The commissioning support market is worth about as much as a large teaching hospital trust and yet the effort being committed to it in parts of England is wildly out of proportion with its marginal workforce compared to other NHS challenges

The commissioning support market is worth about £800m a year. That makes it about the size of a large teaching hospital trust - or a third of the size of this year’s projected deficit for the provider sector.

‘The effort committed to the commissioning support market in some parts is out of proportion’

Yet the amount of time and effort being committed to it at the moment in parts of England is wildly out of proportion with its marginal importance compared to the other challenges facing the NHS.

Last week we reported that NHS England and clinical commissioning groups in Yorkshire and the Humber are at odds over CCGs’ proposals to bring some support services in house following NHS England’s decision to close their CSU.

More important things

Leaders in Yorkshire and in the North West, who are also in the process of replacing their commissioning support unit, privately say they are spending far too much time attempting to resolve this, rather than getting on with more important work.

Some Yorkshire CCGs have had their CSU reconfigured three or four times from on high - each time supposedly for the greater good, and despite the repeated disruption that results.

‘So much senior resource is being committed to an agenda so far removed from the NHS’s priorities’

After all that, NHS England then scrapped their CSU, even though it did not have bad customer satisfaction ratings. CCGs are understandably frustrated with the national body’s interventions, and it is unsurprising they would rather take some services in house.

However, NHS England has three difficult and conflicting responsibilities here.

First, it must nurture the commissioning sector and ensure CCGs have the resources and the space to become excellent.

Second, the government expects it to develop open competition in support services - possibly the last of Andrew Lansley’s market policies that has not been abandoned in favour of more pressing care quality and integration agendas.

And third, it must keep a tight grip on non-clinical spending.

A relic row

The latter is the root of this latest standoff. NHS England is now worried that Yorkshire CCGs will replace their CSU with a patchwork of shared functions, in-house provision and outsourced services.

For complex legal reasons this makes it less likely that TUPE staff transfer rules will apply. That in turn means CSU staff might not be eligible to transfer to the new suppliers, leaving NHS England - which hosts CSUs - with a potentially large redundancy bill.

There are hundreds of staff involved, and the cost could run into the tens of millions unless NHS England can ensure a staff transfer takes place.

‘It is hardly tangentially relevant to forward view reforms’

So if NHS England is attempting to strong-arm CCGs into working as one to procure a new supplier, it is not because it is obsessed with neatness - it is because the neater the outcome, the lower the redundancy bill, at a time when administrative resource is scare.

A problem for the national body is that it is far from clear whether it has the authority to order CCGs to procure collectively, outsource, or to bear the redundancy costs. This mess will likely get stickier before it can finally be cleaned up.

In the meantime, this row feels like a relic of the Lansley vision for NHS commissioning. It is hardly even tangentially relevant to the NHS Five Year Forward View reforms or the pressures mounting up on the provider side.

In a CCG system where funds are scarce, it is difficult to justify so much senior resource being committed to an agenda so far removed from the most important priorities facing the NHS this year.