The Health and Social Care Act 2012 removed the responsibility for providing the NHS from the Secretary of State for Health. Commissioning of services was handed over to a new QUANGO, NHS England (NHSE). This is now the Commissioner in Chief alongside 200+ smaller commissioning groups (CCGS) across the country. CCGs buy in services from various semi-public, private and voluntary sector providers (Any Qualified Provider), who are badged as NHS by NHS Identity, the trademarking division of the NHS.
As the CCGs are not capable of running large, complex tendering exercises, Commissioning Support Units (CSUs), pre-approved by NHSE, are used to manage commissioning for a variety of other services. Notably amongst the top companies approved by NHSE is Optum, the UK subsidiary of UnitedHealth of America.
Our thanks to Adrian Mercer for contributing this blog. We previously re-blogged Adrian’s work here.
NHS Commissioning Support Units: the public sector beyond scrutiny
Commissioning Support Units (CSUs) are impenetrable organisations, offering little information to the outside world about how they operate, their purpose or their decision-making processes. Few commentators have paid much attention to the role of CSUs or their role in developing the private sector within the NHS (notable exception here from Spinwatch).
They were established in 2013 and have a combined revenue of over £500m pa. Their purpose is to provide advice and back-office functions to Clinical Commissioning Groups (CCGs) including contracting, recruitment, procurement, and outsourcing.
The NHS England Provider Framework (2015) has accredited only six regional NHS CSUs:
- NHS North of England CSU
- NHS South East CSU (which subsequently merged with NHS North and East London CSU in April 2017)
- NHS Greater East Midlands and Arden CSU
- NHS Midlands and Lancashire CSU
- NHS South, Central, and West CSU
In addition, three private consortia are accredited to provide support services to the NHS:
- Optum (United Health Group, with KPMG and BT)
- eMBED (a consortium of Mouchel, an outsourcing specialist; BDO, a financial services and tax specialist firm; Engine, a brand consultancy agency; and Dr Foster, owned by Telstra).
NHS CSUs are important because of their size – they employed 9000 staff in 2013/14; and because of their financial clout within the NHS. Together with their private counterparts in 2015 they had an income of over £523m, £402m of which came from the commissioning budgets of CCGs.
NHS Commissioning Support Unit Income 2015/16.
|CSU||CCG INCOME, £m||TOTAL INCOME, £m|
|Midlands & Lancashire||67.95||78.07|
|North East London||75.22||89.94|
|Greater East Midlands & Arden||66.10||104.00|
|North of England||49.14||65.52|
|South West & Central||76.43||92.48|
This information was provided by NHS England in July 2018, in response to FOI requests submitted in April 2017, after being directed to do so by the Information Commissioner Office.
The wider significance of CSUs lies in the role they play as the key channel through which the private sector is inserted, out-of-sight and without public scrutiny, into the NHS.
Detailed information about CSUs is difficult to find – as my experience with FOI requests attests. Documents available on the web serve primarily as advertising. They do not to appear to produce annual reports or detailed financial accounts. Their structures are exclusively executive, lacking a non-executive overview, transparency or accountability that we expect of public bodies.
With such a dearth of public information what can we infer from the information about CSUs that is available? Previous investigation of NHS CSUs has described them as essentially shell organisations which act as a front for the private companies behind them. This is illustrated by this diagram from 2015.
Since 2015, the role of CSUs in contracting with the private sector has potentially expanded greatly following the 2018 publication of the Health Systems Support Framework. The framework accredited approximately 100 different private companies to provide services to CSUs (and to CCGs). The companies include the usual suspects – Optum, the big 4 consultancies and McKinsey and smaller specialist firms.
Despite numerous requests, financial data provided by CSUs fails to quantify the value of individual contracts between these companies and the CSUs on a consistent basis. But what is clear from trawling through the spreadsheets is that the contracts provided to the private sector runs into several million pounds.
It is fashionable to dismiss privatisation is still a live threat to the NHS. The behaviour of CSUs and what we do know about their role in awarding contracts to the private sector should act as a warning that the threat to public service ownership and provision may come not from the outside, but from within wearing an NHS badge.