Passing go

By Iona Joy 7 December 2012

So there we all were, sitting in the sunny uplands of opportunity during the morning session of CharityComms excellent health commissioning event.

Panels (including a representative of the NHS commissioning board) talked confidently about the value that charities can offer to the reformed NHS. All charities need to do is band together to form consortia, evidence their results, and network furiously with the new Clinical Commissioning Groups (CCGs). By the end of the session we had convinced ourselves that the voluntary sector’s ability to connect with patients, and understand their holistic needs, would be welcomed with open arms by beleaguered GPs longing to empty their surgeries of people with badly-managed long term chronic conditions.

The need for the NHS to move from expensive and not very effective episodic care (see NPC’s earlier event on the same subject) played to the voluntary sector’s strengths. We fantasised about revolutions in the culture of service commissioning and delivery to maximise patient satisfaction and outcomes, and increase efficiency. In our minds we redesigned services, closed redundant hospitals and reinvested in what really works.

And then in the afternoon we were brought back down to earth with a bump.

We’d all forgotten about the Commissioning Support Services/Units (no one can quite decide the title) (CSUs). Heard of them? No? Well look them up, because:

  • In the short term all the CCGs have to use the CSUs (and there will be 23 in England) to procure services
  • The CCGs will follow procurement law impeccably (ie, worrying as much about EU competition rules as what will genuinely benefit patients in, say, Staffordshire)
  • They will be populated by PCT staff, which has advantages in terms of experience but disadvantages in terms of baggage
  • They will get the staff—the CSU covering a quarter of London (12 CCGs) will have 600 staff. 600!
  • CSUs are also there to ‘advise’ CCGs on what to commission and procure (ie, busy GPs could well end up just handing the whole job to the CSUs)

The news electrified the room. Immediately everyone understood that not only would they have to get on side with the CCGs (they have the final say and may well set priorities and agenda), but they will also need to network with the CSUs. And how do you identify who to get close to when there could be 600 staff? At the conference there were queues round the block to get to know the chief executive of the London CSU post speech. Charities muttered to each other ‘so where is the real power?’ followed by ‘we’d better get our act together tomorrow’.

Then we moved onto Dragon’s Den. The CSU was on the panel. Three potential providers pitched. I’m not sure if what followed was theatrical or half-genuine.

  • Contestant no 1: Plan to move homeless people with multiple health problems out of A&E into a specialist facility that in a month will try and really fix their health problems, so they aren’t back in A&E the following week. 4,500 homeless people in A&E each year. Cost to NHS? £45m. Cost of new service, with better health outcomes? £30m. Net savings of £15m. Rejected by the dragons. Why? Because if you put people in a specialist unit you’ll still fill the acute beds. But I thought the idea is that you move the patients out to the specialist unit so that THEY DON’T COME BACK next week. For people who work in A&E I would have thought this would be sweet sweet music. So the message here is that we are saddled with existing structures (ie, buildings with beds) and it will be almost impossible to wrestle resources from them.
  • Contestant no 2: A free (yes free) toolkit to help commissioners map the needs of visually impaired people. Brilliant slide show demonstrating what its like with different types of impairment. Already road tested with strategic health authorities (oh and visually impaired people). A commissioner had earlier said that they are hungry for information so that they can do better needs assessments–surely a no brainer. Rejected. Why? Because it was just about blind people, and not lots of other people too. (At least I think I understood that right, but I could be wrong!)
  • Contestant no 3: Training for professionals to offer ‘brief interventions’ with hazardous drinkers—not alcoholics, just the ones that have a few units too many each week and cost the NHS millions later on thanks to liver damage, cancer etc. These ‘brief interventions’ (ie, a health professional talking to people about their drinking habits when they come in for other problems) are surprisingly effective—there’s plenty of evidence to show the reduction of consumption after such pep talks. Training is not costly, and economic analysis showed positive cost benefits. Rejected. Why? Because this proposal wasn’t part of an integrated package of services for all people with alcohol issues—ranging from serious addicts to us middle class middle aged boozers needing a bit of nudging towards responsible drinking.

So the messages seem to be: you will not pass go if:

  • You can’t really really spell out the cost savings, and not only prove that your health outcomes are better but also that you can basically close acute beds as a result of your work. Tricky—hospitals have high fixed costs so hospital managers tend to want to keep the volumes up to reduce the marginal costs…
  • You don’t understand what makes commissioners, including CSUs, tick. I don’t because I really didn’t get why they rejected the free toolkit.
  • You can’t present an integrated solution across wide patient groups—one-offs just don’t cut the mustard.

And when you tender, you really need to know how to do it. Find someone who knows all the tricks because the tender form will very likely be an exercise in scoring and you need to get your boxes ticked. I know. I failed a tender once (in consortium with most excellent partners) because we didn’t play the scoring system…

But before you tender, it’s well worth getting in with the CCGs. My reasoning is that if you can get the CCGs to specify what’s really needed that makes sense for charities hoping to add genuine value to the process, then hopefully CSUs might follow these sentiments. Ultimately, CCGs set the strategy!

Good luck everyone. May the (genuinely) best players win, not just those looking good during procurement processes.