Make, buy or ally? Commissioning support in the new NHS


Unless you work in a Clinical Commissioning Group (CCG) or obsessively follow the medical press, it is quite likely that you have never heard of a Commissioning Support Unit (CSU), but when you go to the doctor or attend a hospital appointment there is a high chance that someone from a CSU somewhere will have played a role in the care you receive. From ensuring that GPs receive the payments they are entitled to, to negotiating contracts with hospitals, and from gathering data about care quality to providing IT support to practices, CSUs are an important part of the new architecture of the NHS. Set up following the enactment of the Health and Social Care Act in 2012, CSUs were originally intended to be ‘standalone’ organisations, ‘spun off’ into the private or third sector and competing to provide high quality commissioning support services to CCGs.  The intention behind the policy was to build upon the tentative moves which had been made during the 2000s to broaden the range of support available to commissioners, bringing in experts from the private and third sectors as external consultants for Primary Care Trusts. So-called ‘FESC’ (Framework for External Support for Commissioning) providers offered PCTs niche services such as service redesign, data analysis or support for Practice-based Commissioners.  Building on this experience, CCGs were established as managerially lean, bringing to the foreground clinical expertise and expected to ‘buy in’ the more technical expertise required to commission effectively. Experienced commissioning staff from PCTs who did not immediately take up roles in CCGs were transferred to a Commissioning Support Service, and these were established as Commissioning Support Units hosted by NHS England once the HSCA came into force.  Their short life has been somewhat turbulent, with the Health Service Journal regularly reporting mergers, crises and concerns. The pace of ‘outsourcing’ from the NHS has been slowed, with acknowledgement that we are some way from a ‘mature’ market in such services .

Against this background, it is important to start to explore how this new model of commissioning is playing out in practice. Whilst the stated objective of widening the base of expertise that commissioners can use to help them do their job as effectively as possible seems unobjectionable, the reality is not necessarily quite so straightforward. Our recent CCG research published in BMJ Open  explored the early stages of this transition, using contracting theory to try to understand how CCGs were approaching the decisions they needed to make: should they ‘make’, ‘buy’ or ‘ally’? We found that some CCGs were reluctant to outsource commissioning support, fearing that they would lose local knowledge and trusted local relationships. CSUs are large organisations (following recent mergers, there are only 19 in England) and CCG staff told us that they were concerned that CSU staff wouldn’t understand their local service needs. Others were disappointed by the absence of real choice, and saw CSUs as a re-creation of PCTs. Many expressed doubts that outsourcing commissioning support would reduce costs, and expressed an intention to build longer term relationships with trusted partners in order to minimise transaction costs. How all this plays out in the longer term is a matter of conjecture; what seems clear, however, is that the original vision of CCGs buying support from a range of independent providers is some way from realisation.

Kath Checkland is a Reader in Health Policy and Primary Care. She leads the Health Policy, Politics and Organisations group (HiPPO) in the Centre for Primary Care, University of Manchester.

Disclaimer: this research was funded by the Department of Health. The views are those of the authors.

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