In 2012, when the Coalition government passed its Health and Social Care Act (HSC Act), it promised that much of the decision-making for the planning and buying (or commissioning) of NHS services would be transferred to Clinical Commissioning Groups (CCGs), led by GPs who, we were told, were the people who knew best about their patients’ needs. As David Cameron put it,
“The whole point of our NHS reforms is to put the power in the hands of local doctors so that they make decisions based on what is good for their local area”.
So, along with at least two thirds of the NHS budget, CCGs were given responsibility for planning and buying health services, and new legal obligations to ensure both NHS and private service providers were able to bid for contracts to provide these.
However, clinical commissioning is a complex activity requiring, for example, legal knowledge, expertise in running contracts and on-going monitoring of contracts, as well as back office support such as IT, human resources and financial services. Most GPs don’t have the time or skills to carry out all the work of commissioning. So, while CCGs will retain legal accountability for this work, many of the functions of commissioning have already been taken over by Commissioning Support Units (CSUs).
Previously, this kind of back-room work was carried out by NHS Primary Care Trusts (PCTs). When the HSC Act (2012) abolished these, there was no mention of CSUs: they seem to have appeared as an afterthought. One of the differences between CSUs and PCTs is that CSUs have to be able to exist in a competitive market place. Another is that, as CSUs evolve, they increasingly allow the involvement of private firms in the commissioning process itself, and are able to decide, for example, which services will still be provided, who will provide them – and even what NHS England calls the ‘transformation and service redesign’ of the NHS.
Originally 17 in number but condensed over time to seven, CSUs were initially NHS bodies set up under the wing of the NHS Commissioning Board (now NHS England), but due to be made autonomous bodies outside of the NHS by 2016. They would then have to compete for work.
It was initially thought that, once autonomous, CSUs would be privatised. For example, in 2011 the Director of Commissioning Support at NHS England said that there was no reason why private companies offering support services (such as Capita, Serco and Atos) could not work in partnership or compete with CSUs. There were even talks about the private sector (e.g. private equity groups) buying up all 19 CSUs (as there were then).
However, direct privatisation of CSUs has recently been ruled out by NHS England, largely because it was thought this development would not be supported by CCGs. Instead, it was suggested that CSUs would either become social enterprises, ‘staff mutuals’, customer controlled social enterprises or joint ventures. (http://www.england.nhs.uk/wp-content/uploads/2014/02/item4-board-0114.pdf).
For some of the issues raised by the use of social enterprises or staff-owned mutuals in the NHS, see https://www.opendemocracy.net/ournhs/caroline-molloy/we-all-already-own-nhs-latest-mutual-spin-is-about-taking-it-out-of-our-hands.
In a new development in early 2015 it was announced that, instead of a system of CSUs competing for work from CCGs, a ‘framework’ of preferred providers was to be drawn up (to be called the Commissioning Support Lead Provider Framework) that would be used by GPs and hospitals to buy services. (http://www.england.nhs.uk/lpf/wp-content/uploads/sites/27/2015/04/lpf-suply-chains.pdf). Preferred providers include CSUs along with private companies: the list, confirmed in early May 2015, is dominated by Capita Business Services, and Optum (part of US health insurer United Health, the previous employer of NHS England’s CEO, Simon Stevens), as well as management consultancies like McKinsey and Price Waterhouse Cooper. (For more details of the companies involved, see http://www.spinwatch.org/index.php/issues/lobbying/item/5769-nhs-the-foxes-have-control.
NHS England has encouraged CCGs to use the Framework to procure commissioning support services when their existing contracts expire – most run out in April 2016 and have to be openly tendered before then. However, by November 2015, only a quarter of CCGs have began the process of re-tendering for a new support provider and in response, NHS England has extended the deadline while issuing a warning that failure to comply will possibly lead to legal action and associated costs.
According to the Director of Commissioning Support Strategy at NHS England, the aim behind the Framework is to strengthen the ability of NHS commissioners so that they have the support they need to buy and improve healthcare facilities. Others see the move as expanding the scope of private firms to the point that they will be allowed to provide services previously delivered by the NHS, while costing taxpayers more. They also fear conflicts of interest as a number of private firms involved – now able to take charge of local NHS budgets – will also be competing to provide the healthcare that those budgets pay for.
Companies included in the framework are in line to win around £5 billion’s worth of work advising CCGs on matters such as contracting, finances, drug purchasing, patient care reforms (whatever these are), handling of NHS patient care data, and consultancy on organisational change, as well as outsourcing services to private sector providers. A spokesperson for KPMG UK –part of a multination corporation offering audit, tax and consultancy services – described the initiative as “a groundbreaking move that will create a market in procurement and all forms of commissioning support for the first time” http://www.ft.com/cms/s/0/4493a3e2-ae03-11e4-8188-00144feab7de.html#axzz3VbWEbnB6.
Some commentators have noted that, strangely, this kind of framework reduces competition (the very thing that we are told will spur greater efficiency and higher quality services), not by ending privatisation but by handing out huge ‘bundled’, long-term service contracts, with complex and hidden sub-contracting, while giving the impression of partnership between private companies, the NHS and charities. https://opendemocracy.net/ournhs/caroline-molloy/100-hours-to-save-nhslabour%27s-manifesto-analysed
In a further development, despite the concern of GPs, NHS England is both cutting funding to primary care support services (which manage GP payments and patient records) by 40% and putting the service out to tender. The deal could be worth £1 billion over 10 years. Bidders for the contract are thought to include G4S and Serco, despite these companies being under investigation by the Serious Fraud Office for previously overcharging on public service contracts (http://www.gponline.com/gps-voice-concerns-outsourcing-primary-care-support/article/1326752).