The importance of NHS-industry partnership for medicines optimisation has been underlined by experts on pharmacy management.

Speakers at the Pharmacy Management National Seminar on 17 April argued that the growing prevalence of long-term conditions (LTC) made it vital for pharma and the NHS to work together in improving sub-optimal medication regimes.

The growing role of community pharmacists in guiding patient decisions on medication was also discussed at an event that brought together pharmacists and the pharma industry.

Keynote speaker Dr Charles Alessi (pictured), Chairman of the National Association of Primary Care, said that GPs were not meeting the clinically and economically vital challenge of medicines optimisation.

“We are in an age of personalisation, of trying to understand value and of dealing with mixtures of clinical conditions,” he said.

But poor follow-up of patient outcomes was resulting in 50% of people with LTC ceasing to take any medication within a year, while “we glibly go on thinking that’s all right”.

Joint working was an important way forward, he argued, with pharma companies helping doctors to address issues such as medicines interaction and compliance.

Dr Alessi also noted that community pharmacists were emerging as the “best placed” healthcare professionals to help people with LTC manage their medication.

Peter Rowe, former national QIPP lead for medicines use and procurement, warned that continuing austerity would mean no additional funding to deal with the “demographic time bomb” of the ageing population.

Medicines optimisation was essential, he said – and the changes had to be fundamental, not incremental. That meant “the NHS must work with pharma to better monitor patient outcomes”.

Other speakers discussed the common interest of industry and the NHS in patient compliance with treatment; and conversely, the need for doctors to help patients move on from unsuccessful treatments.

The train ride towards a new commissioning landscape will reach its final destination next April, but is already encountering leaves on the track along the way.

It’s been another eventful few weeks as the commissioning structure continues to take shape. On Monday 1 October, the NHS Commissioning Board (NHS CB) was finally formally established as an independent body with executive powers and exceptional responsibilities. But it will have to wait until April 2013 to take on its full range of responsibilities.

Professor Malcolm Grant, NHS Commissioning Board Chair, said the formal establishment was a “new phase
in the history of the NHS”. Sir David Nicholson, Chief Executive of the Board, called the new responsibilities the Board now holds a “once in a lifetime opportunity to do things differently”.

The transition completes a hectic twelve months for the Board. Having only been established at the end of October last year, it has played a fundamental role in the Government’s vision to modernise the health service as outlined in the Health and Social Care Act. Arguably its main and most important task, before it takes on full statutory responsibilities next April, has been to assist in the development and authorisation of more than 200 evolving clinical commissioning groups.

As you would expect, this has not been an easy process. Alongside the introduction of clinical commissioning, it has also been given the responsibility for authorising Commissioning Support Units
(CSUs), who will assist clinicians in the procurement of certain services. While this may seem a routine task compared with the authorisation of a raft of CCGs, the Board has been criticised for the time it has taken them to appoint managing directors for the CSUs when clinicians are finally in a position to tender services.

The Board has also issued its response to the Government on the draft mandate for its NHS care objectives. Professor Malcolm Grant agrees the mandate is “fundamental” to the Government’s vision of a ‘liberated NHS’. However, he urged David Cameron and Health Secretary Jeremy Hunt to be “ambitious” in searching for new opportunities to focus on the “outcomes that matter to patients and the public.”

Professor Grant said that the “critical tests” of the mandate will be whether newly empowered CCG leaders can address and analyse the mandate and then say ‘‘Yes, this gives me the necessary freedom to address the needs of my local population.” Grant added that the mandate “provides a unique opportunity to make this happen.”

The Commissioning Board has also been informed by the Department of Health of an initial set of specialist
services it will be expected to commission nationally. Although the central powers for commissioning have now been transferred locally, the NHS CB will still retain responsibility for certain services which are defined as treating rare and uncommon conditions and illnesses. The 38 specialist services, which were selected by the Clinical Advisory Group for Prescribed Services, include:

• Specialised Cancer Services (adults)
• Haemophilia and related bleeding disorders (all ages)
• Cystic Fibrosis services (all ages)
• HIV/AIDS treatment and care services (adults)
• Specialised Mental Health Services (all ages)
• Morbid Obesity Services (all ages).

A final set of regulations will be established later in the year on which services will be commissioned nationally – following a consultation between the DH and the NHS CB on the initial recommendations.

Board under fire
But it hasn’t all been clear sailing for the NHS CB. Alongside being accused of delaying the authorisation of certain CCGs because of its stuttering CSU MD recruitment drive, the Board has admitted that it has failed to recruit a significant number of individuals from ethnic minority backgrounds. Jo-Anne Wass, HR Director, admitted the Board’s recruitment data did “not make easy reading”.

Questions have also been raised about the huge variation between clinical commissioning groups’ internal staff levels when compared to support service organisations. Critics have argued that CCGs will be forced to rely heavily on support units after analysis showed huge variations in staffing levels. Recent estimates from the DH show there are 4,200–6,300 staff employed by CCGs. Commissioning support units are expected to employ around 8,000 people.

Dame Barbara Hakin, National Director for Commissioning Development, has also been put under the spotlight by the General Medical Council. The GMC has commenced an investigation after a complaint against the commissioning director, who allegedly placed United Lincolnshire Hospital Trust under unnecessary pressure in 2009 when she was Chief Executive of the now disbanded East Midlands Strategic Health Authority. It’s claimed that waiting times and A&E targets were prioritised ahead of patient safety, despite warnings the trust was over capacity. Depending on the outcome of the investigation, the GMC may decide to take no action, issue a warning, refer Dame Barbara to a fitness to practise panel where she may be ‘struck off’, or decide on undertakings to allow her to keep her registration.

Commissioning Groups
Yet despite the disparity in numbers, evolving CCGs appear to be in good shape. Following the successful scheduling of all of the wave one applications, the NHS CB confirmed that all 67 CCGs in the second authorisation wave had submitted their applications on time. In fact, every proposed CCG is now involved in an aspect of authorisation with the Board – be it a 360° stakeholder survey, a desk-top review, a case study or a site visit.

However, the authorisation process has been delayed. Initially the Board moved the ‘waves’ back by a month each. It subsequently moved the waves back by an additional month, meaning all CCGs will now be authorised by March 2013.

CCGs have also learnt when their final commissioning budgets will be confirmed. Commissioning Groups will have to wait until December to find out how much money they have been allocated to organise local services to meet the needs of their residents. The budgets will be decided using a system called the Fair Shares formula, which analyses the unique circumstances practices face and the health and wellbeing
of local populations.

Commissioners have aired frustration about the amount of ‘red tape’ they face when trying to organise new local health services. NHS Clinical Commissioners, who represent CCGs across the country, say bureaucracy is hindering doctors in their attempts to redesign new services. Dr Charles Alessi, Chair of the National Association of Primary Care, said there was an “overwhelming number of rules and regulations” which were having a significant impact on commissioners.

Supporting units
But it seems the frustration many commissioners have aired at the slow rate at which CSUs are being established may soon be coming to an end. David Stout has left the NHS Confederation to lead CSUs in Essex and Hertfordshire; Tim Andrews has also been given joint responsibilities at Cheshire, Warrington and Wirral CSU and at Merseyside CSU; Derek Kitchen will lead Staffordshire CSU and Lancashire CSU. Dr Leigh Griffin has also been appointed as the MD of Greater Manchester CSU – meaning only two of the 23 CSUs are still awaiting a permanent managing director.

While the NHS Commissioning Board is readily completing the authorisation process for CSUs it has recently been distanced from employing their support staff. The NHS Business Services Authority has agreed to employ some 8,000 staff during the hosting period up to 2016. The move means that although the NHS
CB will provide oversight and direction to CSUs it will not be the legal employer of CSU employees to avoid conflicts of interest. The new distancing arrangements were welcomed by the Board, who said it would help CSUs “develop appropriately as organisations in their own right.”

After confirming four lead CSUs to provide communications and engagement services around the country last month, the Commissioning Board will now focus on assisting support units to provide services and help to CCGs through the authorisation process, to ensure they are as individually autonomous as possible, to
help CSUs develop to become specialist suppliers and to ensure units seize opportunities open to them.

As the NHS reforms continue to evolve it would seem the commissioning landscape is far from being complete. It’s going to be a busy few months.

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. 

A new guide to best practice by clinical commissioning groups (CCGs) highlights the success the system has already achieved.

Clinical Commissioning in Action includes examples from 12 CCGs across England where clinically-led projects have improved the quality of healthcare for patients whilst saving money.

The guide was published by the NHS Clinical Commissioners (NHSCC) – a new group formed by the National Association of Primary Care, NHS Alliance and NHS Confederation.

Group leaders admit the switch to clinical commissioning was not easy, but was “absolutely” worth it for the benefit of patients and the NHS.

The move, the guide said, has placed patients at the “heart” of the healthcare system and “services were designed to their needs”.

Examples of successful initiatives introduced by CCGs include correcting prescribing habits in Nottingham and reviewing secondary-care referrals in Northampton.

Dr Steve Kell, GP and Chairman of the Bassetlaw Commissioning Organisation in Nottinghamshire, outlined how GPs had been persuaded to reduce the amount of antibiotic prescriptions which can make patients more likely to develop Clostridium difficile infection.

Also, Dr Peter Wilcynski, interim chairman of NHS Corby CCG, explained how referrals had been reduced by a quarter after GPs agreed to review each case.

Andrew Lansley has insisted he and his successors as Health Secretary will have a duty to provide a comprehensive health service via the NHS Commissioning Board and CCGs.

The Secretary of State for Health has said it will remain incumbent for those in the position to ensure services currently provided by the NHS.

Speaking at the National Association of Primary Care conference, Mr Lansley said “that is in law, in essence, what is described as a comprehensive health service.”

Changes to the duty of the Secretary of State to provide a comprehensive health service have been one of the most controversial aspects of the Health Bill since its release and its debate in the House of Commons and the House of Lords.

“It’s the duty that has been placed on me and my predecessors for more than 60 years and it will be incumbent on you to discharge that duty in the future - and it will remain incumbent on me and my successors to ensure that through the NHS Commissioning Board and through your CCGs that service is provided,” Mr Lansley told delegates.

The Health Secretary also emphasised the freedoms CCGs would have under the NHS reforms. But he outlined the opportunity would only come with the responsibility to ensure patients have “access to the NHS services” they require.

“You will have the freedom to choose who should support you in taking charge of local health services,” he said. “Clinical senates and clinical networks will be there to advise you, not to tell you what to do.

“You will have the freedom to structure yourselves to meet the needs of your population, providing you involve members of the public, with nursing and secondary care experience on board.”

The NHS Alliance and the National Association of Primary Care (NAPC) have joined forces to create an independent body representing Clinical Commissioning Groups (CCGs).

The coalition will be the collective voice for practising clinicians, CCGs and their leaders to ensure that commissioning bodies are fully involved with the new NHS.

Dr Johnny Marshall, Chairman of NAPC, said: “We are seeing many obstacles, from all quarters of the NHS and elsewhere, being placed to deter and restrain the successful engagement and operation of CCGs.”

Dr Michael Dixon, Chairman of the NHS Alliance, commented: “We will listen to and represent CCGs’ views and concerns without compromise, wherever and whenever necessary. We will be a united voice that will serve to balance the top heavy approach often seen in the NHS.

“As the two organisations that have wholeheartedly championed clinical commissioning over the last two decades, we have a long history of commitment and dedication to the clinical commissioning cause.”

The coalition has agreed a number of shared principles. They include:

• NHS commissioning should be a public function exercised by statutory bodies in the public sector alone. NHS commissioners should be free to choose the support they need from whatever source they feel to be appropriate.
• The NHS should be based on an approach that maximises local responsibility and ownership through local determination rather than central direction, meaning that the NHS Commissioning Board should only take responsibility for things that must be done at national level.
• CCG Boards should have GPs as majority members with a strong primary care focus.  Boards will need to ensure the appropriate involvement of other clinicians and managers and have strong representation from local communities and independent directors.
• NHS provision should be appropriately distributed across the public, third and independent sectors according to the public interest. Those providing NHS services should clearly subscribe to NHS values of openness, transparency and accountability and behave in a manner consistent with those values.
• The NHS should develop integrated care, centred on the needs of the patient rather than the providing organisations, supported by appropriate payment systems.

The coalition has also established a number of priorities it sees as essential. They include:

• To lobby the Government to review the role of the NHS Commissioning Board to ensure that it is set up as an organisation that enables rather than controls CCGs’ work.
• CCGs’ self-determination – Clinical Senates, Clinical Networks, and Local Health and Wellbeing Boards should help not hinder CCGs, who must have the final decision with their patients. 
• Work with the Government to ensure that aspiring CCGs receive the funds intended to support their development.
• Oppose suggestions that CCGs should be constrained in their choice of commissioning support.
• Monitor and CQC to demonstrate that they are acting in the public interest. The coalition will seek to ensure that CCGs have the means of challenging their decisions.
• Transparency - the coalition believes that the payment of any quality premium to reward CCGs which commission effectively should be transparent, represent good value for money and be in the public interest. 

Both forces will contribute to and have ownership of the new initiative, whilst acting as individual identities regarding other functions.

Dr Johnny Marshall added: “Our respective organisations bring their particular strengths to the table to enable us to be bigger than the sum of our parts.

“The strength of our two organisations working in partnership on the same agenda should reassure Clinical Commissioning Groups of our commitment to their cause and that of their patients.

“We will strive to ensure that CCGs are not overburdened with NHS bureaucracy and red tape and are set free to deliver innovative and population focused services.”

A steering group is advancing the coalition's collaborative work.