There is a pattern visible in the development arc of many policies which propose greater private sector involvement in the NHS. Ministers and their advisers declare it is time for an injection of new blood and that hurdles will be cleared to make way for the entrants.
These commitments are usually accompanied by some covert or overt denigration of the shortcomings of those public servants currently carrying out the task targeted for “liberation”.
Within months, however, civil servants have brought the inherent risks of such a strategy to the attention of ministers and the bold claims of the original policy start to be watered down. There also tends to be a growing awareness that those “underperforming” public servants are not quite as dispensable as suggested.
It seems as if the development of commissioning support services is becoming a textbook example of this pattern.
CSSs were promoted as “free-standing enterprises” which would cross-fertilise with private sector firms to create a “market” from which clinical commissioning groups could take their pick. Some of those opposing the reforms feared they would be Trojan horses for the privatisation of commissioning, a belief encouraged when firms like Capita, KPMG and UnitedHealth were brought in to “advise” the emergent organisations.
As late as this March HSJ was receiving signals that the assessment process CSSs were going through would create “failures” – leaving gaps for the private sector to fill – and that those that survived would be “new businesses, not new organisational forms”.
The messages emanating from the NHS Commissioning Board now have a very different tone. In his interview with HSJ Joe Rafferty, the director of the board’s business development unit, stresses the importance of avoiding leaving CCGs without support through CSS market failure. Mr Rafferty also talks of the “strong case” for the board to have a regulatory role in the governance of CSSs and of business models, the majority of which still involve the board retaining a stake in the new organisations. There is still a desire to create a market, but an equal determination to avoid “the barn door obvious mistakes” of previous, controversial, public flotations.
As suggested above, this a predictable development and reflects a sensible weighing of the risks. It is also a sign of the commissioning board, itself still a lightly staffed emergent organisation, coming to terms with its responsibilities and liabilities.
These exist in two tiers. At the macro level, the board is responsible for making the new commissioning system work. Gaps appearing in commissioning support through over-enthusiastic application of market pressures would kill it dead in no time. In other words, stability trumps choice in the provision of commissioning support for the foreseeable future. The board wants CCGs and CSSs to develop the system together over a number of years, rather than stage a rush to a smorgasbord of providers – something with which the majority of GP commissioners are likely to agree.
At a more practical level, the board is likely to remain the direct employer of the bulk of CSS staff for the next four years. As such it has a direct responsibility to make sure CSSs remain going concerns during this period.
Choice in commissioning support will still be promoted as a goal. Indeed, Mr Rafferty will be replaced by two people when he leaves the board in September. One of them will be responsible for working out how to create the commissioning support market, the other for developing the new organisations. But the fact there will be two separate roles suggests the launch of CSS is no longer inevitably tied to the creation of a “market” for commissioning support services.