In May a survey of 141 CCGs for the NHS Commissioning Board (NCB) found a quarter are expected to source commissioning support exclusively, or almost exclusively, from NHS clinical support services (CSS); a third aiming for between 50 and 69%; with 27% aiming for 30-49%; and 17% expecting less than 30%.
With regard to exercising choice during 2012/13, the majority of emerging CCGs intend to carry on with the same NHS CSS, one in ten said they wanted to exercise choice and around a quarter didn’t know. Around 60% want more information about the choice available to them.
Beyond authorisation and CCGs assuming PCT responsibility in April 2013, there is a high degree of uncertainty with a third wanting change and 29% don’t know what their support will look like.
Up to April 2013, half of support was expected from CSSs, 32% in-house, 15% shared with other CCGs and just 3% sourced from outside the NHS.
Indeed only 32% of emerging CCGs expected to source any support from outside the NHS at all. Among those who did expect to source from outside the NHS, the average amount was only 8% (with the maximum for any emerging CCG not exceeding 25% of the whole).
CCGs that intended to secure commissioning support from outside the NHS were asked which services this would be for. Common themes included: organisational development, practice-level support, consultancy support, joint commissioning and IT.
NHS CSSs are able to source from and work with organisations outside the NHS to support emerging CCGs. The expectation among emerging CCGs is that support from these ‘other sectors’ will most commonly come from local government – 67% of emerging CCGs surveyed said they envisaged that this would be the case. Around half said they envisaged that NHS CSSs would source from the commercial sector (52%) and the third or voluntary sector (48%).
The art of the possible
National Association of Primary care chairman and Surrey GP Dr Charles Alessi said: ‘I think the information CCGs need is really around what is the art of the possible? What can commissioning support do for them? People know what commissioning support has delivered for them in the past but now they don’t know what they don’t know.
‘The new system is around clinical engagement with localities rather than at the centre.
‘There is a need for a bespoke service to CCGs rather than this is what we have, you could buy it. Are models of care more sensitive to the needs of local populations? It’s completely impossible to ascertain the care of local populations unless one has an understanding of local populations and information given is sensitive to the locality. In the past this never happened when the units of currency were SHAs. This needs to change. CSSs need to be far more locally focused. People are really wanting more information. CCGs need to be able to make appropriate choices.’
Shift outside the NHS
There is a shift towards services from outside the NHS with 45% of CCGs expecting up to 32% of services to be provided from outside the NHS in April 2013 (compared with 33% before this).
Some 42% were not confident that commissioning support would be delivered in a new and innovative way, one in 10 were not at all confident.
A quarter were not confident that leadership within their main NHS CSS would develop the organisation into an entity that could operate confidently in a commercial environment. The report adds: ‘Ultimately, emerging CCGs will be able to source commissioning support from outside the NHS so it is essential that NHS CSSs are seen to offer a robust alternative to the commercial and third sectors as well as in-house sources. The survey findings suggest that emerging CCGs are not wholly confident in this regard.’
The report says: ‘There are reasonable levels of confidence in the ability of leaders within NHS CSSs to deliver the core services that emerging CCGs require, namely commissioning support post-authorisation. However confidence is by no means universal. Emerging CCGs have lower confidence that leadership will help to deliver in an innovative way or provide vision and ambition. This suggests that leaders within NHS CSSs are regarded as competent rather than inspirational.’
Journey not easy
NHS Confederation chief executive Mike Farrar gives credit to PCTs and CSSs for working hard in a short space of time to get up and running to offer the kind of support that CCGs want. He says: ‘The journey has not been easy for CSSs which have been subjected to significant scrutiny so they meet the necessary service quality standards.
‘CSSs will be a vital component of ensuring the NHS reforms are successful so it is pleasing to see that the overwhelming majority of CSSs have raised their game, focussed on the CCG as a customer and continue to improve their offer.
‘There is an opportunity now to use the data from the survey to work on the areas that need improvement so CSSs are ready to succeed – offering truly innovative services based on strong business relationships with CCGs in an open marketplace.’
The challenge to offer bespoke services has been set by Dr Alessi. Whether CSSs rise to it will determine how ‘privatised’ the NHS becomes. Although, ultimately, all such services are to work in the openmarket.