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Report on commissioning support services


17 March 2014

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As independent sector providers join the commissioning support services market, options open up for clinical leaders seeking to deliver radical changes for the NHS
As independent sector providers join the emerging commissioning support services (CSS) market, resources diversify for clinical commissioning groups (CCGs) and existing commissioning support units (CSUs) face more open competition.

As independent sector providers join the commissioning support services market, options open up for clinical leaders seeking to deliver radical changes for the NHS
As independent sector providers join the emerging commissioning support services (CSS) market, resources diversify for clinical commissioning groups (CCGs) and existing commissioning support units (CSUs) face more open competition.
With radical changes outlined in the NHS Call to Action highlighting the need for a competitive and sustainable CSS market, NHS England has played an active role in helping to diversify and make accessible CSS resources across the commercial and voluntary sectors as well as the NHS.
Here we discuss emerging trends in the second part of a soft intelligence report about CSSs, produced by The Commissioning Review’s parent company, Cogora, in conjunction with NHS England in December 2013. We carried out 23 face-to face interviews with independent sector organisations about their CSS offerings. The report, Mapping the Market: Commissioning Support Services, provides a snapshot view of CSSs across the NHS and private sector spectrum and is available at cogora.com
 Although still a relatively nascent market, there have already been significant developments.
CSUs hosted by NHS England until 2016, consisting largely of former primary care trust staff, have already dropped in numbers from 23 to 18, with further mergers predicted by the independent sector providers interviewed in this report.
In the face of the uncertainty that confronts them, however, some CSUs have responded by expanding their customer base and undertaking innovative approaches to suit customer needs:
Managing director of Arden CSU, Rachel Pearce says: “One of our strengths is that we are a relatively small, agile and creative organisation. We have been able to produce innovative work and we are able to adapt our approach to customer needs. Our strategy is to become an excellent specialist provider of support rather than being as big as possible across a very broad portfolio. We now have an approach to providing commissioning support to other NHS and public sector organisations.”
Forays into council work may also prove invaluable following the looming elections as Labour has spoken about local authorities taking on health commissioning. 
Understanding of this arena could result in CSU survival should policy change in 
this direction. 
Also slightly easing the pressure is that former speculations that independent sector providers might compete with CSUs to provide end-to-end services are not immediately apparent. 
Instead, it would appear that there 
seems to be an emerging trend of independent sector providers working predominantly through CSUs to provide commissioning support. 
This could be attributed to the fact that CSUs are able to work at scale compared to CCGs, some of which are quite small. 
A particular concern among independent sector providers is that the CCGs limitation in size may mean difficulties in effecting change across the whole health economy.
The picture is not completely clear-cut, however, as working through CSUs does not rule out independent sector providers also working with CCGs directly, which albeit to a lesser extent, is something which most providers are currently engaging in.
To add to the mix, there are also a few providers such Bain, Attain and Capita, who work mainly directly with CCGs rather than through CSUs, and others, who although stressing that they would not do anything to upset the balance of their working relationship with CSUs, are keeping their options open about working directly with CCGs.
Peter Bull, partner of PA Consultant Group said: “I think an overarching answer [regarding our challenges] is getting the balance right between the work we do with CSUs and not wanting to be left out of the market to provide services to CCGs directly if a clear market for that opens up. We work well with a lot of CSUs and we would not look to upset that relationship. That said we would consider each future opportunity with CCGs on its merits.”
With independent sector providers exploring all options, this paves the way for a larger market share should CSUs fall by the wayside.
CSUs and the independent sector, however, both clearly have their respective areas of strength and weakness to provide for the varying needs of commissioners.  
With CSU staff comprising mainly of ex-primary care trust staff, they have an obvious advantage over independent sector providers with regards to their knowledge of NHS culture and frontline commissioning experience. 
Furthermore, being “hosted” by NHS England for the time being, and having had a history of working within the NHS, CSUs have a head start in garnering the trust of CCGs and forming alliances with them.
However, what the independent sector lack in knowledge of NHS culture, they gain in cross industry commercial experience and long-term investment in infrastructure, knowledge development and resources.
Their commercial experience has given rise to innovative payment models with some organisations offering to put their fees on the line unless desired outcomes are achieved. Others are proposing to take responsibility for the risks given that they have a share of the savings derived. Bain’s Head of healthcare in the UK, Dr. Christian Mazzi says: “For example, we worked on a mental health model originally developed in Germany, which was piloted in the UK for schizophrenic patients where all the risks of managing the patients were transferred to provider and savings on delivering the results were then divided between the commissioners and the provider.”
The independent sector’s focus on understanding customer needs also puts them in good stead as CCGs strive to gain clarity on what areas of commissioning they need support with and CSUs get to grips with working in a competitive environment.
Be it work with CSUs or CCGs, there seems to be a clear consensus among independent sector providers of the need for skills transfer, which in the long-run is very helpful towards providing empowerment.  
In contrast, despite having more established relationships within the NHS, the focus on customer care is relatively new for CSUs as they seek to adjust to ex-colleagues now being clients and to providing advice instead of undertaking commissioning directly themselves. 
However, they are quickly moving from strength-to-strength in this regard, with many CSUs having customer relationship managers in place.
Across both sectors, providers are increasingly placing emphasis on transformational service redesign, business intelligence and data analytics, all of which are key in effecting the substantial changes that clinical leaders are seeking to deliver. 
In the area of data analytics and business intelligence, “Big data” capabilities and making use of unstructured data are particular areas of focus moving forward as CSS organisations strive to coordinate more integrated and joined up care.
As providers find their way in the market, individual organisational capabilities are beginning to emerge as providers trim down some services and sharpen their focus on others.
Among CSUs, for example, there is an increasing trend of providing certain services at scale and a move towards providing more specialised services elsewhere. 
Managing director of West and South Yorkshire and Bassetlaw, Alison Hughes, says, “Our strengths rest in our ability to leverage the benefits of at scale delivery while providing a bespoke, personalised service to meet the unique requirements and circumstances of each customer. This is no easy task and we challenge one another every day to enhance our service delivery and improve our value proposition.”
Among independent sector providers, COBIC, for example, focuses on moving CCGs away from payment by results and one-year-activity- based contracts on to outcome-based 5-7-year contracts for populations.
Each provider’s respective areas of strength has led to a variety of networks and alliances being formed within and across both CSUs and independent sector providers.
In turn, this provides a very promising range of offerings for commissioners to mix and blend according to their individual commissioning needs, especially 
with the voluntary sector set to further deploy their expertise in the market.
With CCGs showing an interest in the lead provider framework, which allows both independent sector providers and CSUs to respond to tenders on an equal footing, it remains to be seen how organisations will learn to balance partnering with competing. 

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