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We live in interesting times in the NHS. From the Lansley reforms to the NHS’s £30 billion deficit to Simon Stevens’ Five Year Forward View, it is a fascinating period to be working in this sector. A particularly interesting area that has seen dramatic change in recent years is commissioning. The Health and Social Care Act introduced by the current government completely changed the way commissioning takes place in the NHS, with Commissioning Support Units coming into operation to support GPs, providing services, solutions and support that would free up their time so they could focus on improving outcomes for patients and healthcare for local communities.
Despite the dramatic change and challenges, huge progress has been made in the 18 months since the reforms came into effect and Commissioning Support Units are beginning to prove they can be a successful model. There have been some teething problems – for example, the number of CSUs has declined from 27 at inception to the nine that exist in England today. It’s also possible that this number will fall further, although it will be important that enough are retained to give customers sufficient choice.
But the successes far outweigh the challenges. The marketplace is viable and functioning well, and collaboration, innovation and efficiency are being put at the heart of the CSU model. An example of this came earlier in 2014 when a group of likeminded CSUs, including the North of England CSU which I lead, came together to form the Elis Group with the aim of working collaboratively to share best practice, benchmark, share expertise, and reduce development costs across a range of programme areas. The group now works with more than 90 Clinical Commissioning Groups (CCGs) and other NHS organisations, covering almost half the UK population.
While collaboration is championed, the Elis Group’s CSUs also compete against each other. This creates a dual dynamic of collaboration and competition that gives service providers – and even more importantly patients – the best deal possible.
The financial challenge
As the landscape has evolved over the past 18 months, the management resources available have continued to reduce and commissioners need to be even smarter with how they utilise resources for the benefit of their communities. It has been estimated that the spend on management resources is some 40 per cent lower than when Primary Care Trusts (PCTs) were at their ‘peak’ around five years ago – a saving of around £1 billion. But these financial pressures are far from disappearing. NHS England needs to find further 15 per cent management cost savings and CCGs 10-15 per cent by 2015/6.
Logic tells you that working in an increasingly constrained financial environment should enable smarter thinking and commissioning, and we are seeing evidence 18 months on from the inception of CCGs that this is the case.
CSUs were established to enable efficiency in two areas – management of the commissioning process, and management of the direct commissioning of health services themselves. Everything we do is focussed on being more efficient and effective – in particular through collaboration, spreading best practice and encouraging commissioners to work with outcomes front of mind when making key decisions.
At their best CSUs can bring scale, resilience, standardised processes and levels of efficiency to enable the new system to work effectively. Not just for CCGs but for NHS England too.
One recent example is the work we’ve done at North of England CSU (NECSU) around business intelligence. Prior to 2013 we had five PCT clusters in our region all either having established or in the process of establishing separate business intelligence tools. This meant the system of processing and collecting data across the primary and secondary care sectors was being replicated many times over at unnecessary cost. We quickly realised this did not make sense and by consolidating the best of the systems in development into a single business intelligence tool (RAIDR) we could share and exchange information more easily and at a significantly lower cost. So successful has this process been that not only is the system being used throughout the North East and Cumbria it has now been taken up by 43 CCGs from Suffolk to Yorkshire covering 20 per cent of the country.
We are very proud that a product developed by the NHS for the NHS is leading the market. The competition is intense and our aim is to keep RAIDR ahead of the pack and for that reason we continue to invest heavily in its development – £0.5 million this year alone in new dashboards for our customers.
Sharing best practice
Sharing best practice is at the heart of what we do. However, what might sound like a fairly simple concept is not without its challenges. The past few years has seen a number of initiatives from the Department of Health and NHS to foster a culture and climate of innovation and learning from others in the NHS. These include things like David Nicholson’s Innovation, Health and Wealth initiative and the NHS Innovation Challenge Prizes.
But more work still needs to be done to highlight the benefits of sharing of experiences and how learning from others can both prevent mistakes being repeated as well provide ideas for improvements that have already shown they work. Organisations should not be afraid to be open and transparent, to share and learn.
A key initiative of the Elis Group has been to establish a Knowledge Hub. This is a web‑based repository for best practice that can be accessed by all CSU customers. People are incentivised to use it in a number of ways, for example through their staff appraisal process. We work with CCGs to upload their case studies and experiences that can be built on by others in the field. There’s also a chat forum where people can post their good ideas and comments. It’s very much an iterative process and one that we hope will be opened up to a larger community in due course.
Competition is clearly vital to ensure a strong and vibrant marketplace – but so is collaboration. We are seeing more and more evidence of how collaborating with our peers makes the best sense for patients and customers alike. We have experienced this ourselves partnering successfully for projects such as waiting list validation and patient engagement contracts.
We are also actively encouraging collaboration to drive efficiency with a specific workstream in place to drive business development across CSUs. For example, the CSUs that comprise the Elis Group have collaborated to establish the Elis Framework.
This is a framework that gives CSUs and their customers faster, procurement compliant access to a range of small to medium sized enterprises, as well as some larger suppliers, when they need to access additional expertise or capacity – saving the NHS money and speeding up service delivery.
Driving thought leadership
We are also committed through the Elis Group to providing leadership in debating and solving some of the biggest issues around commissioning. We are planning to run a series of nationwide workshops that bring together leaders in primary care to address these issues, and ensure we maximise the collective intellectual experience and firepower that we have at our disposal.
We are also establishing the Elis Group Academy, an educational initiative that brings together the brightest and the best minds to drive forward excellence in commissioning support. This virtual learning programme will enable staff to achieve an accredited academic qualification targeted at commissioning support services. This will also allow staff to share best practice, ensuring high-quality commissioning is not delivered in silos.
As CSUs have evolved, we are steadily increasing the type of work we do to focus more on ‘transformational’ rather than ‘transactional’ work. As CCGs mature and grow in confidence we are seeing opportunities to work with them in more of a consultancy capacity. While ultimately commissioning decisions are in the hands of CCGs, we can play a valuable role in helping them identify where they can make the most significant improvements and where their investment will see the best return in improving the health of their communities.
Third sector partnerships are also a key feature of our approach. While CCGs have their own local relationships with third sector partners, through the Elis Group we are seeking to engage with more organisations with a national footprint. This includes liaising closely with the Association of Chief Executives of Voluntary Organisations (ACEVO). We are particularly interested in drawing on their ideas on service redesign, patient experience and information, as well as their expertise in engagement and consultation with local communities.
Some have cast doubt on the future of Commissioning Support Units. However, I hope this shows you the opposite is the case. Innovations like the Elis Framework are boosting efficiency. A fascinating mix of collaboration and competition is creating a thriving marketplace that is driving innovation, investment and improvement. Knowledge sharing is creating a system where best practice is championed, not forgotten. In short, the future is bright for CSUs with innovation, efficiency and collaboration at the heart of what we are doing and achieving.