As clinical commissioning groups look set to outsource most of their functions, an open mind towards innovative measures is required, says Howard Freeman.
From the outset of the new policy there was a mantra that clinical commissioning groups would do things differently. Increasingly one of the “differences” CCGs will have that has become apparent will be the leanness of their organisations compared with that of primary care trusts.
There are a number of drivers for this: PCT leaders do not wish to recreate PCTs, CCGs will not have all the functions of PCTs and, perhaps most importantly, with an operating allowance of £25 per head, CCGs will not be able to afford similar staffing levels as PCTs. So how will PCTs discharge their functions?
The core staff employed by most PCTs will be relatively small; indeed, some PCTs are saying they do not wish to employ any staff at all. Effectively CCGs will outsource most of their functions. While employing nobody at all is an option it does make the ability of a CCG to be an “intelligent” customer somewhat difficult. It is hard to envisage a business model predicated on outsourcing when the entity employs nobody at all. The concept of how the dog wags the tail starts to become more difficult to envisage.
Most CCGs are considering employing a small core team in order to coordinate their other activities as a minimum. Over and above this there are examples emerging where CCGs working collaboratively locally will employ more staff that they will share between them to undertake a wider range of critical functions – for example, commissioning services from a common shared acute trust or a small shared team to work on strategic pathway change across a wider area than just a CCG area.
One of the main areas of difference that CCGs have described is in their working relationship with their coterminous local authorities. PCTs have been involved in joint commissioning at varying levels and most CCGs aspire to continue this, probably increase it, and look at where other synergistic activities can occur with their local authority. This could range from just traditional joint commissioning right up to a number of local authorities which are aspiring to become commissioning support organisations.
At the start of the transition there was a lot of discussion about how functions that local authorities currently undertake could support CCGs. Examples bandied about were procurement functions and communication functions. However it has increasingly become clear that while local government uses similar terminology to the health service in many cases, the way it discharges that function is often very different from the NHS – as such, direct use of the same service is not going to be possible.
The biggest area of outsourcing will be to commissioning support services run by commissioning support organisations. Initially these will all be hosted by the NHS Commissioning Board but the aspiration for divestment is clear. The dilemma with commissioning support organisations is the cheapness that scale brings versus the remoteness of scale. Historically the NHS does not have a track record of delivering successful organisations at scale. Perhaps more importantly, the anxiety of CCGs is that large monolithic commissioning support organisations will end up running the CCGs and not vice versa. While many assurances have been given about this the jury is still out.
Initially there will be no other choice to whom CCGs can outsource services. Once we start to move from what is effectively an NHS closed shop into a more open marketplace then exciting possibilities start to emerge. The expertise in the non-NHS marketplace will come into play as will the ability of new niche support organisations, for example in mental health, to be new market entrants.
Clearly we need to take things step by step – learning to walk before entering the marathon is always good – but I suspect CCGs will not be patient and will aspire to progress rapidly with outsourcing. The new NHS opens up a range of possibilities for innovative ways of delivering outsourced support services to CCGs. We need to be hopeful that the old NHS’s reluctance to allow innovation does not follow it into the new world.
Dr Freeman will be speaking at the Commissioning Show on 28 June.