Feature / Helping hands

CCGs may be at the more headline-grabbing end of the commissioning process, but commissioning support organisations will be critical to their success.

Seamus Ward reports on progress to establish CSOs across England.

While the debate over the merits of the health and social care bill has drawn the NHS into the spotlight in Westminster over the past year, work on the ground has focused on establishing the infrastructure needed to ensure the reforms work, including setting
up the new commissioning support organisations (CSOs).

CSOs - also known as CSSs, or commissioning support services - will offer clinical commissioning groups (CCGs) a range of services currently provided in primary care trusts. These include back-office services such as payroll and human resources and providing information for CCGs' commissioning decisions. While large CCGs may have a dedicated CSO, most support organisations will provide services to a number of CCGs. This should allow CCGs to remain within their administration budget.

The NHS Commissioning Board, which will oversee the CSOs from April 2013, says the current indications are that between 20 and 25 CSOs will emerge. It is understood that around 35 prospectuses for CSOs were developed at the end of last year, but this number is falling to reflect the need to keep costs down by providing services at scale. Before being authorised, CSOs must pass three 'checkpoints' (see box above) and will start in shadow form during the 2012/13 financial year.
 
But there is uncertainty about their future. From 2016, they will be expected to become stand-alone organisations (social enterprises, for example) or be subsumed into other organisations (a CCG or another public or independent sector body).

CCGs will be able to choose their commissioning support from April next year and the signs are that they are not happy with what's on offer at the moment. In March the Clinical Commissioning Coalition, a collaboration between the NHS Alliance and National Association of Primary Care, published the results of a survey of 95 respondents across four strategic health authority areas. More than four-fifths expressed dissatisfaction with the rolling out of the programme of commissioning support, while 71% were unhappy with the support being offered. However, 27% indicated that they had opted to go with the PCT cluster offering because relationships with PCT support staff were good.

One respondent expressed strong approval for the quality of PCT support work and indicated excellent relationships, but feared the PCT cluster's offering would be unaffordable.

Intelligent customers
The dissatisfaction appears to hinge on whether CSOs  are perceived to be different in culture from their predecessor PCTs.

'Clinical commissioners should be treated as intelligent customers, not, as happens in some areas, as servants of their commissioning support. Furthermore, they should be able to get the right quality of commissioning support and have a proper choice of who will provide that,' says Alliance chairman Michael Dixon.

KPMG partner Piers Ricketts says the variability of PCT support services must be kept in mind when addressing the issues raised by the survey. 'Some PCTs were really good at doing this; others were not,' he says. 'Starting with PCTs leaves an inevitable legacy of considerable variation. But one of the reasons for these reforms is to make the NHS better at doing these things. CCGs can't do their jobs without better management information.'

The Commissioning Board insists setting up CSOs is not just a case of corralling services together (physically or virtually) and putting a new sign above the door. Relationships have to change. CCGs are now customers and in 12 months' time they could begin looking to take their business elsewhere.
Even so, there have been reports that the Commissioning Board has concerns over the development of a number of CSOs. Leaked papers have reported that some of the organisations were 'on the cusp of failing'.

According to a board spokesman: 'Emerging CSSs have been working very closely with CCGs to develop responsive and customer-focused services that take account of CCGs' needs. Checkpoint 1 showed the significant progress that had been made by NHS staff over the past year to create truly excellent services that add real value to CCGs. The vast majority of these services are doing a great job and making significant progress with CCGs.'

He adds: 'But it's important to remember that we're less than half way through the business review process and there is still a long way to go. The challenge for emerging CSSs is to ensure that they are transforming commissioning support services into something that is markedly different to the PCT model, providing a customer and outcome-driven service.'

Some PCT clusters moved quickly to set up CSOs to ensure they did not lose their best staff. Staffordshire Commissioning Support Service (SCSS) was one of the first and is offering services to seven pathfinder CCGs.

Complete package
SCSS provides all services essential in helping the CCGs and the cluster to fulfil their roles - functions such as business intelligence (the collection and analysis of patient activity), contracts management, finance, IT, estates, human resources, governance and patient engagement. It also offers support to commissioners in areas such as primary care contracting and continuing care.

Staffordshire PCT Cluster finance director Tony Matthews says setting up the CSS quickly was key (it was established over nine months in 2011), as was doing it right first time. The cluster wanted to give staff clarity on their future roles as soon as possible, which led to the early development of the CSS.
'We took a decision early on to assign key commissioning support people to the CCGs, the cluster and by default the commissioning support strand. It was the right thing to do for our staff. For the organisation there was a danger that by not doing it we might lose people,' he adds.
 
It's also worked closely with its CCGs. CSS project director Derek Kitchen says the organisation's vision and mission were developed with its staff and customers during the first quarter of 2011 at a series of workshops. These were augmented by one-to-one interviews and visits to CCGs to ensure the CSS fully understood their requirements.

It aims to provide value for money, with costs less than 50% of the CCG running cost allocation per head of population. The CSS will in future play a full part in delivering cost efficiencies required in the local health system.

Commercial approach
Rachel Pearce, director of delivery systems at Arden Primary Care Trust Cluster, which also developed an early CSO (see box left), points out that such a customer-based, commercial approach is vital.
'After 2013 we will potentially see more competition between the CSOs, but this will probably be within the NHS environment,'

she says. 'I think at that point the CCGs will be clear about what they want and start to exercise their powers. Commissioning support is part of CCG authorisation, but once they are authorised they will be asking, "Are we getting best value?".

'We have a year to get our act together and get more commercial. We have a mixture of people from NHS and private sector backgrounds. However, I don't think we will see a fully commercial environment in commissioning support but a hybrid with strong NHS, patient-centred values,' she adds.
Mr Matthews agrees that CSOs must secure commercial skills - particularly within their finance functions. 'It wouldn't surprise me if the chief finance officers in the commissioning support organisations will have commercial backgrounds or be able to demonstrate commercial and marketing skills,' he says.

The environment will change as the transitional period progresses and new structures and functions become apparent. 'The CSOs need to be light on their feet and flexible in order to adapt to a rapidly changing environment,' he adds.

The creation of a commissioning support market will draw interest from other parts of the public sector, as well as private and voluntary sector bodies. KPMG's Mr Ricketts says his firm is 'potentially' interested in providing commissioning support services to CCGs. The organisation is advising five CSOs through the set-up process.

Collaboration options
CSOs may have to find partners after 2016 (CCGs or other public or private sector organisations). But at the same time Mr Ricketts believes non-NHS providers will also be open to collaborations. And middle-office services, including contracting, informatics and business intelligence such as patient flows or spend per provider will be at the heart of this need for partnership.

'There is no-one at the moment - private or third sector or local authorities - that could provide middle- and back-office services at scale,' he says. 'A lot of organisations can provide back-office at scale - NHS Shared Business Services being the obvious example - but CSOs will stand or fall by their ability to enhance value-added services.'

Arden CSO is keen to work with Coventry City Council and Warwickshire County Council. 'In principle, we are committed to working together, though not as an integrated organisation,' Ms Pearce says. 'The local authorities also provide commissioning support and see the benefits of collaborating to support the commissioning of health and social care.'

This could benefit CCGs - for example, in commissioning contracts for services to individuals where there may be health and social care elements.

'CCGs do not want to deal with a number of suppliers and this will offer them a more joined-up approach,' adds Ms Pearce.

CSOs will soon be a familiar part of the NHS landscape, but Mr Matthews warns that neither the organisations nor their staff should be considered less important.

'CCGs will be seen as the more glamorous end of the commissioning process, but it is important that CSOs are seen as near equals,' he says. 'There is a danger that CSOs will be regarded as a sub-service to the CCGs, but they are a business-critical function working alongside the CCGs.'