When Equity and Excellence: Liberating the NHS was published in 2010, it was envisaged that the clinical commissioning groups (CCGs) would be lean organisations with the facility to carry out the commissioning functions individually or collectively, or buy in from other organisations. The types of function included under this umbrella are activities such as negotiating and monitoring contracts, procurement, information and data analysis, human resources and IT. This has been termed as “commissioning support” for CCGs. Thoreya Swage looks at it in detail.
What is commissioning support?
Commissioning involves a number of complex interrelated activities which can be simplified into three distinct phases.
Planning: this includes health needs assessment, engagement of patients and the public, appraisal of options, evaluation of effectiveness of interventions, service redesign and prioritising the needs for different services — this determines how health services should best be delivered.
Agreeing contracts with a range of providers to deliver healthcare services, including standards of quality and mechanisms of payment.
Monitoring these contracts, ensuring that they are delivered according to the agreed service specification, checking quality and safety, and ensuring that they remain within the agreed financial limits
Within this framework there are transactional and transformational actions. Transactional actions include contracting and procurement functions whereas transformational actions include leading change through clinical leadership, services redesign resulting in improvement, and engaging with patients and the public to agree priorities. Given that CCGs are to be lean organisations they will more than likely require external help to carry out these functions.
This commissioning support can be undertaken by a wide range of organisations such as the independent, charitable and voluntary sector as well as the emerging Commissioning Support Services.
Over the past year the NHS Commissioning Board (NHSCB) has been working with a number of NHS stakeholder groups including CCGs and potential suppliers of commissioning support to develop the ideal picture of this function. Five key characteristics of future support for commissioning were identified.
The support should be focused towards the needs of the customer (ie CCGs and the NHSCB). For this to work effectively CCGs and the local offices of the NHSCB will need to have a clear vision for what they are trying to achieve for their populations and provide a strategic direction. (The local offices of the NHSCB will be “hosting” those CCGs that have not yet achieved full authorisation post-April 2013.)
During the early phase of development this will enable the clinical commissioners to manage the transactional functions without getting too deeply involved in the details of the process.
The focus of commissioning support is expected to change from managing activity to quality and outcome issues as the organisations (CCGs and Clinical Support Services (CSS)) mature.
The environment in which commissioning support will operate will be in a market and competitive setting, based on the specific requirements of clinical commissioners.
This will build on the effective relationships between commissioners and support organisations across the private, voluntary and public sector (including local authorities) so that innovation and cost-effectiveness can be achieved.
It is recognised that no one model will work for all situations, but for most services it is anticipated that there will be close working between the commissioners and support staff. For a few services these may be commissioned through pre-procured framework arrangements that will have been developed to meet the needs of CCGs. Furthermore, there will be situations that require “specialist subject matter expertise” such as mental health, safeguarding, continuing care or health economics.
Lessons learned from the current system
Most of the current commissioning expertise is located within PCT clusters which have gained this from the constituent PCTs. There are other NHS organisations that have such expertise,including the current commissioning support units (which were developed by the Department of Health) and procurement hubs (which were set up by the NHS). Other commissioning support for specific activities came from the independent sector.
Some of the functions of these differing organisations overlap or are duplicated. Therefore for commissioning support to be effective some redesigning and standardising of approach is required, as well as re-engineering the commissioning support to respond to the needs of the new clinical commissioners.
Developing successful commissioning support
The NHS is required to save £20 billion by 2014/15. A significant portion could be achieved through streamlining a number of backoffice functions, eg finance, HR, IT and procurement. These types of functions can effectively be provided by shared services or commissioning support.
The NHSCB has identified the following key indicators for successful commissioning support.
It will not be possible for a large CCG or local office of the NHSCB to undertake all the commissioning functions in house and at the same time deliver best value. By providing commissioning support to a number of commissioners it would be possible to concentrate expertise while ensuring value for money through economies of scale and making a contribution to the Quality, Innovation, Productivity and Prevention (QIPP) challenge. By taking the backoffice burden off the CCGs the commissioners will be free to focus on the clinical aspects of commissioning.
Working with CCGs
For the most effective commissioning support to develop it is essential that CCGs work with potential commissioning support suppliers to refine their requirements and determine which support models best suit their needs.
Working with the PCT clusters
These provide the current commissioning services. The clusters need to ensure business continuity whilst enabling the new commissioners to develop their commissioning skills.
Working with other agencies
This entails CCGs, commissioning support services and local authorities working jointly to develop the public health function. It also concerns the activities that will support joint commissioning between the CCGs and local authorities, as well as balancing the matter that local authorities could be potential providers of commissioning support.
Best scale of delivery of services
This concerns the issue that there must be an appropriate balance between cost effectiveness, flexibility and quality in the delivery of commissioning support. It is not envisaged that there will be the same number of CSS as PCT clusters or that they will cover the same geographical area.
The types of commissioning support that CCGs may wish to use depend on with which element of their commissioning activities they require external help. This includes a range of functions such as:
“one-stop” commissioning support — this may be used when a number of CCGs need to negotiate with major providers of healthcare services collectively and have some common ground across clinical networks. This type of service would be used directly by CCGs
specific services and/or products — this would include products and services that can be used directly by CCGs, or may be part of a commissioning support service for groups of CCGs or individuals, eg risk stratification tools
running an organisation — these include the transactional functions such as payroll and HR as well as the transformational actions. Some of these activities could be managed by external organisations, eg the transactional functions whilst others must remain within the organisation such as key clinical commissioning decisions.
The transition process
Setting the direction of activity is the NHSCB, whose role it is to oversee the development of CCGs and CSSs during 2012/13. In order to do this it will ensure that:
systems are in place to provide the appropriate support to CCGs while they assume responsibility for the delegated commissioning functions and build up their expertise
CCGS are authorised, thus demonstrating their capability and capacity to take on their commissioning role. As part of that process CCGs are required to consider the type of commissioning support they need. It is expected that they will have clarified the type of organisation to provide the one-stop commissioning services and have considered other products or services they will need from other providers
the skills of PCT personnel are retained, as far as possible, and that existing NHS staff will be given the opportunity to develop commissioning support services, which will help CCGs achieve authorisation and to become part of a viable organisation, which continues to provide this support post-April 2013
different organisational models for commissioning support are encouraged, that the skills of NHS staff are retained and external knowledge and expertise are brought in. The models include joint ventures, partnerships and social enterprises.
Timetable and CSS authorisation process
A Business Development Unit (BDU) is being set up by the NHSCB to develop the emerging CSS, with the remit to assess and assure them so that they are fit and able to provide support to the CCGs.
The BDU is currently working with the four Strategic Health Authority (SHA) clusters to oversee and co-ordinate the development of the CSS, ensuring that the needs of the shadow CCGs are met in order to achieve authorisation and prepare to become statutory bodies.
The process for validating the CSS is outlined here.
By March 2012
During April 2012
April 2012 onwards
CCGs to have shadow service level agreements (SLAs) in agreed and in place with their chosen CSS
Full business plans submitted to BDU
Business plans assessed
October 2012 onwards
Staff transferred to final CSS from PCTs
Final SLAs in place between CSS and CCGs
Risks and opportunities during the transition period
PCT clusters are currently in the process of establishing CSS and the eventual number will probably be between 20 to 25 across the country. There will be a great emphasis on achieving savings as part of QIPP,which will mean that fewer resources will be available to implement such a change.
There is no clear plan as to what the outcome would be for CSS staff, or the CCGs they work with, if the emerging CSS fails the validation process. It is in this situation that strong and experienced leadership is vital to ensure successful development of the CSS. The process of recruiting CSS leaders has begun and they come from varying backgrounds including mixed NHS and commercial experience and management consultancy firms.
Another key area vital to the success of CSS development is the level of engagement between the commissioning support organisation and the CCGs. Good relationships will mean a better understanding of the requirements of CCGs and a more focused service by the CSS. Poor relationships will mean ineffective use of scarce resources and possibly poor outcomes.
Meanwhile national charities are positioning themselves to offer commissioning support in the areas of data and information intelligence and pathway redesign. For example, Diabetes UK has published a guide setting out the core components of good diabetes care and Macmillan is able to collate information about cancer prevalence, outcomes and data on local services to provide a picture of cancer care in a locality. A major strength of this approach is that patient representation and input is already in-built.
Whatever models of commissioning support that do develop, the picture needs to become clear rapidly: there is less than 12 months to establish the CSS and to support the CCGs in the 2013/14 commissioning round.
The NHS Commissioning Board papers on Commissioning Support can be found on the Commissioning Board website.
Last reviewed 16 April 2012