“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.