The theory behind commissioning under NHS reform is beginning to fall into place. But support for commissioners remains a concern, argues Helen Mooney, and doubts remain over whether the ideas can be successfully put into practice.

Whatever you may think of them, having passed through the Commons after a third reading the government’s (amended) NHS reforms are moving on. In theory, what is set to emerge will put clinicians in the driving seat. 

Clinical commissioning groups are, on paper, in charge of commissioning for the local populations they serve, ensuring that the patient voice is heard and that patients are catered for in a way that puts outcomes ahead of targets. 

Primary care trust clusters have, however, been saved from the scrapheap and are intended to provide help and advice to these clinical groups in a way that is consensual and ultimately for the benefit of the patient. 

Meanwhile the clinical commissioning groups will also commission help from commissioning support providers to help them get better value out of the contracts they buy into. This is the theory but in practice how effective will all this be?

In a somewhat ill-judged swipe at NHS managers earlier this year prime minister David Cameron said that the new system would mean that bureaucrats would be working for clinicians not vice versa.  His statement missed the point that they both need to be working effectively together. Inherent in the new structures are the tensions that will exist between the three parties. 

Difficulties will inevitably arise given the different cultures and behaviours of the three strands. In a letter to NHS staff at the beginning of June NHS chief executive Sir David Nicholson confirmed that structures based on the clusters would remain in place as “local arms of the NHS Commissioning Board”. 

He said that “after April 2013, these local arms would oversee commissioning groups that have been authorised and would also commission some of those services, such as primary care, which are directly commissioned by the board.” 

However, the letter also warned that, because they would have “significantly less capacity” than PCT and strategic health authority clusters, many PCT staff would still “want to consider opportunities for moving to clinical commissioning groups or establishing commissioning support providers”. 

Sir David’s letter also said that: “By reflecting the arrangements for PCT and SHA clusters in the way the NHS Commissioning Board will be organised, our intention is to give all existing staff in commissioning organisations a potential pathway into the new system, subject of course to agreed people transition policies.” 

It remains unclear exactly how commissioning support organisations will emerge and for the time being it seems that current PCT staff are not being actively encouraged to establish bodies outside of the NHS.  In the short term it looks like support groups will be linked to NHS organisations. A new government command paper also now includes a requirement to “ensure [CCGs’] work coherently with local partners”, acknowledging the likely tensions that will arise between the different factions. 

Dr Paul Zollinger-Read, director of GP commissioning at East of England SHA, warns that it is crucial that commissioning support is set up well. “PCT staff who are moving into commissioning support organisations need the right skills and training for the new job because PCTs themselves have been average in their ability to contract at best and they are not good at holding to account performance against those contracts.”  

He says that across his patch some areas are moving forward well but some remain problematic. “Some PCTs feel they have fought hard to get financial control and they aren’t ready to give it up to CCGs that easily.” 

Dr Zollinger-Read admits that many consortia will also need to ramp up their management talent to include safety, quality, infrastructure, governance and finance at board level. “There will be tensions [between clusters, CCGs and commissioning support organisations] that need to be ironed out and these will be interesting times,” he says.

Dame Barbara Hakin, national managing director of commissioning development at the Department of Health, says that clusters have been asked to “support” emerging clinical commissioning groups to take on their new roles and to develop options for “ensuring that effective commissioning support is provided.”

Asked about the potential tensions that could arise between the groups she says that it will be “important” that PCT clusters work closely with emerging clinical commissioning groups to “help them take on their roles and determine what kind of support they need; which functions they want to carry out themselves, those that they will share with other commissioning groups and those where they will seek support from external organisations.

“The important thing is that emerging commissioning groups have access to a range of high quality and responsive commissioning support that will enable them to carry out their functions effectively and deliver the best outcomes for their patients. Dame Barbara says that although the new groups will be clinically led, in order to achieve the best outcomes for patients they will also need the “excellent management skills” that she believes PCT and SHA staff have. 

However, Dr David Colin Thomé, a consultant, former DH national clinical director primary care and member of the Hunter Healthcare talent pool is not convinced that such staff do have the right skills. “I don’t think this augers well because with honourable exceptions those who are meant to provide commissioning support to consortia have not done very well at commissioning in the past.  The big inherent problem will be that a large cohort of NHS managers tend to find it difficult to enable people, they are top down people and tensions will arise if they take this approach when working with clinicians.”   

He is concerned that Sir David Nicholson wants to preserve a hierarchical approach to NHS commissioning and that in doing so risks “alienating” otherwise keen GPs. Dr Colin-Thomé believes that if the managers of commissioning support organisations are to be effective they need to be leaders not just with technical competence but also have the right attributes to affect change management.  

“I can’t see that the average cluster or commissioning support organisation will have those skills.  Will they be able to review contracts so that they focus on outcomes? They will need to have better enabling skills and I can’t see that those skills are very common in our health services.”

According to Dame Barbara the government’s aim is that the NHS Commissioning Board and PCT clusters will work together with aspiring clinical commissioning groups to help them get ready by putting the “right skills, relationships and other arrangements” in place, but it remains to be seen whether this will happen. If, as former junior health minister Norman Warner warns in his book on the NHS, the government underestimates the “self-interest of PCTs” things could go drastically wrong. 

The DH says that all prospective pathfinder clinical commissioning groups will receive a broad range of development support from their PCT cluster and SHA. This will include financial support as well as assigning key personnel with expert skills to them, such as senior finance managers and people with commissioning expertise and experience. The National Leadership Council is also offering leaders of pathfinders and their team’s access to a number of development tools, including personal and team coaching.  Whether this will be enough to ensure that clinical commissioning groups can do an effective job remains to be seen. 

Outgoing chief executive of the Outer North West cluster Robert Creighton is more optimistic. He thinks that CCGs and PCT clusters in the main are developing mature relationships.  He says that there is a “future” where clusters, commissioning support organisations and CCGs can work together successfully but only if they all recognise the skills that they each have.  “If however we go down the route wherein we marketise everything and open everything up to competition then yes everything will be quite difficult,” he warns.

Mike Sobanja, chief executive of the NHS Alliance and also member of the Hunter Healthcare talent management pool, sets out two polarised versions of how the clusters, commissioning support groups and CCGs could work.  One will see clusters and commissioning support organisations working subserviently for and acting on behalf of the CCGs.  In the other he envisages clusters as no more than extensions of the NHS Commissioning Board used to control the CCGs, in which case he says the first scenario will completely reversed.  

“Commissioning support organisations and clusters have to become servants of consortia and do what they ask them to do otherwise the system will be the same as we have now and the tensions will always be as they have been between the intermediate and operational tier.”

Dr Zollinger-Read warns that there is a “small window of opportunity over the summer months” to get the relationships, skills and structures right otherwise commissioning as we know it he says is doomed to failure. 

As is often the case with the NHS we will once again have to wait and see and in the meantime cross our fingers that patients will not suffer too much.