Feature / In the spotlight

27 September 2013

Login to access this content

Clinical commissioning groups may have received top billing so far, but their support act is about to take centre stage. Seamus Ward reports


It May be because they are responsible for the less glamorous back-office jobs that commissioning support units have not received much attention. Even so, their customers – chiefly clinical commissioning groups – have always been at pains to point out that CSUs are their equals and an integral part of the post primary care trust landscape.

That CCGs are customers hints at something else, though. CSUs have a commercial outlook and customer focus that could see them become some of the most dynamic and innovative organisations in the health service.

There are currently 19 CSUs across England, though one is expected to be wound up by the end of this year, according to NHS England – which acts as the host body for the units (see CSUs: a short history). They offer a range of business and commissioning support services, including advice on financial, legal and employment matters, information technology and contract management. Financial services tend to focus on traditional support areas, such as cash management, accounts payable and receivable; technical accounting such as VAT advice; and annual accounts production. CSUs also manage the local interface with the nationwide commissioning finance system, the integrated single financial environment, or ISFE (see box overleaf).

Nationally, there are nine data management and integration centres, providing business intelligence services, while 16 CSUs provide healthcare procurement hubs that offer market analysis and development as well as advice on strategy and project management.


Significant variation

NHS England says there is significant variation in the volume and type of services CCGs take from CSUs. Some CCGs are choosing to keep the functions in-house; others are outsourcing the vast majority of support functions to a CSU; some are likely to be receiving support from non-NHS suppliers, it adds.

Staffordshire and Lancashire Commissioning Support Unit provides services to 17 CCGs and three area teams, as well as contract management for a number of local authorities. The CSU covers four counties – Staffordshire, Shropshire, Herefordshire and Lancashire. Managing director Derek Kitchen says most CCGs in the first three counties take the vast majority of the CSU's services, while those in Lancashire range from taking all services to a smaller, bespoke selection. The CSU provides finance services to all CCGs and as a consequence CCG finance departments tend to be smaller than in PCTs.

North Yorkshire and Humber Commissioning Support Unit business services director Jon Cooke says the volume of its services taken by CCGs in its patch varies. Some CCGs purchase an end-to-end service, while others take less. The CSU serves eight CCGs within its geographical boundary.

The level of financial services provided to each CCG also varies. ‘For some CCGs, we provide a full range of services,’ says Mr Cooke. ‘These CCGs may have only a chief finance officer and a support person. All services will be provided by the CSU, from the interface with SBS for the ISFE, including ledger management, right through to reporting and financial management. The CSU offers management accounting, engagement with the budget holders, cash management and forecasting, financial management support for contracting, as well as financial support to QIPP and service redesign.’

However, other CCGs take no financial services, preferring to keep it in-house with a finance team of seven or eight staff.

‘We believe that the efficiency of the health community could be improved if we provided financial support services to all CCGs. It would lead to efficiency savings both for them and the customers we have already. But recognising the historical financial challenges locally these CCGs are keen to maintain local control over finance, which is understandable.’

A key feature of CSUs is their focus on customers. ‘We pride ourselves on our ability to work closely with our customers to provide a complete support solution,’ explains Simon James, chief finance officer of NHS South Commissioning Support Unit. ‘Many of our people have clinical backgrounds – including our directors – meaning that we have an in-depth understanding of CCG priorities. This enables us to work in a proactive and collaborative partnership, having evolved from a more traditional service supplier relationship.’

The CSU has 12 CCG clients, though it will gain a further seven (previously supported by Surrey and Sussex CSU) on 1 November. It offers a range of services, including its provider management service, which is taken by most of its CCG customers. It supplies out-of-area contracting for several CCGs and business intelligence for a number of local authorities. Finance staff work as part of CCGs’ finance teams, often at the CCG offices.

‘One of our selling points is our ability to tailor our commissioning support offer to client need; not just by the services they choose but also the way in which the range of services is shaped collaboratively,’ says Mr James.


Transformational support

Most managers believe the NHS funding gap will only be bridged through transformational change and Mr Kitchen says his CSU is keen to get involved in supporting this.

He points out that the NHS has to respond to major challenges. These are:

  • NHS England's Call to action, published this summer, which calls for a public debate on the future of the NHS and estimates that the funding gap between resources and demand will be £30bn by 2020/21
  • The Francis report
  • Don Berwick's report on zero harm
  • Sir Bruce Keogh's review of the 14 hospitals with the highest mortality levels.

'The NHS needs to address these while managing within available funds, so we have to transform the services that CCGs commission,' says Mr Kitchen. ‘For us and other CSUs, the challenge is to become pivotal within health economies in the space between area teams, commissioners, local government, providers and the voluntary sector – all the agencies that need to come together.’

'The challenge for CSUs is two-fold: the first is to generate that new thinking, the new ways of commissioning and designing services; second, they must gain the confidence of the CCGs and all the other players.'

The CSU is, for example, supporting the Staffordshire CCGs in one transformation project – 10-year contracts for cancer and end-of-life services. It also works with clinicians, CCGs and providers to negotiate and then manage healthcare contracts. Mr Kitchen says the latter will be an ongoing process, with the CSU working with providers to ensure the contracts deliver the services required.


Multi-disciplinary approach

The South CSU believes its multi-disciplinary team approach to provider management allows it to offer a more in-depth service, including system reform and transformation.‘Our contracting team is pursuing new approaches to contracting, including COBIC – commissioning for outcome-based incentivised contracts,’ Mr James says. The CSU and HFMA are to run a COBIC webinar on 18 November.

North Yorkshire and Humber’s Mr Cooke says his CSU is focused on delivering excellent customer relations and can bring together experienced NHS commissioners and those with a deep understanding of service areas to facilitate specific projects or wider QIPP programmes. The CSU is leading significant transformations in two CCGs in its area to deliver fundamental service redesign around out of hospital care.

‘It’s an area where a lot of CSUs will believe the future lies. Our success or failure hinges on how well we deliver transformational support. So far, we’re doing well. We bring a different way of looking at issues and this will contribute to delivering the change required in the NHS.’

The need to innovate is partly driven by CSUs’ wish to survive. NHS England intends to make all CSUs independent bodies by April 2016. This process – externalisation – will see them as standalone bodies or acquired by another organisation from the public, private or voluntary sectors. However, recently NHS England has reportedly replaced the term externalisation with the softer-sounding ‘autonomisation’. While both terms are still likely to set a plain English campaigner’s teeth on edge, the shift is significant and opens the door for CCG ownership.

‘The CCG shareholder model is one of a range of options being explored and which we will be consulting on later this year,’ an NHS England spokesperson confirms. ‘The deadline remains the same – all CSUs will become independent entities by April 2016.’

A shortlist of options is expected later this year. ‘CCGs owning shares in a CSU may well be an option that works in some health communities. But there are legal restrictions underpinning this option that may make the model unworkable in other areas, especially where CSUs are providing services to other customers,’ says the spokesperson.

While there’s a lot of discussion nationally, and internally, about CSUs’ future Mr Cooke insists deciding on an organisational form now is like putting the cart before the horse. North Yorkshire and Humber is focusing on its strategy, and when this is developed it will then consider the most appropriate form. ‘We won’t dismiss anything and will give the idea of CCG ownership due regard,’ he says. ‘But we must be clear about function and strategy before we look at the legal form it might take.’

Mr James says that, regardless of externalisation, South CSU wants to retain the values and beliefs associated with delivering and supporting NHS care. At the same time, it wants to look and feel like a commercial organisation and recognise that it receives revenue by delivering great service. The CSU is reviewing which vehicle will be most suitable, with a decision likely in late 2013 or early 2014.


Staff concerns

Reports of a CCG cooperative arrangement being considered have brought uncertainty about autonomy into the minds of staff, says Mr Kitchen. He moved quickly to issue a statement to all staff and CCG clients.

'I said we would evaluate the options of social enterprise, mutual organisation and greater CCG involvement,’ he explains.

‘I said these three because they all give us the opportunity to keep our stakeholders involved – staff and CCGs. They are the three best options to protect staff terms and conditions.

‘There may be an affordability argument that says we can't afford to protect these terms and conditions, but the other side of the argument is that if we don't value them, staff could walk away or become disaffected. We are committed to retaining and attracting motivated and engaged staff as we develop our business.’

While the clock ticks down to 2016, CSUs will have to maintain the quality of the services they provide while developing new ones that support the transformation of clinical services. Achieve this and perhaps then they will be more widely considered star performers.

CSUs – a short history


The number of CSUs has halved since the number planned at the start of 2012, when they were known as commissioning support services (CSSs). PCT clusters initially developed plans for 36 CSSs (the Department of Health had estimated there would be between 25 and 35), but their number declined to 23 by May 2012 as the (then) NHS Commissioning Board Authority assurance process swung into action.

Following a rebrand as CSUs in August 2012, further mergers took place as CSUs sought to prove their sustainability. And in March this year, just before CSUs were formally launched, units in West Yorkshire and South Yorkshire merged to form West and South Yorkshire and Bassetlaw CSU, reducing the total to 19.

The number will fall to 18 by the end of this year as Surrey and Sussex CSU is wound up, its services transferred to neighbouring CSUs. All CSUs have been authorised by NHS England.

NHS England says a number of CSUs are exploring more collaborative working arrangements, including CSUs in south and west London and a group of six CSUs across England known as the Elis Group. This partnership working is expected to increase as CSUs look to create arrangements that support their sustainability in the long term, it adds. Initial service level agreements between CCGs and CSUs were for 18 months (until October 2014), but NHS England recently announced that CCGs could extend their agreements for a further 18 months, taking them up to the April 2016 deadline for CSUs to become independent organisations.

 

Integrated single financial environment


The integrated single financial environment (ISFE) is the basis for the accounting and finance services provided to all CCGs, CSUs and NHS England by NHS Shared Business Services (SBS). CCGs must use the Oracle-based system as part of their authorisation.

SBS managing director John Neilson says the ISFE gives NHS England access to commissioning organisations’ financial information, allowing it to monitor their position. CSUs can use the information in the system in a number of ways, including managing ledgers and balance sheets, chasing invoices and reporting on management accounts.

But Mr Neilson says it would be doing the ISFE a disservice to describe it only as a ledger. ‘As well as the ledgers, we can provide procurement, chase debt, advise on and collect VAT and manage CCG bank accounts. It’s similar to what we previously provided to PCTs, but with an improved version of the system.’

SBS provides payroll services to about 40 CCGs, the rest using in-house, CSU or other providers. But Mr Neilson says: ‘We don't see ourselves as competitors to CSUs. We have held conversations with CSUs and CCGs to talk about how we can partner with them to provide our expertise to support their activities.’

SBS aims to expand joint working, especially in analytics and data management.

Mr Neilson says: ‘Approaching each CCG is not the most cost-effective way of working. It’s better for us to work with the CSUs, so we are looking to establish greater partnerships with them.’