Archive for the ‘Commissioning Support’ Category


Motion: ‘This house believes that promoting choice and competition between CSUs is the best way to secure effective commissioning support for CCGs’.

Opening statement for: The Centre

Based on the experience of PCTs we know that CCGs are too small to be able to provide the whole range of commissioning services in house at sufficient quality.  As a result CCGs should go through a process of deciding which services they will provide directly, which they will share with other CCGs and which they will buy from a CSU.

We (the centre) have spoken to CCGs and they have outlined three issues: concerns about the capability of CSUs; concerns about how the capability of CSUs is going to be raised; and that choice of commissioning support provider is important.  Fundamentally we believe that operational improvement will be accelerated by CCGs’ ability to manage an SLA effectively and to exercise choice.  As a result we are going to put on SLA workshops for CCGs, and create a procurement framework for CCGs to be able to exercise choice as easily as possible.

We want private companies to enter the commissioning support market.  We believe this will improve the quality of offering for CCGs.  So to do this we will ‘externalise’ CSUs from the NHS to create a level playing field and promote effective competition.

Opening statement against: CCGs

We (the CCGs) want capable, effective, responsive commissioning support.  We are frustrated where service delivery from CSUs is not at the level it needs to be.  We are concerned that it is not improving at the rate it needs to.  We want the option to change things if that is what is needed, but only as a last resort.  What we really want is high quality support.

We believe the centre is trying to solve the wrong problem.  We believe the problem is not how do we create an effective choice of CSU, but rather how do we make CSUs capable.  FESC (framework for external support for commissioning) did not work for PCTs, and we don’t think a similar framework for CCGs will work. 

Instead we want to focus on creating strong partnerships between CSUs and CCGs to make each individual service line effective.  We believe procurement frameworks and an over-emphasis on SLAs will make this harder not easier, by creating transactional rather than transformational relationships.  We believe the centre would have more impact by ensuring the leadership of CSUs is clearly focussed on partnering effectively with CCGs.

Closing Statement for: The Centre

We are concerned that CSUs are not developing quickly enough so we will limit the number of slots on the procurement framework to force CSUs to work together.  Whilst this might divert management time it will be worth it because it will ensure that CSUs focus on their strengths and ensure that only the best survive.

We are concerned that in practice CCGs are not exercising choice, but instead choosing to take services in house.  We believe this is a mistake.  We have therefore created guidance to make it more difficult for CCGs to do this, and we will reinforce the need for CCGs to follow a make, buy, share analysis to demonstrate the need for services to be provided by an external provider.

Closing Statement Against: the CCGs

We are concerned about the externalisation of CSUs.  We are worried that staff with whom we are beginning to develop relationships will leave.  We believe that operational stability is what is needed at this stage to enable CSUs to focus on the operational improvements that most are trying to put in place.  We don’t want CSUs distracted by developing mergers and alliances at the expense of making services on the ground effective.

We understand the benefits of delivering services at scale.  We weigh up regularly the potential of these benefits versus the disbenefits of services being provided by others who are not improving them at a rate we are comfortable with.  We want the option to say the risk of leaving it to others is too high and we need to manage these services ourselves.  We need this option because it is the performance of our organisations that is ultimately on the line.


The CCG challenge to the centre is to really listen to what CCGs are saying, rather than simply hearing the parts that fit with existing direction.  CCGs are on the whole committed to commissioning support.  But what CCGs want is a focus on CSU leadership, partnership with CCGs, and attention to operational improvement,  rather than choice, mergers and procurement.



The CCG Development Team at NHS England is working on a directory of development support for CCGs.  The idea is to connect up those who can provide support with CCGs to accelerate their development.

But what have we learnt as CCGs in our first 6 months about support?  What have we found even at this early stage about what works and what is less successful? 

I am sure it will be different for each CCG, but for me there are 3 lessons that I would say are already starting to emerge:

1. Start by understanding my problems.  CCGs are very different from any predecessor NHS organisation.  They are membership organisations with elected GPs and they all operate very differently.  As a result the development needs of each CCG are very different, and care needs to be taken to make sure they are understood properly.

I have found that the unique nature of the CCG means that support has only been successful when it has taken time to really understand the problems that are being tackled.  At its best, partners work with the CCG to carry out some form of diagnostic.  The results of the diagnostic are then used to design the intervention.  Which brings me to the second lesson…

2. Avoid ‘one size fits all’ solutions.  There have already been a number of examples where organisations have designed a service or a product or a course, which they are then keen to impose on CCGs.  Often these are available only on a specific day (and as a side note there is no point arranging sessions for Mondays or Fridays if you want GPs from CCGs to attend).  Worse is when CCGs are required to carry out certain actions, or free up so many people for so many days, in order to be able to access it. 

CCGs are not time rich organisations.  GPs, who are often new into leadership roles and the ones for whom development support is best initially targeted, work for only two or three sessions per week for the CCG.  So any investment in support needs to be built on an understanding of how the CCGs works, and be highly tailored to the specific needs of the organisation. 

3. Treat me as a partner, not as a customer.  As support organisations get used to the new world there has been a lot of talk of CCGs as the ‘customer’.  What this is resulting in is a focus on things like customer service and relationship managers, who seem to spend their time making sure that the CCGs are happy.

My view is that this has all gone too far.  Ultimately what is important is that whatever the CCG and their support provider are working on is successful.  If the CCG is not playing its part, then the support provider needs to let the CCG know. 

I think ‘partner’ is a better description than ‘customer’ in terms of what CCGs need at this stage.  CCGs have much to learn, and employ support to provide the necessary skills, expertise and challenge.  The relationship needs to be two way, with support providers being robust in their challenge to the CCG where it is required to ensure that agreed outcomes are delivered.

So in summary I would say that the learning so far is that great support is rooted in my world, is tailored to my needs, and is where the provider works with me in as challenging a way as is necessary to make sure that whatever we are trying to achieve is successful.


We are at a crossroads.  April 1st has passed, and now Clinical Commissioning Groups (CCGs) are free to procure commissioning support from whomever they choose.  But once it’s gone, it’s gone.

Many CCGs harbour a strong desire to bring commissioning support in house.  They are frustrated with the service they are receiving from their Commissioning Support Unit (CSU).  They believe they could do a much better job by either hosting services themselves or jointly with other CCGs.

It is undoubtedly true that there are problems with CSUs.  They are in the early stages of development.  They have had to manage a difficult transition of staff from PCT roles into service supplier roles, that many were not suited for.  They are having to learn how to function as they go.  The information capabilities are taking time to develop, and are often built on a weak inheritance of what existed before.  The national information governance issues are making progress in this area even slower and even more frustrating.

But here is the dilemma.  The ability of CCGs to partner with a large commissioning support provider is most likely a once only opportunity.  And it is right now.  Some PCTs tried to do it using FESC (remember that? For those who don’t it is the ‘Framework for External Support for Commissioning’).  Very expensive, very difficult to procure, even more difficult to make work. 

Nearly all CCGs on the other hand have started life in partnership with a large commissioning support provider.  It is relatively easy to break these partnerships.  But once they have been broken, it will be incredibly difficult (and expensive) to bring these partnerships back.  Once it’s gone, it’s gone.

In manufacturing the days of going it alone have long gone.  So writes Jill Jusko in an article in Industry Week entitled, ‘How to Build a Better Supplier Relationship’.  You can find it here .  Please read this article.  What is clear is that building these partnerships is difficult.  But the best companies, such as Toyota and Proctor and Gamble, have found ways of doing it.

The article provides the Institute for Supply Management’s definition of customer-supplier partnership, ’A commitment over an extended time to work together to the mutual benefit of both parties, sharing relevant information and the risks and rewards of the relationship. These relationships require a clear understanding of expectations, open communication and information exchange, mutual trust and a common direction for the future.

The main actions needed to make the partnership work, it would seem, belong as much to the customer as to the supplier.  Customers (in our case CCGs) need to listen to suppliers rather than think they are firms needing to be managed.  The CEO has to set the tone and be clear that the customer organisation (CCG) will work as hard to make the supplier successful as they expect the CSU to work to make the CCG successful.  Partnership is more than sharing information.  It involves joint decision making.  How many CCGs genuinely allow their CSU to be part of their decision making processes?

We need to be honest and recognise that as CCGs we are not yet fully mature organisations.  Hardly surprising, as we are less than 100 days old!  We have more to do to make the partnerships with CSUs successful.  It is going to take time.  Bob Ricketts, however, is set on a timescale of full procurement within 18 months. 

This is far too soon.  We need longer to make these partnerships work.  We need longer for CSUs to develop as effective suppliers.  We need longer to learn how to be an effective customer.  Giving up now is a big mistake.  It will be an opportunity lost that we will not get back.  If our ambition is to be as effective as we possibly can as commissioners, we at least need to give these relationships a chance of success.

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Commissioning support is not working. Something needs to change, or else not only will it fail, but it will drag CCGs down with it. In an uncertain world one thing is certain: it will not and cannot remain as it is now.

CCGs are, by and large, frustrated with their Commissioning Support Unit (CSU). While there are some pockets of satisfaction, it is fair to say most CCGs are planning to change their commissioning support arrangements at the earliest opportunity.

This dissatisfaction exists for a number of reasons. The costs of service are not transparent. They are not comparable within individual CSUs, let alone between CSUs. It is not uncommon for two different CCGs working with one CSU to be paying a totally different price for the same service.

And the issue is not just price. Those leading CSUs seem much more concerned with creating the future rather than fixing the present. CCGs are working hard to get on top of performance and are being thwarted rather than supported by their CSU. It very rarely feels like CSU colleagues are striving to ensure delivery; much more common is passing over problems to CCGs saying that they have done their ‘bit’.

CSUs for their part are frustrated with CCGs. The inability of CCGs to clearly articulate what they want, followed by sniping criticism of any service that is offered, is a recurring gripe from CSUs around the land. As an aside, a good CSU will make it their business to know what CCGs want better than they know themselves, but we have not yet reached this level of customer service from the newly formed CSUs.

So what does the future hold? The authorisation process has constrained CCGs. Few have fancied the challenges of getting in-house services accredited on top of everything else. Most read the runes that authorisation would be a clearer path for those who chose to use CSUs. That process is coming to an end (hopefully – there are worrying plans for ongoing assurance that are a topic for another day), and there are large numbers of CCGs who are just waiting for the opportunity to bring services in house.

I think this is a mistake. The mantra of ‘not becoming the PCT’ extends beyond clinical engagement. PCTs were hampered by the extent to which they had access to first class contracting support and business intelligence. Those CCGs that take these services in house are likely to make an improvement on where things are today, but the potential of where they will get to will be limited forever by the capacity at which they are able to operate.

The future lies in commissioning support providers that are not monopoly suppliers over a particular geography, but rather those that specialise in specific service lines in which they have expertise. The system has made a fundamental error in allowing the CSUs to be defined by geography rather than by service line. But it is one that CCGs can act quickly to rectify.

CCGs will not simply switch from one CSU to another. None are good at everything. They will procure the support they need on a service line by service line basis. At a stroke this will expand the potential market available to CCGs. Good HR and organisational development services can be provided by any large organisation with a strong in-house department. We may decide we want NHS expertise, but this still allows teaching hospitals and national organisations to bid for services that are tendered. Many organisations have strong procurement teams, and local government are a prime example of somewhere that has been doing this better than the NHS for years.

In future, and not the distant future, CCGs will have a range of commissioning support providers delivering high quality services at attractive prices. CSUs will survive only if they decide what they are good at and focus on being the best at it, rather than trying to do everything. To get there CCGs need to work together to ensure that it is ‘buyer power’ (for an article on this click here) that shapes the market, not the NHSCB.

It is up to CCGs to turn the CSU situation around, and to do it quickly. The only thing that will stop us is ourselves if we give up now and in-source everything.



How as a CCG do you know if you are getting what you need from your commissioning support provider?  Is it if you have agreed specifications and these are being met?  No.  Is it if strong relationships are in place between the leadership teams? No.  Ultimately it is because you are being successful as a CCG. 

This point is lost on most commissioning support leadership teams.  Their world is checkpoints and recruitment and managing the NHSCB.  They want service specifications finalised and agreed and to be able to demonstrate an operating surplus.  Most have no idea what the current performance of the CCGs they are supporting is. 

CCGs around the country are in different positions.  Some have few performance problems and are receiving a high quality offering from their commissioning support provider.  While there are probably one or two areas that need to be improved, on the whole the relationship is developing well and both sides are happy.

However, many CCGs are unhappy with the support they are currently receiving.  The commissioning support organisations are having to make significant changes to set themselves up effectively.  These organisations have become inwardly focussed on making the progress the need to get through the checkpoints.  As these CCGs go through their own authorisation process they are criticised because of the poor quality service they are receiving.  In authorisation terms this is picked up as, ‘failure to manage commissioning support effectively’.

The consequences of this are significant.  There are a number of CCGs that have already changed their commissioning support provider.  This has been determined by geography so far.  There are other CCGs who have determined to change their provider as soon as the opportunity arises.  In many places the relationships between the two are ‘difficult’ at best.

These negative cycles need to broken, and broken quickly.  The key to this is developing a partnership relationship between the two organisations, rather than one supplying (or not) a set of pre-determined inputs.  So how do CCGs create this shift in the relationship?  Below are three suggestions:

1. Set the expectation that the success of the relationship ultimately depends on the CCG being successful.  It is critical that CCGs choose partners whose priority is CCG success.  If a member of staff in a commissioning support provider cannot respond to an urgent CCG deadline because they are too busy developing the next checkpoint submission for the NHSCB, the relationship is not right.  Leaders of commissioning support organisations need to be clear that failure to prioritise the CCG needs will ultimately result in procurement of a commissioning support provider that will.

2. Put in place a mechanism for making the current CCG priorities visible.  There are different ways that this can be achieved.  A member of the commissioning support organisation can be invited onto the CCG director meeting.  Regular executive to executive meetings can be set up to share priorities and progress.  A relationship is needed that enables the commissioning support provider to input into the decision making, to identify how its own resource can best be mobilised, so that it can function effectively as a partner.

3. When there is a performance crisis, involve the commissioning support provider.  If a CCG has a big deadline to meet, or the finances go significantly off track, or performance dives in a certain area, there has to be an expectation that the commissioning support provider will contribute actively and directly to the resolution of that problem.  It is important that the CCG involves the commissioning support provider in the crisis discussion directly, rather than providing a list of actions that need to be completed.  Partnership is a two way process, and this starts with the behaviour of the CCG.

It is the responsibility of CCGs to change these relationships.  CCGs are the organisations that are accountable.  As over 200 different CCG to commissioning support provider relationships develop, it is critical that learning and good practice are shared.  If you have a developed a strong partnership relationship with your commissioning support provider or CCG we would love to hear from you, so that we can share your story with others.  Email us at



Take the first step, and your mind will mobilize all its forces to your aid. But the first essential is that you begin. Once the battle is started, all that is within and without you will come to your assistance. Robert Collier

There is a key deadline approaching of the 31st August.  That is the date when the Commissioning Support Services (CSS) need to submit their documents for their Checkpoint 3 submissions.  Are Clinical Commissioning Groups (CCGs) going to sign the SLAs by then?  CCGs are concerned with the overly legalistic approach to SLAs that many CSS have taken, and are reluctant to sign the proposed SLAs in their current form.  On the other hand, as with just about everything else, CCGs are being told that authorisation will ‘depend on’ having signed SLAs in place.

So should CCGs sign the SLAs? The obvious answer is only if they are happy with them.  Here are 5 things that CCGs should insist on:

  1. Clarity of CSS Vision.  As we have discussed before on this site, CSS are going to take time to deliver quality product.  This is because of the size and scale of the organisational development journey they need to go on.  Before any SLA is signed, CCGs need to be convinced that their commissioning support provider knows where they are going and has clear, deliverable milestones to get there.
  2. Notice Period.  There are rumours circling CCG-land that CSS are trying to insist upon 12 month notice periods.  6 month notice periods are the maximum that CCGs should be agreeing to at this stage.
  3. Outcome-based Key Performance Indicators.  There appear to be broadly to type of key performance indicators (KPIs) that are being suggested by CSS.  There are a group that appear to be about how the CSS will operate, e.g. quality of staff, speed of response, ease of contact etc.  These should not be pursued.  There is a second group that focus on the outcome of the work, e.g. timeliness, quality etc.  These are the KPIs that CCGs should use to form the basis of the specification.
  4. Value for Money.  One of the key reasons for developing at scale offerings is so that they can deliver efficiency and value for money.  Through agreements of SLAs CCGs need to be driving the efficiency requirement.  However, in the financial planning guidance for Checkpoint 3 CSS are told to include a 4% figure by the NHS Commissioning Board (NHSCB).  CCGs need to decide the amount for themselves, but should use the 4% figure as an absolute minimum.
  5. Client Satisfaction. CCG satisfaction with CSS clearly needs to form a key measure for the SLAs.  The most obvious suggestion for this is a regular (annual?) survey of all CCG staff.  The first survey will act as a baseline, and then improvements against baseline can be incorporated within the SLA.

This first round of SLA agreements with CSS is critical for CCGs.  If CCGs are weak in the negotiation process it sets a terrible precedent for the future.  CCGs need to establish themselves as the client, as those driving the SLAs, and as those with the final say as to what is included and what is not. 

The reality is that CSS need the SLAs signed quicker than CCGs do.  The requirements for their checkpoint 3 are that the SLAs are signed and submitted by 31st August.  Worse for them, in September there is then a CCG survey, followed by a meeting between the NHSCB and CCG leads as part of the process for checkpoint 3, to check on CSS ‘customer focus’. 

CCGs need to use this negotiating position to their advantage, and insist on SLAs that meet their requirements.  Going forward CCGs would do well to find ways of working effectively together, to agree standard contract clauses and a common efficiency requirement, in order to maximise their negotiating power.

At present CCGs seem to me to be keeping their heads down and are avoiding controversy ahead of authorisation.  The time has come for CCGs to start raise their voices, both collectively and individually, and step into the arena.  Failure to start to fight soon will mean that it could be lost before it is even begun.

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As the new world gets closer and closer, one fact is becoming abundantly clear: Commissioning Support Services (CSS) will not be very good.  While to some this is simply stating the obvious, there are CCGs persevering with their heads in the sand, glad that the services they have ‘outsourced’ are now someone else’s problem and one less thing to worry about.  But the reality is these problems are becoming bigger and bigger every day that they are ignored.

Don’t get me wrong, I am a big fan of the whole concept of CSS.  Some services, and in particular information, IT, business intelligence, back office finance and contracting, can clearly be provided more effectively at a larger scale.  Clinical Commissioning Groups (CCGs) are right to understand what services need to be delivered in house in order to realise the advantage that clinically led commissioning brings, and then to outsource those that others are better placed to provide.

But this whole concept is starting to collapse as reality bites, because provision at scale does not of itself realise any benefits.  The benefits are not automatic.  It is already clear that the new CSS are not going to be able to deliver these benefits in the near future.  Here is why:

1. The staff they have inherited.  Staff ‘assigned’ to CSS by and large do not want to be there.  They do not want to travel any further than they already do.  They do not want to leave the NHS.  Staff buy in to delivering the benefits of scale is not only absent, it is actively resisted.

2. The leaders are not in place.  It is not only the staff who do not want to be there.  According to this week’s Health Services Journal (28 June 2012 edition) there is a shortage of applicants for the CSS managing director posts.  Dame Barbara Hakin claims this is because ‘people’ have not realised how big the jobs are.  The counter views reported are that they are too risky with the prospect of losing business year on year as alternative providers develop, coupled with the need to pass the next checkpoint and so needing to risk taking up a post that may only exist for a few months.

3. CCGs are taking the best staff for themselves.  How do you think the average CCG decides which PCT staff and functions to take, and which to leave for the CSS?  They take the high performing staff and functions in house and leave the rest.  So even large CSS are left with a number of low performing departments, which through the magic of ‘economies of scale’ they are expected to make high performing overnight.

4. CSS do not know how to share.  The theory that if there is a great IT product in one area that it can be rapidly and effectively deployed in another area is compelling.  The reality is that the NHS is terrible at spreading innovations, and there is no reason to expect CSS to be any better.  Whilst it is true they are now one organisation, very few feel like that and geographic tribalism is alive and kicking across most CSS.

5. PCT staff do not know how to provide a service.  The staff that have been assigned to CSS have in the main never worked in a customer facing environment.  Many have been part of top down command and control structures that outgoing SHAs worked so hard to create.  The requirement for staff in, for example, IT departments, who over many years spent most of their time telling PCT colleagues why they could not help them, to now be able to start being able to help their new ‘customers’ is a much bigger stretch than most recognise.

6. Very few private sector partnerships are in place.  The one way through all of this may have been for these organisations to partner with a company that is customer facing, that is experienced at operating at scale, and that can rapidly disseminate innovations and good practice.  But as CSS remain stuck in NHS mud, not only are these partnerships not in place, the likelihood of them developing in the next few years also seems remote.

So how should CCGs respond?  I think there are two choices.  The first is the wide road, which is to take all of the services in house.  This could be on their own or in partnership with other CCGs, depending on their size.  This will probably deliver the best results in the short term, as it is safe, staff will know what they are doing and results are likely to be solid.  But it limits the delivery of these service to the best of that which has gone before.  Contracting (as an example) will only be as good as it was in PCTs, because it has nothing that can make it any better.

The second choice is the narrow road, which is to partner with the CSS.  It is to acknowledge all of the short term difficulties that the CSS faces, and to create a trusting partnership to create a vision of the future and to commit to working together to deliver it.  It is narrow because results will not be good in the short term.  But what it creates is the potential for results in the future that are significantly beyond those which are deliverable today, even by the best in class.

It is not going to be possible to deliver this partnership through highly specified service level agreements (SLAs).  While CSS need them for checkpoint 3 and CCGs need them for authorisation, the future requires both parties to not allow these documents to shape the relationship between the organisations.  CCGs need to invest time, effort and resources in working with the CSS to support them to get to where they need to be.  There is no point investing effort in beating CSS with SLAs that they are not able to deliver.  Adversarial, contract-based relationships will simply accelerate the demise of CSS.  It is the CCGs who need the CSS to be successful, and so it is CCGs that need to start taking seriously their responsibility to give them the support that they need.

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Clinical Commissioning Groups (CCGs) must find ways of developing ‘buyer power’ over Comissioning Support Services (CSS’s).  The seminal article on buyer and supplier power was written by Andrew Cox in the Journal of Supply Chain Management in Spring 2001, ‘Understanding Buyer and Supplier Power: A framework for procurement and supply chain competence’ (37, 2).  Every CCG leader must read this article!  He contests that the traditional model of organisations confirming their core competencies and concentrating on these; outsourcing to others competencies that are core to another firm (suppliers); concentrating resources on a limited number of suppliers; and improving supplier and supply chain performance through proactive supplier development activities is fundamentally flawed.  This is because all buyer and supplier relationships operate in an environment of relative buyer and supplier power.  Success in the traditional model is predicated on buyers’ dominance over their supply chain partners.

We see this at play in the supermarket industry.  Buyers such as Tesco are able to exert great leverage over their suppliers  because they have multiple suppliers for each product, because switching between suppliers is easy, and because they can determine the terms of business upon thier suppliers.  Supplier power exists in other industries such as the oil industry where suppliers work together, set prices collectively, and ensure they get the best deal from their buyers.

In 1776 Adam Smith in, ‘The Wealth of Nations’ argued that the best defence of a buyer’s interest was to ensure suppliers are forced to operate in highly contest markets, with perfect information for the buyer about the suppliers’ respective offerings.  Supplier power comes about when the number of suppliers is limited, or when there are ‘opaque supply markets’, where the buyer lacks the information or resources to leverage benefit over the selected supplier.

What does this mean for CCGs? Where will the power lie in relationship with CSS’s?  As it stands things do not look good.  There will be 20-30 CSS’s and 220-240 CCGs.  The CSS’s will all be hosted by the NHSCB, and therefore have the ability to share information effectively with each other.  CCGs will have no obvious mechanism of sharing information, or understanding the relative benefits of the variuos offerings of different CSS’s.

CCGs need to act now to ensure that the model that prevails is not one of supplier power.  There are 4 actions that all CCGs should be taking now:

1. Increase the number of suppliers.  Each CCG should work to ensure they have a number of different suppliers, and not limit supply to only the NHSCB hosted CSS’s.

2. Network and share experiences of CSS’s.  Buyer power will come to CCGs where they act as a collective not as 240 individual organisations.  CCGs are not in competition with each other.  Collaborative working between CCGs is critical to success.  CCGs need to find an online mechanism of sharing experiences of CSS’s with each other, that is rapid and leads to collective action.

3. Develop the ability to switch suppliers.  One of the key facets of buyer power is the ability to switch between suppliers.  Where a service is not good enough CCGs must switch suppliers and develop competence in switching suppliers.  If CCGs are stuck with a local monopoly CSS, then the suppliers will control the market.

4. Keep the build/buy decisions under review.  Cox argues that it may be necessary for organsiations to develop in-house competencies that it continually improves as a preferable situation to operating in an environment of supplier power, where there is no incentive for the suppliers to improve.  There may be functions that are not the core competence of CCGs today that may need to be developed in future.

For what it is worth, this website is committed to making Clinical Commissioning Groups successful.  We will do whatever we can to provide information about CSS’s and provide reviews and reports on them as they develop.  These next few months are critical in developing this new market, and we will be encouraging and supporting CCGs to work together and doing whatever we can to ensure that it is CCG power and not CSS power that drives commissioning in the new world.

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There is alot of noise in the press at the minute about Commissioning Support Services (CSS’s).  The NAPC/NHS Alliance have carried out a poll (that received a massive 95 responses!) whereby 80% said they were dissatisfied with the progress being made by CSS’s.  This is hardly surprising as they are brand new organisations, none of which have been properly formed, and the majority of which are still working out what size they should be.

The other message coming out from Roy Lilley and Charles Alessi (and others) is that CCGs will somehow end up working for CSS’s.  This is a very odd concept, and does seem to miss the point that CCGs will be the statutory bodies and that CSS’s will be the customers of CCGs.  That said, small CCGs that have to ‘buy’ the majority of their services from a monopoly CSS do have little option at present but to commission the way the CSS wants to commission (if the CSS won’t listen to them).  Of course this presents a peculiar conundrum: the majority of GPs are anti-competition in the NHS, but it is lack of competition in the CSS market (and therefore lack of ability of a CCG to move to a more customer focussed CSS) that makes the required customer focus less important to CSS’s.

So how should CCGs be managing commissioning support today?  I would suggest there are a number of ways:

Find a mechanism to exert buyer power.  The most obvious route for larger CCGs to do this is to deliver services in house, and threaten to increase the amount of in-house provision should service delivery by the CSS not improve.  Smaller CCGs should collaborate with larger CCGs and use the option of sharing in house provision with a larger CCG as a viable alternative to using the CSS.

Do not allow a monopoly CSS provider situation to develop.  Identify at least one service that you will actively procure from a different provider.  This could be something relatively small, but will send an important message to your main CSS that you are actively seeking alternative providers of higher quality.

Get CSS ‘skin in the game’.  One of the emerging issues is that CSS’s are not motivated by the same issues as CCGs.  For example CSS’s providing contracting support to a CCG have no real incentive to ensure that contracts are signed by the SHA Cluster deadline.  Where previously internal PCT performance was the ultimate marker of success for these services, now it is how much business the service can attract.  CCGs need to find ways of heading this issue off, and the main way is to find a way of making the success or otherwise of, for example, the contract negotiation as much a concern for the CSS as it is for the CCG.  This is likely to be based on the way that CCGs contract with CSS’s (for example payments are reduced to the CSS based on a sliding scale on the amount over a pre-agreed target contract value).

Decide the nature of the relationship you want with the CSS before you contract with them.  There is a temptation for CCGs to create very detailed SLA’s with CSS’s so that they can hold them effectively to account.  The issue with this is that the relationship can deteriorate into arguments about what is or is not in the SLA.  Ultimately the CCG will need the CSS to be flexible as requirements change in year.  At the same time CCGs will want to create an accountable relationship, with some contractual levers to fall back on.  It is important that CCGs establish a dialogue with their CSS and agree how they want the relationship to work, and then to ensure the contract with the CSS is developed to reflect this.

Recognise the point that CSS’s are at in their organisational development.  My sense is that it is too early to be writing any emergent CSS off.  CCGs will perform much more effectively if they are working with a highly effective CSS.  As such CCGs need to be directly involved in, supporting and directing the development of their potential CSS’s.  It is much easier to be shaping something into the way that you want it before it is fully formed rather than waiting until it is and trying to change it.  If there are only going to be 20 national providers there is not going to be much choice, and so supporting the 20 to be effective has to be a CCG priority.

All of this depends on a real understanding of the co-dependence that exists between CCGs and CSS’s.  Most leaders of both of these organisations pay lip service to this, but at present it is surprisingly rare for this to be being translated into joint work to shape the development of CSS’s.  If the system is going to maximise the potential that CSS’s undoubtedly bring, it is this that urgently needs to change.

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