Kingston CCG is satisfied with the service from its commissioning support unit, but chief officer David Smith believes commissioners will soon demand real choice - and councils may be among those in the market
CCGs' aspiration must be to have real choice to decide whether their support services should be in-house, shared or outsourced
“A commissioning support unit is a remote, expensive bureaucracy; an unnecessary overhead that takes resources away from the clinical commissioning group.”
This was probably a view held by many CCGs 18 months ago.
‘CCGs had little choice as to who would provide their commissioning support’
With only £25 per head of population for CCGs to spend on running costs – half of what primary care trusts used to spend – passing more than half of these meagre resources on to a separate body was never going to be popular.
The reality was that CCGs had little choice as to who would provide their commissioning support. We also had to pass the authorisation test.
Not the warmest of welcomes
The creation of CSUs was not wholly welcomed by my CCG in Kingston.
We received a pretty poor service from the previous acute commissioning unit so we thought “we could do it all ourselves”. But what has our experience of CSU services been?
Kingston CCG buys its commissioning support from the South London CSU, an organisation providing commissioning support for 12 groups in south London and three in Surrey, as well as IT support to a large number of CCGs in Sussex and London.
‘CSUs have robust systems and processes for tracking data, challenging trusts and ensuring we are fairly paying for activity’
We spend roughly £1.6m – or one third of our £25 per head budget – on a package of support services including acute commissioning, human resources, finance and communications. All other support services are provided in-house.
In our first year our experience of the support unit was mixed. Perhaps this was inevitable; as new organisations, both CSUs and CCGs have had to establish themselves. On the plus side, we have seen substantial improvement in the quality of information produced on acute commissioning compared to what we experienced previously.
In our experience CSUs have robust systems and processes for tracking data, challenging trusts and ensuring we are fairly paying for activity.
Notwithstanding this real grip on acute activities, some of our acute contracts are overspending, although the CSU cannot be blamed for this.
As we plan for the future we wish to explore the potential for performance related contracts with the CSU as a better risk/reward structure than we have at present.
Mindful of the “make, share, buy” advice and guidance for commissioning from NHS England, CCGs will also want to ensure their existing commissioning support arrangements represent improved quality and better value for money.
The elephant in the room
The CCG aspiration must be to have real choice to decide whether their support services should be in-house, shared or outsourced, and be able to resist the potential “elephant in the room”.
Will CCGs be pushed to buy to ensure the financial viability of CSUs?
Of course, CSUs face a continued juggling act: trying to strike a balance between delivering a bespoke service to CCGs and deriving the benefits of delivering services at scale.
‘Will CCGs be pushed to buy to ensure the financial viability of CSUs?’
To some CCGs, CSUs have sometimes sought to charge groups for “extras” when in their view these extras are covered by the sum already agreed for a tailor made service.
We have had good customer and communications support from the South London, but the level of engagement of CSU staff with CCGs is variable, with some CCGs reporting far more positive experiences than others.
Perhaps where it works best, it has been because both CCG and CSU have accepted equal responsibility for making the relationship work.
A troubling future
The future model of commissioning support services being provided by only 10 organisations fills us with some trepidation.
While we can see the advantage of more competitive pricing and the offer of more specialist skills, there are also significant risks, including an inevitable concern that, as large organisations, CSUs run an increased risk of focusing even more on their own organisational development than on their customers.
CSUs will need to position themselves working hand in glove with CCGs to help deliver strategic change, rather than being just a provider of support services.
In Kingston we have formed an integrated health and social care commissioning collaborative with the council so our future commissioning support must be flexible enough to support this integrated model.
At present our support services are provided by a plethora of providers. South London CSU provides some of the same functions as the council such as finance and communications; we employ some direct staff, get our IT support from the council and our community services from social enterprise.
This does not strike me as the most efficient way of procuring our support services. Unpicking existing arrangements and creating new ones is a challenge that we have yet to overcome.
For example, it makes no sense that my mental health commissioning manager – a joint appointment between the CCG and the council – gets their finance support from two separate bodies. If we are to derive the full benefits from integrating our commissioning, we have to make it easy for them.
What must be tackled
Does the council finance team provide all her support or do we buy it all from the CSU? Which system is used for paying the bills? Who keeps the accounts? These are not necessarily insurmountable problems but they have to be tackled.
Similar challenges exist for the CSU and the council. As services are unpicked there is a danger that there will be a loss of expertise and diseconomies of scale.
Some smaller services may no longer be viable and will have to merge with others. We are already seeing this in local government where we have created shared support services in IT, legal and HR covering a number of south west London boroughs.
With such services on my doorstep, when it comes to support for the integrated commissioning collaborative, we now have a viable alternate provider for some of the functions previously provided by the CSU.
‘As services are unpicked there is a danger that there will be a loss of expertise and diseconomies of scale’
My view is that we will see more of this as local councils attempt to shed overhead costs, therefore becoming major competitors for CSUs. This should be a benefit, but it does mean that CCGs will have to manage a more diverse and greater number of providers and contractual relationships.
The functions provided by a CSU to support acute commissioning is the largest element of a CSU contract and arguably its unique selling point.
The only choice
Local councils are not equipped to take this on and we, as CCGs, are not large enough to run these ourselves; we could potentially join with other CCGs but why would this be better than using the CSU?
It seems the only “real” choice will be to buy from one of the CSUs with the risk that we will be obliged to make decisions based on what is needed now rather than in the future.
It is debatable whether the proposed lead provider framework for eight CSUs and two external providers is enough to give us real choice.
Some CCGs may wish to test going to an external provider but, given the ever changing nature of the current climate, it remains to be seen whether there will be much appetite from the market.
David Smith is chief officer at Kingston Clinical Commissioning Group and director of health and adult services at Kingston Council