Richard Vize explores the development of the commissioning support services and the wider implications for the health sector. Are cracks beginning to show?
Just weeks after the health reforms passed into law, serious cracks have emerged in the new system that could derail both the quality and financial stability of NHS services.
The NHS Commissioning Board has revealed that as a result of its "Checkpoint 2" tests for the viability of the plans for 25 regional commissioning support services, two have had to be abandoned: West Mercia and Peninsula (Devon and Cornwall). A further nine require "more rapid management" to stop them from failing.
The support services are often wrongly described as providing "administrative functions" for clinical commissioning groups. This does not begin to articulate the breadth of their work and their importance in determining whether the reforms succeed or fail.
They will lead change and service redesign, identify gaps in services, spot and manage risks, identify service providers, manage tendering, negotiate contracts and do much else besides.
Getting the support services off the ground would be difficult enough if they were just run of the mill public sector bodies. But they will eventually be "free standing", selling their services into the NHS. So the commissioning board has been charged with setting them up not only to help CCGs reform the health service but to then blossom into commercial, independent organisations. It takes a fertile imagination to see how a board steeped in a culture of central control can be an incubator for business start-ups.
Any weaknesses in the operation of the support services will be exposed in both service quality and financial stability. The turbulence in the NHS as real-term funding cuts collide with the reforms means there is a serious risk of a financial failure or a local deterioration in quality that goes unspotted or unchecked. The cuts alone increase this risk substantially; support organisations teetering on the brink of failure are unlikely to identify problems and work with providers to address them in time.
The Treasury has been worried about handing over £60bn of public money to new and unaccountable organisations. With the dire verdict of the NHS Commissioning Board on the state of the nascent commissioning support services they now have reason to be terrified.
No-one has ever claimed that GPs' skills lie in managing NHS finances – their strength is in understanding patient needs and clinical pathways. The support services are vital for effective financial control.
The commissioning board now has to fill the gap left by the abandoned services. The strategic health authorities are moving quickly, and neighbouring services whose preparations are going well could be asked to take over. While expansion has its advantages, changing boundaries and taking on new CCGs and populations will make the further development of their existing operation more complex.
The board also announced it has abandoned plans for a national communications and engagement service for CCGs. The service would have had the advantage of keeping costs down but looked suspiciously like a Ministry of Information for the board, which would have undermined the notion of a locally accountable NHS. Noises are still being made about a nationally co-ordinated communications service, but the hope must be that CCGs will now have more freedom to develop an approach to communications and engagement tailored to their own area – albeit made out of cheap cloth.
But even this is symptomatic of how desperately difficult it is for managers, GPs and the national board to stop the reforms from toppling over. Overlay the problems in support services with the setbacks and difficulties CCGs are experiencing as they struggle to establish themselves, and the wealth of management talent leaving the service, and you have a national picture of growing uncertainty and risk. Staff across the system are fighting to make it all work, but the chances of something going badly wrong are escalating.