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Customer focused

Customer focused
8 February 2013

Commissioning Support Units (CSUs) are one of the less well understood elements of the health reforms. And yet they are going to be an important part of the new health architecture, employing somewhere in the region of 9,000 staff. So what are they, how will they operate and how will their relationship with the clinical commissioning groups (CCGs) work in practice?

Commissioning Support Units (CSUs) are one of the less well understood elements of the health reforms. And yet they are going to be an important part of the new health architecture, employing somewhere in the region of 9,000 staff. So what are they, how will they operate and how will their relationship with the clinical commissioning groups (CCGs) work in practice?

These are the questions that I have been asking myself over the last few weeks since I took on the role of managing director for two CSUs operating in Hertfordshire, Bedfordshire and Luton and Essex in October 2012.

Let’s start with what CSUs are not. They are not PCTs and are not responsible for commissioning services for the local population. That will be the responsibility of CCGs who are the statutory bodies with legal responsibilities for commissioning all local health services, apart from the services – mostly primary care – which the NHS Commissioning Board (NHS CB) will directly commission.

CCGs cannot delegate this commissioning responsibility. A central tenet of the government’s healthcare reforms is precisely that the GPs and other primary care clinicians need to be in the driving seat. But what they can do is buy in help to do the job efficiently and effectively. That is where CSUs come in.

The coalition government’s consistent view during the debate on the Health and Social Care Bill was that they did not want to turn clinicians into managers. They wanted commissioning to be clinically-led, but with strong and effective managerial and administrative support. CSUs are being established to offer CCGs exactly this sort of service.

So what are CSUs and what kinds of services do they offer? CSUs are organisations that are being developed as part of the transition from the current PCTs. They will initially be hosted by the NHS Commissioning Board but will be ‘externalised’ by 2016 so they become independent organisations in their own right.  

The bulk of the CSU staff have been initially drawn from experienced PCT staff, although there will also be people recruited externally as CSUs look to develop new ways of working.

CSUs offer a range of different services from back office functions such as HR and IT support, through transactional functions such as contracting support, procurement and business intelligence to more transformational services such as service redesign.

The CSU role is to offer expertise, support and advice to CCGs. It is absolutely clear that decision-making ultimately sits with the CCG but a good CSU will bring strong ideas to the table and act on occasions as a critical friend. To make this work CCGs will have to have real confidence in CSUs who will be acting on its behalf in critical areas of work.

CCGs have options for how they can organise their commissioning functions. They can:

– Directly manage the commissioning functions themselves within their CCG.
– Collaborate with other CCGs to share functions across more than one CCG.
– Purchase commissioning support from CSUs.
– Buy-in the support services from other external organisations, including those in the private sector.

Most CCGs have opted to go with their local CSU, for the majority of their services. But each CCG is different and it has been interesting to see the range of patterns of service that they are looking for – even within the eleven CCGs served by my CSUs.

A few of the larger CCGs in other parts of the country are providing all the commissioning support functions in house, while others are looking to keep their in house teams as small as possible.

There has been some debate about how much choice CCGs really have in practice about where they will get their commissioning support. Realistically, CCGs had relatively little room for manoeuvre in agreeing their initial support arrangements as they had to get these agreed in time for the CCG authorisation process.

Even so, some have exercised choice – for example in my local area Luton and Bedfordshire CCGs agreed to switch CSU support to the Hertfordshire CSU at the end of October 2012.

I expect CCGs will be shopping around more over the coming months and years. Some are already impatient for change, while others are relatively happy with the current arrangements but will expect to see improvement.  For CSUs to be successful they will need to be much more responsive and flexible than NHS organisations have generally been in the past. The opportunities to win new business and also the risk of losing business mean that the traditional ‘one size fits all’ approach will no longer work. It seems likely that the market for commissioning support will grow and potentially quite quickly.

CSUs will need to be able to innovate to respond to external challenge, developing new and more effective ways of supporting commissioning. They will also want to find ways of offering the benefits of working at scale – for example my CSUs cover around 3.5 million people between them, which should mean we can offer more sophisticated analysis without increasing cost. If CSUs don’t quickly start to innovate then CCGs will undoubtedly look to other organisations, such as those in the independent or third sector as well as other CSUs, to provide elements of their commissioning support.

In the very short term – between now and April 2013 – the pressing need is to make sure the existing commissioning arrangements safely transfer into the new organisations being established as part of the health reforms. CSUs need to play their part to ensure that there is stability during the transition to the new system.
As well as going through an overhaul of the commissioning landscape with the establishment of a range of new organisations, we also need to successfully deliver a challenging commissioning round. This is an inherently risky time.

We cannot afford to lose grip on either service quality issues or the financial performance of the NHS.

CSUs will need to play an important part in providing continuity in a very turbulent environment. Failure to manage this commissioning round well will immediately put CSU reputations at risk among CCGs.

At the same time, CSUs have the prosaic but essential task of having to agree service level agreements with the CCGs they serve. This means they have had to agree the service specifications, key performance indicators and price of the services that they offer.  No mean task as we have never had to operate in this way in the past and made even more challenging because CCGs have had to work through their own authorisation process at the same time.

In most places it has been possible to reach these agreements through sensible negotiation, but there is little doubt that in some parts of the country, relationships between CSUs and CCGs have been put under great strain. It is important to remember, however, that we are both looking for a long-term working relationship, not a short-term quick win. Developing trust on both sides is absolutely critical to making this work.

Beyond these immediate tasks over the next few weeks, what will CSUs have to offer and how will they add value? I think that CSUs will ultimately be judged by the success of the CCGs they are supporting. We could hardly claim to be running successful CSUs if our client CCGs are failing.

CSUs need to really understand what the CCGs are trying to achieve and provide them with the support they need to achieve their goals. The task facing CCGs is enormous in improving outcomes for patients and raising the quality of care in an increasingly pressurised financial environment.

The only way to square that circle will be for CCGs to provide the clinical leadership to oversee a transformation of the way in which health services are delivered. The sorts of changes the CCGs will need to make are not likely to be popular with either clinicians in provider organisations or with the general public.

I believe that successful CSUs will ultimately be the ones that provide the analytics and business intelligence services which give the clinical leaders in CCGs the evidence base they need to make confident, informed decisions about the future patterns of healthcare in their areas, as well as providing the CCGs efficient and effective tools to intelligently involve local people in making those decisions and implement them.

This is not business as usual for the NHS and will require a step change in the way we commission services. CSUs will need to learn new skills, develop partnerships with other organisations that can add to their in-house expertise. CSU staff will need to learn how to manage relationships with CCGs as customers. And we need to develop fast. The organisational development challenge for CSUs as well as CCGs is huge.  

Can we achieve this? I certainly hope so. The NHS is too important to let it fail

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