A health expert has predicted that the failings of CCGs will see them replaced after only two years by a more effective system of commissioning healthcare services.

Kieran Walshe, Professor of Health Policy Management at Manchester Business School, told the BBC 4’s Today programme that there are no real benefits to GP-led commissioning and accused the Government of being obsessed with this approach.

“This is the most recent version of GP-led commissioning,” he said. “None of them have worked very well. The research suggests there aren’t really great benefits in GP-led commissioning, so why this Government is embarking upon essentially doing the same thing is very hard to follow.”

Professor Walshe said the UK should follow the commissioning models adopted across Europe to get better value for money. He claimed that larger organisations instead of smaller commissioning groups are in a better position to leverage better deals for patients.

“GP commissioning groups are smaller than the old PCTs and are going to be like ‘corner shop commissioners’ – who gets better value for money? A corner shop or a supermarket?” he said.

“The change in all of this which is really interesting is the creation of the NHS Commissioning Board and its local area teams. That’s commissioning at scale. They’re going to be dealing with around 40% of the budget and they will be the driving force in this. In two years’ time I suspect we’ll be back sitting around a table saying ‘CCGs haven’t worked. What shall we put in their place?’ But the scale of commissioning by the NHS Commissioning Board may have some future.”

Dr Michael Dixon, NHS Alliance Chair and acting president NHS Clinical Commissioners, argued that Professor Walsh’s prediction was inaccurate and GP-led commissioning will see improved standards of care. “The benefits [of CCGs] are that doctors and nurses that actually see patients make the decisions as to what needs to happen,” he said.

“The Nuffield Trust report showed only last week that money continues to go into hospitals and not into primary care services. What we need to do is to turn that around.”

The NHS Alliance has warned the Government and the NHS Commissioning Board to allow clinical commissioning to unfold organically.

Dr Michael Dixon, Chair of the Alliance, said GPs must be allowed to make their own commissioning decisions if the NHS reforms are to be a success.

Speaking at a health forum, Dr Dixon said politicians should learn from previous mistakes if clinical commissioning is to be a success.

He commented: “For me, the way the DH and the Commissioning Board are setting things up, seems a bit like saying to David Cameron and Clegg that yes you can come to Government but Gordon Brown will come in and tell you the rules, and then he is going to continually assess you on what you’re doing and come in and take over Government.

“Do you ever create a revolutionary change in that way?”

The NHS Alliance chair also called for GPs to become further engaged in CCGs or they risk being “subservient” in the new NHS.

Dr Dixon also called for the Government to make the commissioning structure as uncomplicated as possible “because if the frontline conditions return to how they were before then we have lost the plot”.

Commissioning Support Services have been rebranded. But what will incoming CSUs actually do?

The infrastructure of commissioning support has evolved rapidly this summer. In the past month, the NHS Commissioning Board Authority has renamed Commissioning Support Services (CSSs) as Commissioning Support Units (CSUs), and introduced 23 CSUs that will be managed by the NHSCB during the transition period. The rebranding is designed to distinguish the NHS units from the wider commissioning support services marketplace. 

The move marks the first part of wider efforts to develop a sustainable network of CSUs. This will be led by a CSU Transition Programme team that will focus on establishing key components of commissioning support, including a standard contract, a CCG procurement framework, market development and the commercial development of CSUs. The Transition Programme Team will be appointed shortly. In the meantime, details of how CSUs will collaborate to provide essential services at scale have been unveiled, following an NHSCBA business review.

CSUs will provide at least one of four ‘scale services’ for CCGs. These are:

• Business intelligence

Business intelligence services will comprise data management and integration centres that provide data validation, integration and storage to cleanse and link national and local data sets. This will ensure that meaningful data are available for further analysis by CCGs and CSUs.

• Healthcare (clinical) procurement

These comprise market management activities such as market engagement, analysis and development. It also includes procurement strategies such as procurement project management, strategy development and process compliance.

• Business support

This includes HR, payroll, procurement of goods and services, legal services, information management and technology.

• Communications and engagement service

The configuration of this area is yet to be finalised.

At present, a number of CSUs are evaluating their capabilities and determining which scale services they wish to provide. However, 23 have been assessed and approved.

Dr Joe Rafferty (pictured), Director of Commissioning Support at the NHSCBA, said the national configurations go a “long way” towards providing stability for CCGs when they take over the responsibilities of PCTs next April.

Context and progress
The NHS reforms opened up a free market to service providers. Officially, any organisation can assist CCGs in tendering for services. But the introduction of support organisations by the NHSCBA provides a safety blanket for CCGs when in need of external commissioning assistance. Although CSUs have been given titles referring to different regions they are free to provide services to any of the 212 CCGs in England. 

CSUs are currently completing the third ‘checkpoint’ stage introduced by the NHSCBA to ensure not only that they are competent and financially robust, but that any “potential commissioning and financial risks are manageable” when they are fully authorised. The Board has made it clear that although it will oversee the transitional stage of these organisations, staff will not be employed by the NHS – nor will it be responsible for the services they tender. CSUs are transitional partners in a shift away from the old healthcare system dictated by top-down management. Also, CCGs have been informed that they will be responsible for the services organised by CSUs.

After the CSUs passed the Board’s first checkpoint at the turn of the year – a peer review process which assessed the preparedness of CSSs to be “responsive” to CCGs’ needs – three CSUs were disbanded during the second stage of the authorisation process. Plans for West Mercia, Peninsula and NHS Communications and Engagement Service CSUs were scrapped after the three were found to have “failed outright in their development”. A further nine CSUs were identified by the NHSCBA as being in need of  “rigorous management” – though the Board agreed to develop them further through its own business development unit. 

The third and final checkpoint will “comprehensively test the full business plan, strategy and overall feasibility” of commissioning services. The deadline for this has been set at the end of September 2012.

Services
Long before the introduction of CCGs and the controversial NHS reforms as part of the Health and Social Care Act, staff working within PCTs were tasked with commissioning services to meet local health needs. It’s expected that the majority of these staff will continue to play prominent roles in future CSUs – allowing pharma to maintain important contacts within the health service. In fact, the first 16 managing directors of the 23 CSUs have now been appointed by the Board and include a number from high profile PCT positions.
The NHSCBA has called upon the units to be “innovative” and provide “greater value for money”. It is expected that the main functions of support organisations will be to assist in transformational and transactional commissioning functions such as procurement, contract negotiation and monitoring and risk stratification.

The NHSCB’s Developing commissioning support: Towards service excellence outlines how CCGs may wish to utilise the services provided by CSUs:

• ‘One stop’ commissioning – CCGs share the services of support units to form a collective power when negotiating with healthcare providers. These services are expected to be built on medium to long-term arrangements.
• Specific products and/or services – although currently delivered by a range of suppliers, CCGs may ask CSUs to deliver assistance through a wider end-to-end commissioning support service.
• Business support – services such as key decision-making activities must be carried out by CCGs but highly transactional functions are likely to be outsourced.
• Scale services support – services that should be delivered for larger populations by a large number of organisations.

The response
A recent report by the National Association of Primary Care and the NHS Alliance found that half of the 212 CCGs across the country expect to source services from CSUs. Slightly less than a third (32%) indicated they plan to use their own in-house expertise with just 5% saying they plan to use services outside the NHS to commission.

CCGs also indicated they plan to work with their local CSUs – and maintain a working relationship with the commissioning support service used as part of their authorisation process. Although concerns were raised over the cost of outsourcing commissioning, nearly half (45%) of CCGs said the costs associated with CSUs were affordable. Only 12% disagreed.

But not all commissioners are sold on the idea of outsourcing services. Only 8% of respondents said that commissioning units can deliver support in a more innovative way than had previously been experienced. Also, the majority of CCGs called for further information on procuring commissioning support and information on choices available to them.

There has also been criticism from CCGs about the number of CSUs across the country and the speed of their development. As part of their own authorisation, commissioning groups must establish a contract with a support organisation. But Dr Joe McGilligan, Chair of ESyDoc CCG, recently revealed that the “most difficult” challenge his organisation faces is finding a CSU. He added that when an offer was received by his local CSU it far exceeded their budget.

Those claims were echoed by the NHS Alliance. Its chair Dr Michael Dixon said there needed to be more than 23 CSUs across the country to serve the 212 CCGs. He said a bottleneck was being created as commissioning groups moved through their own ‘waves’ of authorisation and that a “lack of sellers” may push some commissioners towards the private sector.

The NHSCB recently staged a commissioning support unit scenario to explore the proposed relationship between CCGs and CSUs, and to try and anticipate likely challenges which may be faced in the future. However, if the Board continues to slow down the authorisation of CCGs, it’s expected that many will be forced to turn to the private sector instead of their preferred support unit options. 

The development of CCGs in their authorisation process is being hampered by a lack of offers from commissioning support units (CSU), the NHS Alliance has said.

Dr Michael Dixon, Chair of the Alliance, said there were not enough CSUs across the country for CCGs to use – something which is creating a “bottleneck” effect.

The chair said there was a “shortage of sellers” which may influence CCGs to turn to the private sector for assistance.

In May this year the number of CSUs fell to 23 after three groups failed to pass the NHS Commissioning Board’s second ‘checkpoint’.

Dr Dixon said CCGs had anticipated a “take it or leave it” attitude when searching for a CSU but have found finding a CSU more difficult than many had imagined.

He added that if CCGs do turn to the private sector to assist their authorisation process they must be able to do so without any repercussions. “It is important that if CCGs want to look to privately-owned and run CSUs, they are afforded the flexibility to do so,” he said.

The NHS Commissioning Board said the recruitment for more leaders of CSUs is “well under way”.

Only half of CCGs will be given access to their full budgets by April 2013, Dr Michael Dixon, NHS Alliance, Chairman, has predicted.

Dr Dixon believes a lack of support from the Government and the NHS Commissioning Board will prevented GPs from engaging and being authorised for their full budget. He also said overly strict requirements would also stop certain groups from being established by next April.

Speaking in a New Year’s message to the HSJ, Mr Dixon said that Number 10 was not taking clinical commissioning “seriously”. He also claimed that Health Secretary Andrew Lansley and fellow health ministers were “lone voices”.

Clinical Commissioning Groups are scheduled to take over £60bn of the NHS budget when PCTs are abolished in 2013. But, if they are not in a position to do so, the NHS Commissioning Board will take on this responsibility or arrange suitable alternatives.

The Government has yet to reveal how it would plan to do this and Mr Dixon believes this scenario would create a two-tiered NHS.

The NHS Alliance chair called for the Government to fully support the move to clinical commissioning if it is to retain the support of those in favour of the switch. “The coalition government, as a whole, must put its full weight behind CCGs and CCG leaders,” said Dr Dixon. “If they do represent the future of the NHS then they must be explicitly recognised and celebrated as such.

“If government fails to recognise this and to recognise this fast then the heart and soul of clinical commissioning will walk. The prime minister and coalition government must see this as a crisis far beyond the importance of compromising with any self interested factions within or outside the NHS.”

In the message, Dr Dixon also raised concerns at the lack of CCG leaders which were involved in the design of the Commissioning Board. He warned that mistakes had not been learned ten years after PCTs were created and a lack of clinical engagement was sought.

GP consortia should continue their pace of development, despite the second consultation period for the Health and Social Care Bill, says the NHS Alliance.

The group believes that there will be no u-turn on clinical commissioning and is set to open a listening exercise to give GP consortia the support they require.

Dr Michael Dixon, Chairman of the NHS Alliance (pictured), says there is “no going back” on the plans outlined in the Bill and that political discussions will not result in “significant changes”.

The Alliance will now launch its own listening exercise to ensure consortia have a prominent voice at a time where it says there’s a “lack of real representation and a lot of confusion”.

“We are encouraging all GP consortia, especially pathfinders, to continue their pace of development and to not be distracted by the current hiatus in the passage of the Bill,” said the Alliance’s Chairman.

“It is undeniable that we need to listen to all professionals involved in making clinically-led commissioning happen, including nurses, allied professionals and consultants.

“But, to be meaningful, this listening exercise needs to be led by frontline commissioners. It is about time that commissioners' voices are truly heard. That is what the NHS Alliance listening exercise will do.”