) or struggling to engage.

    Finally have to remember that a lot of this is going to land on the Practice Managers desk and they can quite often be busier than the GPs...

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  • I hope the CCG authorisation process is at least as rigorous as that for CSS. Politically of course, it's much easier to bash the bureaucrats.

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  • Certainly gives the impression that CSS organisations have been set up to fail - well there's a surprise. Gives the top dogs just the amunition to make this very large portion of the NHS private. So which part of the NHS is next. I think we all realise that privatisation of the NHS is inevitable however the poor unsuspecting public are not party to much if any of this information. Fortunately for them services continue to be provided without any or little disruption whilst many of us are continuing to work long hours, in departments that are often short staffed, compared to last weeks staffing establishments, being talked about and treated like last weeks shopping. I would so like to see the big guys at the top make a sensible decision and stick to it, oh and it might be helpful if your timelines were reasonable, believe it or not we have the day job to do.

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  • So many questions..... I agree this is a mess and that HR is muddled. NHS experience is essential as is commercial acumen, but then many of the big 4 and others have already headhunted people who took MARS. If you just look at the management costs per head of population then it doesn't look commercially viable, but that's if you're thinking at cluster/ CCG level. I think the DH are thinking on a bigger scale, as are those advising them. Will there be a return of FESC2? Either way, my heart goes out to the poor people stuck in the middle. It might be about changing attitudes and better communication styles, but it's still a crap way to treat people and implement change.

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  • Michael Golding

    Sooner or later the CSSs will be required to bid for work from the CCGs and will be competing with private sector organisations. Far better they structure themselves in preparation for this now or risk playing catch up later. There clearly needs to be a shift of customer focus and, for some, an about face in mindset. CSS leaders would benefit from looking beyond the NHS, and their designated suppliers, for support in creating organisations that locate their NHS experience within a private provider culture.

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  • Another shining example of the failure to learn from experience. When PCTs were set up, Bedfordshire Shared Services failed, now here we go again.

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  • As someone in the middle of this transition, the prospect of CSS failing is absolutely no surprise - the radical nature of the white paper has been swept away by the centralist nature of remaining senior executives and civil servants to the extent that it now feels like trying to recite the lords prayer whilst being smothered

    There is no management evidence in the world that cites major change can be achieved with the same managerial attitude in place prior to the change required - that aspect is the inherent weak link as these reforms are progressed - we will be saddled with a National Hotpotch Service promising everything, changing nothing but every tick in the box perfectly entered


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  • still doesn't make any sense - people bang on about the private sector stepping in but they'll have to take the CSS staff on, and there simply isn't enough cash in it to make any money. quite apart from which these organisations have no experience of doing the daily grind that PCTs do - their experience is all about project work, not the endless contract monitoring meetings and disputes regarding room rental and invoice payment etc etc - cannot believe they'll see that as an area they want market share of and yet frankly it's a lot of the crap that PCTs have always had to sort out.

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  • Given the NHSCB has just published its guidance on getting past checkpoint two (a whole 4 weeks before detailed outline business plans are needed). It's hardly suprising they're concerned some might not pass.

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  • So, if I understand the spin correctly - CCGs, comprising GP commissioners with little or no NHS commissioning, contracting, performance management experience (as in end to end commissioning) will succeed and become the be all and end all of the NHS, and the CSS that will comprise some of the most knowledgeable and experienced staff with years and years of NHS transformational and transactional experience (accepting commercial skills will require development)- will fail??? Something just doesn't add up.

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  • From the people who brought you NPFIT ( £6Bn wasted money and time) we have CSS with commercial attitude ! What a load of cobblers the whole proposal is and we are all mugs for going along with a complete lack of evidence based change , no compelling vision for what the "new" NHS is going to look like never mind cost and deliver for the public.

    PCT's were delivering better commissioning according to WCC improved scores in 2010 and we get top down change with no mandate from the Coalition and SoS who said "no top down change!"

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  • Aren't Govt allowing licenced Commisioning Support Groups CSG's to take the strain if CCG's can't manage this task for which they have no real training or experience. The CSG's of course are private comercial enterprises, and will then be holding the reigns. As an aside: SERCO (private company) is taking over Eastern Region support sevices shortly. They don't have a good track record with staff. And they now run MOD, prisons and court services and several other previous public services etc. But they are cheap, mainly because they cut staff and corners. They TUP'd MOD civil servant staff over but I understand only guaranteed the pay and conditions for a year! I wonder if the monopoly commission is looking at how these large companies are taking over.

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  • As someone who is currently destined to end up in the Greater Manchester CSS I am worried sick - so far it has all the makings of a complete disaster....please, please let me have the chance of redundancy rather than that

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  • CCGs dissatisfied with CSS arrangements. So let's guess where blame will be directed when this new cock-eyed system goes belly up... those bloody PCT bureaucrats who were stuffed into the CSSs!!

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  • phil kenmore

    Is it just me or is the headline of this article a touch overstated? - CSS's are on the "cusp of failing" ...what? Failing 'checkpoint 2' of the DH's own process; i.e failing a process measure! Bit premature to try to imply this is some sort of real organisational 'failure.' They're new and like all new organisations will have a lot to learn, new skills and capabilities to acquire and totake some time to get up to full operating performance. CCGs of course will very probably be the same...

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  • Hi Phil - I think the headline is justified as if a CSS fails checkpoint 2 - or breaks its development agreement with the BDU - it will be scrapped. Failure in this context means a CSS will have been judged to be non-viable - it will mean the end of that organisation.

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