There is a new breed of organisation spawned by the current round of NHS reforms: The Commissioning Support Unit (CSU). There were 23 of these bodies six months ago, but a series of mergers has seen that number whittled down to 18. They are run by managing directors with backgrounds ranging from physiotherapy and radiology to corporate law and accountancy. And they employ more than 8,000 staff predominately from former primary care trusts (PCTs).
While they will be ‘hosted’ by NHS England (formerly known as the NHS Commissioning Board) until 2016, they can’t rely on public money. Their sole source of income is generated by working for clients – predominantly from, but not limited to, the 211 clinical commissioning groups (CCGs) that are driving the government’s ‘clinical commissioning’ NHS reform programme. CSUs provide sophisticated advisory and procurement services to their clients, and if they fail to perform their customers will simply take their business elsewhere.
CCGs do not have to employ CSUs. The benefit, though, is that they cancommission across a wider area and bring about savings through economies of scale. As a result, the majority of CCGs are working in some degree with a CSU which offers some of the seven broad areas set out by NHS England – these cover business intelligence, procurement and market management, support for redesign, and communications and engagement.
Campden Health has interviewed 18 of CSU managing directors to produce a soft intelligence report creating a snapshot of commissioning support across the UK at the point when CCGs take responsibility for huge chunk of the NHS budget (1 April 2013). The MDs were asked the same questions via a face to face interview, a phone interview or, in the minority of cases, via email.
There are broad agreements on challenges and plans for the future but there are differences in offerings and vision. Most CSUs have set up a ‘matrix structure’ whereby the service teams intersect with the functional teams to promote sharing of knowledge and prevent silo working. The idea is that this will benefit a CCGs as they will be able to access certain expertise more readily. MD of South West CSU, Jan Hull, explained it as having “functional teams consisting of experts in their particular service areas and cutting across this [are] delivery teams consisting of experts from different specialist areas working together to deliver to the
customer”. However, a handful have employed alternative set-ups. North of England CSU, for example, has established a so-called ‘enterprise programme management office’ (EPMO) which takes a “helicopter view” of the organisation that will ensure sound project management is being followed. “It’s a different way of working, a bit like a consultancy, but people will need to get used to it if we are to price accurately and deploy resources sensibly in the future,” said MD Stephen Childs.
In terms of the interface between the CSU and their clients, there is more variation. Some CSUs have multiple points of contact: MD of South London CSU Nick Relph estimates that 70% of his staff are in contact with customers in some way, while others promote having just the one “go to” person. In Central Southern CSU, for example, which covers an area half the size of Wales, from Buckinghamshire across to Gloucester and down to Wiltshire MD John Wilderspin explains that each client has one “account manager who is responsible for customer care and every aspect of the service”.
Perhaps most pertinent to the long-term viability of the CSU model is that it’s already clear that some will need to diversify their client base beyond CCGs. Jan Hull is aware of this as her South West CSU has four CCGs customers, making it one of the smallest of the 18. It generates 70% of its budgeted turnover from CCGs and 30% from other business. If only one of their clients was to cancel their contracts, the CSU could immediately find itself in dire straits.
The biggest short-term challenges, though, are around recruitment. All MDs that would disclose it have vacancies ranging from 20 at Kent and Medway CSU to 120 in the North of England, although these figures are changing daily. Some CSUs are using private companies such as Attain to bolster numbers.
But even when/if they get the staff in place, there are issues around their working practices. MD of Arden CSU, Rachel Pearce, said: “The majority of staff are from a PCT background, keeping that customer focus and not being the lead commissioner is a journey our staff have to take.”
MD of Greater East Midlands, Professor John Parkes, added: “The majority of staff will still want to hold on to public sector values. We need to become commercial and how we do that in a way that takes account of those ideas and values intellectually is an interesting challenge.”
On the much discussed area of private sector involvement in the new NHS the MDs are in agreement that it is unlikely that there would be competition for ‘end-to- end’ services. Instead, companies will look to offer niche products via CSUs. Stephen Childs said: “When you provide a full complement of commissioning we know that some service lines can run at a loss. Why would a company come into that when they can cherry-pick the best bits?”
There is already in place a range of agreements with the big name consultancy firms and others making deliberate moves to make links with smaller local providers. In West Yorkshire, South Yorkshire and Bassetlaw CSU Ernst and Young has helped with service development and KPMG has worked on financial and commercial planning, while Global Black Swan helped with business development.
Birmingham CSU has partnered with Atos Healthcare which has helped with transition. While Attain has worked with North Yorkshire and the Humber CSU for the last 18 months as partners helping to develop commercial teams. And Greater East Midlands CSU has contracts with KPMG, McKinsey and PWC.
It’s a different story in Arden. MD Rachel Pearce, said: “We haven’t engaged with the private sector in a way some other CSUs have. I think that’s because we are smaller…. we have a strong in house team and have done a lot of the work ourselves.” It’s a view echoed by South CSU MD Keith Douglas. “We are not just looking at the big five consultancy firms. We are looking at sole traders and signing them up as individuals so we can call on them as individuals… This gives us a diversity of staff and skills,” he said.