By Richard Caulfield, Chief Executive, Voluntary Sector North West

On Monday last week, I attended a day looking at the potential opportunity for voluntary & community sector engagement with commissioning support organised by PCC, Macmillan, NHS England, Neurological Commissioning Support and ACEVO in London. It was a well attended and well facilitated day – but it asked more questions than it answered for me!

The overriding difficulty for me was that we all had slightly different views of what commissioning support is. This is not surprising as in many respects it is a relatively new concept – in other respects it is what many organisations have been doing for years but have never called it that.

I assumed that the focus was based upon the compact between ACEVO & NHS CSU Network, and the opportunity to explore the potential for building commercial opportunities between CSUs and voluntary sector organisations. This also built on my previous experience of exploring this agenda for VSNW and Regional Voices which led to the research ‘Towards Effective Commissioning’, when we tried to look at the concept of commissioning support at the start of the health reforms. Then, as now, we struggled to keep the conversation away from the role of VCS as a service deliverer.

I don’t think we really managed to answer the exam question on Monday despite some excellent debate – and some nuggets of good practice – and when it came to what could happen next, there was some difficulty in identifying practical activities.

Let me list some of the key issues that sprung to my mind during the discussions and the thinking behind them:

1)  There appear to be a continuum of VCS engagement in commissioning support
At one extreme, the VCS as a general supporter of the process. In Manchester there was a recent call for evidence for the JSNA to help develop some of the work streams. This is commissioning support, as is taking part in surveys and consultation exercises that may help commissioners make better decisions. Many in the sector will give time freely (capacity permitting) to do this as this may be what their cause is focused on. A big question then might become – if an area is redesigning their Stroke pathway for example, how involved should an organisation like the Stroke Association be for no charge and should it develop a paid offer alongside or instead?

In the middle is the VCS as a paid provider of a commissioning support service. For example, a CSU or CCG may approach someone like the Lesbian and Gay Foundation to help look at the needs of the lesbian and gay community during the redesign of sexual health services. They may pay for expert staff time, data analysis and even community engagement to ensure the services that are developed have maximum reach. This is where Neurological Commissioning Support and Turning Point appear to operate.  (Interestingly, on the dedicated commissioning support website, Turning Point are considered Independent Sector not Voluntary).

Indeed, much of the investment in CVSs and other voluntary sector infrastructure is essentially commissioning support as this involves supporting commissioners in navigating the sector, promoting new ways of delivery and co-ordinating and supporting the engagement of particularly smaller and local groups engagement in providing evidence to influence commissioning – from high level priority setting to service redesign.

At the other extreme, the VCS pay to be involved. This may not appear logical but it does show how powerful commissioning support can be when we get to service redesign. It has happened for some time with a number of big nationals, such as Macmillan, contributing significant amounts of money to help service redesign in areas such as Manchester and Staffordshire. It is by no means a new model and others have done similar things. They believe by helping the service redesign, they are directly improving the service that will be received by the patient group they focus on.

2) What is and what isn’t commissioning support?
We discussed an awful lot about patient and public engagement. In my view, this is a subset of commissioning support and the VCS can provide access to some of the communities that commissioners sometime struggle to engage with. Community engagement may be part of the offer but one would expect CCGs or CSUs to do a lot of this on a day to day basis and have strategies in place. However there may be room for an offer that is based on specific moments in service redesign that takes that engagement a step further and support a very targeted engagement.

So if a VCS group wants to sell commissioning support, it needs to be really clear on what the offer is and develop a package.  I think it has to be more than an offer to provide general community engagement and needs to be sophisticated in terms of data collation and analysis and more. It is unlikely that a community engagement offer in one geographic area is going to generate the sort of income necessary but nationals like Turning Point, as highlighted earlier, have developed a model at scale which they can sell to a range of commissioning bodies.

3) Data as an asset versus open data
Now if you have access to a load of data from delivering services, research or other means, do you lob that into the mix of discussion – or do you turn it into an asset you can sell?  This can create a moral dilemma as the collaborator, as the influencer in you may want to share and use the data to influence. However the ‘business manager’ in you may feel the need to generate income from it – after all, the sector is constantly being told to be more business-like.

4) Capacity of VCS, CCGs and CSUs
My current experience is that there is less and less space for thinking and working partnerships through as we all have real pressures on time and budgets. I don’t think a ‘saleable’ commissioning support offer is financially practical for most small local groups: local infrastructure may be able to help devise an offer but even then I think this is optimistic and may be best done as an extension of existing arrangements.

Certainly many CCGs will have little capacity to spend any more on commissioning support as many have little breathing room within the centrally dictated financial envelope. This means the best chance for the sector will either be CSUs or possibly Clinical Networks.

5) Market Immaturity
Part of the difficulty with 4) is that the market is still immature. CCGs are only just working out what they want from CSUs, now they have a few months under their belt. Also, CSUs are working out how viable their current service offers are and we are all trying to learn how we interface with Clinical Networks. There is going to be more turbulence in the system and people and organisations will disappear.  This in itself makes it difficult for the sector to develop the relationships necessary  to take the leap into developing products with and for partners.

6) Geography as a barrier
Getting a ‘local’ offer together will be difficult and require work by infrastructure organisations to produce something worthwhile if the smaller local groups are to engage in a big way. Unfortunately there are few infrastructure organisations who operate at the geography of CSUs or Clinical Networks. This not only means that services will be slow in developing but it also means that there will be a range of ‘navigators’ of the system that the NHS bodies will need to engage with to understand the sector.

7) Provider v influencer
There will be cries of ‘conflict of interest’ if those who support commissioning see the aim as creating services that they are ideally placed to provide. This can be a fair criticism but can also be overcome with transparent processes from all sides.  There is a challenge though as sometimes the conclusion of VCS engagement in the process may be to move services out of the sector. VCS involvement in commissioning support is NOT and should NOT be about increasing VCS role in provision of services – it must be about ensuring best services for patients and service users.

8) Grant provider
One of the key roles the sector can play – which is a commissioning support role – is both encouraging the use of grant programmes and either facilitating them or supporting the delivery of them. There are examples across the North West of the sector doing this in recent months – Macc in Manchester will be supporting the delivery of a grant programme for the three CCGs. As I said at the outset, there are some things we already do that is commissioning support – we just don’t badge it as such.

To go back to the start, whilst some of the sectors activity is commissioning support, I don’t think this is just about rebadging. There is an arena for exploring the potential business opportunity for some of the sector – and space to re-emphasise the importance of good engagement. Ultimately, ‘going for it’ with commissioning support requires great commitment: of time, money and resources. Neurological Commissioning Support has developed over a number of years and required (as I understand it) significant central NHS funding and investment of the partners own funds to help develop an effective model. Partners will need ongoing reassurance that this way of investing is the best way of improving services if investment is to continue.

I suspect, in the immediate future at least, commissioning support services (paid for) will generally be for the big condition specific organisations who have the scale and resource to take the risk and perhaps a few brave equality groups who can make the case/take the gamble – Turning Point perhaps being the exception. Operating effectively these larger organisations may engage with smaller local groups in their networks but commissioning support as I define it, providing a sellable service to the CSUs, CCGs, Clinical Networks and others will remain a minority sport for many in the sector.

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