Health Service Focus

The future of commissioning support

From 1 April, three CSUs are merging to form a single South, Central and West Commissioning Support Unit, covering a population area of 10 million people and 40 CCGs. NHE spoke to two of the people leading the merger: Jan Hull, managing director of South West Commissioning Support, and Keith Douglas, managing director of South CSU.

“CSUs have got incredibly skilled people – but there is a potential for organisations to overlook what’s on their doorstep. We need to ensure people recognise those opportunities, both nationally and locally.” 

That is the view of Keith Douglas, who says that too many NHS organisations are relying on expensive private consultancies for advice and skills that are actually available in droves across the commissioning support units. 

Constant mergers since their creation three years ago and formal launch two years ago have consolidated the number of CSUs. The merger of Central Southern CSU with the existing alliance of the South and South West CSUs (SaWCS) brings the number down to just six providing ‘end to end commissioning support’. 

Those six were the successful bidders to get onto the Lead Provider Framework’s (LPF’s) Lot 1, alongside three private companies. But two CSUs, North West and Yorkshire & Humber, failed to get onto Lot 1, threatening their viability and putting staff at risk – though they did get onto Lot 2b, ‘supporting Continuing Healthcare and Individual Funding Requests’. 

As explained on page 45, CCGs in the affected areas are now having to make tough decisions about the future of commissioning support. 

North West and Yorkshire & Humber CSUs – ‘A very unfortunate outcome’ 

Douglas said: “It’s very unfortunate for everybody, including the CCGs. It’s one thing to think you might want to do something different about your commissioning support, and having time to plan it. But it’s another thing to suddenly find your service will in essence no longer be there and need to start taking urgent action. I suspect that even some of those who might have been critical of the service and organisations that were in place would not choose to do it in the way that has been happening to them.” 

Jan Hull, director of South West Commissioning Support, which is merging with Douglas’s organisation, said: “Clearly we know a lot of the people affected by that, and it’s a very unfortunate outcome.” 

Phenomenal achievement 

Douglas said a vast amount of work went into his team’s LPF bid, and said it was a “phenomenal achievement” to get on it – all while continuing to offer high-quality day-to-day services to existing customers. “Our CCGs didn’t care we were trying to get on a framework – they just wanted us to deliver!” he said. “We had a really strong internal team, and used very little external help – we wanted to do it ourselves and have ownership of that process. 

“The importance of it, we always recognised. But it was only in the last few weeks, when it became apparent there were likely to be one or more CSUs that didn’t make it onto the framework, that that level of importance became apparent to us. The importance for us was absolute in the end – we had to get on that framework, and we are on it.

 “We can debate how much it might be used and what it will be used for, but not being on it would have been literally catastrophic for us.” 

Hull said it was a demanding 10-month process to get on the LPF, and that it was important that both the SaWCS alliance and Central Southern CSUs won a place. “Culturally, as we go into the new organisation, it’s given tremendous positive impetus to our merger. It’s given us a really good framework on which to build.” 

‘I don’t know if it’s the right scale or not’ 

As they have merged and grown, CSUs have become used to listing off the benefits – flexibility, economies of scale, sharing best practice, assured viability. But, we asked Douglas, if those benefits accrue from agglomeration, why stop with this merger? Why not bigger: pan-regional mergers or one national CSU? 

He said: “It’s a good question, and I don’t think anybody has the answer. The vulnerability of the [CSU] organisations has become apparent at smaller scales. Initially, South CSU looked after eight CCGs and grew to about 18, and even at that level it was clear we were still at risk of one or two CCGs deciding to do something different, creating viability issues.” 

He said the merger had its own logic with the nature of patient flows in the region. 

But he was candid: “I don’t know if it’s the right scale or not. You could argue that there may be a scale across the entire south of England, so maybe there should be three or four CSUs nationally instead of six. There’s a balance we need to find between being bigger, more viable, less subject to market vagaries – but also the loss of local knowledge and understanding, and loss of direct relationships with customers. 

“For me personally, I’ve always prided myself on knowing all the AOs [accountable officers], clinical leads, and CFOs [chief financial officers], at all our CCGs. So [the merger] will create some issues. I’m not sure this is necessarily over yet, but I do think it’s a sensible and logical thing for us to be doing at this time.”

Best-of-breed 

The CSUs behind the scenes are reviewing all their service offerings and processes and trying to decide which to keep and expand. “We are being as open about that as we can. Wherever the best is, we’ll use the best. We should get best-of-breed across the three coming through,” Douglas told us. “It’ll take us time to reach a place where we’ve got commonality, I think that’s natural. 

“But the way we operate and deliver is dependent on what the people who pay us want. Our model will vary depending on CCGs’ and NHS England’s and other customer requirements. 

“I would very much hope we will create a cohesive single organisation offer and we will have a standard operating approach and vision. The reality is, it will take some time for culturally people to not feel part of something old, but we will do everything we can to help staff with the OD [organisational development] work to become engaged and involved in the new organisation.” 

Hull said it will be important to ensure the new, much larger CSU retains strong local footprints and local relationships, even while sharing a joint vision and single way of doing things. Relationships with NHS England area teams, clinical senates and Academic Health Science Networks (AHSNs) are also important. “I’m aware that in other areas, CSUs and AHSNs don’t talk. Not because they’re antagonistic, the links just aren’t there,” Douglas said. 

Services and locations 

The new CSU will have three principal locations, in Bristol, Eastleigh and Newbury, but also operate out of 20 local offices shared with CCGs and other partners. Customers will include the obvious ones – CCGs and NHS England – but also GP practices, provider trusts, the Department of Health, Public Health England, councils and third sector providers across 10,000 square miles. The merged organisation will have about 1,200 members of staff. 

For now, as with all CSUs, it is offering a “full spectrum” of services. But the LPF could change that. Hull explained: “As time goes on and we see how the LPF tenders come through, I think probably all of the CSUs, who are already providing the wide range of services, might be looking at those, looking at their strengths and weaknesses, and looking at profitability and taking a view.

“One thing we intend to do in our first year is that careful stock-take. But certainly at this point, we’re pleased to be a ‘full range’ provider. The market will drive all of us to develop a number of specialist areas.” 

She said a key strength for the organisation will be business intelligence and interoperability – joining up data across different parts of the system – as exemplified by Somerset’s Symphony project. 

Another is transformation, shifting care to the right setting. “Obviously, that’s what the Five Year Forward View is about, and the New Models of Care programme. We’re very actively supporting that agenda across all of the different elements of the system. 

“I see a big role for our CSU in supporting the integration agenda,” Hull said. 

Another strength is provider management, Douglas added. “We’ve just supported NHS England over the back half of this financial year with the work it’s been doing on Referral to Treatment times. 

“It’s become apparent that some of the skills the NHS had in abundance in the late 1990s and early 2000s maybe aren’t there [any more]. But they do exist within our CSU, we’ve got a number of people who are highly experienced. As with provider management, it almost comes as a surprise that you’ve got skills that maybe aren’t as broadly held as you thought.”

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