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www.england.nhs.uk
Advice for CCGs reviewing whether to
make, share or buy their commissioning
support services
Principles and tools for MSB
Gateway Number: 02788
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About this advice
• This document offers key principles and tools which CCGs have found useful when reviewing whether to make, share or buy commissioning support services.
• It is supplementary to the core MSB guidance to CCGs published on 20th of November 2014
• http://www.england.nhs.uk/commissioning/ld-prov-frwrk/
• It also builds on the full MSB advice published on 13 November 2013
• http://www.england.nhs.uk/2013/11/13/ccg-mk-shr-buy-tool-kit/
• This advice is presented in three sections:
1. A recap of the existing advice
2. Additional tools CCGs have found useful when undertaking an MSB exercise
3. Advice and material to support consideration of strategic partnerships and relationships with other CCGs and CSS providers
• To access support or advice on undertaking a Make, Share or Buy process please contact [email protected]
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Section 1: Recap on the existing
MSB advice
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A four stage MSB process was recommended
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What are we seeking to achieve?
•At this stage the CCG should aim to review its organisational strategy, organisational development (OD) plan and existing commissioning support provision. This stage should also identify the resource that will run the MSB assessment and there should be assurance that organisational resources will be appropriately freed up to participate in the overall process.
What are our CSS needs?
•Review the existing commissioning support performance and using the local strategy and OD plan as a baseline for the MSB review; any MSB process should understand individual and joint needs with neighbours and partners.
•Needs and requirements may be benchmarked and compared to existing commissioning support arrangements. Working with neighbours is critical to agree how VFM, scale and quality might be achieved through collaboration. This phase should also highlight the key areas of focus for further MSB assessment.
What are the options?
•Options should be analysed with suppliers, partners and local CCGs. If significant change is planned a business case must be developed which meets the NHS England guideline standards.
What’s our decision?
•This stage involves finalising the decision with sign-off and agreement both internally and externally where required. If the change is not significant a simple notification of intent should be published.
In summary, the approach presented in the original advice was split into four stages
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Outputs:Stage 2: What
are our CSS
needs?
What are our
commissioning
support
requirements?
Engage
stakeholders
and review
existing
arrangements
Select areas
for more
detailed
analysis
Stage 4: What’s
the decision?
What is our
decision? Who
needs to agree
it?
Declare
intentions or
decision
Business case
for significant
change
Stage 1: What
are we seeking
to achieve?
Preparing to
review
Do we need
additional
support?
Taking stock
What
resources do
we have to
deliver this?
ImplementImplementation
plan
Stage 3: What
are the
options?
What CS
options are
available to
us?
Develop
Business Case
with options
analysis
What are our
priorities
Each stage was broken down into 3 sub-stages; detail can be found in the advice at:
http://www.england.nhs.uk/2013/11/13/ccg-mk-shr-buy-tool-kit/
Each stage had recommended sub-stages
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Section 2: Additional tools
useful when undertaking an MSB
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Additional tools and their uses
Additional tool What is it for?
1. MSB Excel Tool To methodically capture and review CCG progress through an MSB
process, and – through using a common format – to aid
benchmarking and discussions with neighbouring CCGs.
2. Needs Assessment To ensure that the CCG will be securing services that allow it to
deliver its five year plan and the NHS Forward View; and to check
that the running costs budget allocation across service lines is
aligned with achieving this.
3. Service Positioning To stimulate thinking about how service lines differ and how this
may affect the approach the CCG wishes to adopt.
4. Flow Chart To check the sequencing of decision making steps.
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Tool 1: The MSB Excel Tool
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NHS England has developed a MSB tool in excel which supports documenting:
Existing commissioning support provision
Future commissioning support intentions
When SLAs are due to be competed, and when major change is going to take place, supporting project planning
Using a set format to support benchmarking with other CCGs
Evidence to use in audit exercises.
The tool can be accessed via the NHS England website:
http://www.england.nhs.uk/resources/resources-for-ccgs/
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Tool 2: Needs Assessment
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• Detailed information on completing a needs assessment can be found in the MSB advice published in the recent MSB Guide http://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2014/11/lpf-summary-msb-updated-guide.pdf
• CCGs are expected to be able to demonstrate that their commissioning support plans will allow them to be successful commissioners, as highlighted in the core MSB guidance issued in November 2014.
• Every CCG has the fundamental need for commissioning support that enables it to be a successful commissioner: achieving its clinical and financial goals, delivering its five year plan and the NHS Forward View.
• Undertaking a formal needs assessment will help the CCG to articulate the support it needs under each service line to be successful (see standard service line taxonomy on next page). It is the first step in undertaking a MSB decision making process.
• Starting from its experience of support services to date – how much it pays and what quality it receives – the CCG will want to assess the extent that this current quality and price offer must change under each service line.
• Running costs budgets are limited and the transformation challenge is very significant. The more spent on “transactional” services, the less available for “transformational” services –working with neighbours will allow more to be achieved with these limited budgets.
• The needs assessment should consider how needs will evolve over time: providers (bought in or in-house) will need the stability of multi-year arrangements to deliver excellent affordable service.
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Tool 2: Needs Assessment – the LPF taxonomy
supports benchmarking and co-operation• Planned annual expenditure on each service line must be sufficient to ensure that
the CCG has the capability to deliver its five year plan and the NHS Forward View.
• Close co-operation with other customers is likely to be key to achieving this within
the limited running costs budget.
Transformation and Service
Redesign
Research and analysis
Strategy and planning
System and commissioning
transformation
Pathway optimisation, revision
and redesign
Business Support Services
Financial management and
accounting
Payroll
HR services and
organisational development
Information Communication
Technology (ICT)
Corporate governance and
risk management
Healthcare Procurement and
Provider Management
Healthcare procurement
Market development
Contract requirement,
definition and negotiation
Provider and contract
management
Lot 2 A
Medicines management
and optimisation
Lot 1 – End to End Commissioning Support Lot 2 – Specialist Decision Support
Business Intelligence
Business Intelligence and applications Business analytics
Communications and PPE
Proactive communications Patients in control
Reactive communications Patient and public participation at strategic and
operational level
Lot 2 B
Individual Funding
Request (IFR) case
management
Continuing healthcare
and funded nursing care
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Tool 3: Service Positioning
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• Almost all CCGs currently have a mix of in-house and bought-in commissioning support: a very small number of CCGs wholly buy-in, or wholly supply in-house, their commissioning support.
• When undertaking an MSB, CCGs may wish to change this mix between in-house and bought-in services – or indeed use the flexibility of the Lead Provider Framework to buy different services from different providers.
• CCGs have found it helpful to use the tool of service positioning when thinking through whether it would be right to take different MSB decisions for different service lines.
• Service positioning is done by creating a number of service segments (categories) and then rigorously assessing which segment the service fits into.
• The benefit is derived:
o In defining the segments – exploring/confirming the key considerations for the CCG; and
o In allocating service lines to segments – challenging the CCG’s assumptions about if it truly understands the supply options.
• Choosing a segment is often an iterative process depending on how requirements develop. Some service lines may also be split to distinguish between transactional and transformational components e.g. transactional IM&T vs. digital transformation.
• If done well, the matrix should result in the CCG being able to articulate more clearly why it is taking a different approach to different service lines.
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Strategic
Positioning a service here does
not necessarily mean Make. Buy
is an attractive option provided it is
within a strategic relationship
Leverage
Potential for aggregation at a
cluster, regional or national level
Essential
A key consideration is the level of
direct control required.
Collaborative Buy may give critical
mass
Non-Critical
Critical mass can be achieved
from Buy, within a suite of
services, or Collaborative Buy
Low High
Expenditure
High
Business
Impact
Low
Tool 3: Service Positioning –
example of segments
Criteria CCGs may wish to use in undertaking such service segmentation include:
• Whether neighbouring customers are willing to co-operate in securing the service lines
• The CCG senior team’s confidence in ensuring the high performance of in-house or bought-in supplier service delivery
• The need for major change of – or investment in – services
• The perceived strength of offers that will be made by external or in-house providers
• Statutory/regulatory requirements that must be met
• The extent to which operational complexity will be increased by delivering service lines independently as opposed to bundling
them together as an end-to-end service
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2. Has an MSB
process been
completed?
3. Refer to
MSB advice
6 .Populate
MSB
Assessment
Tool
7.Submit to
lead CCG or
MSB Co-
ordinator
Yes
No
4.Complete
MSB
assessment
1. Read
updated MSB
advice and
supporting
documents
8. Joint
Intentions
Workshop
9. Governing
body sign off
11. Planning
for MSB
(procurement,
build)
implementation
Stranded costs
policy
Business case
for in-housingLPF Guides
Other policy
updates
10.In housing
submission
5. Service
Improvement
options
Below is an extended MSB process developed through MSB in action with a cohort of CCGs. It is a process other CCGs may find useful in working through their MSB decision making.
Tool 4: Flow Chart
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Section 3:
Considering how to work with
other customers and providers
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• CCG engagement has identified the benefits of working together in the market; it
provides economies of scale, more efficient use of resources and lower risk transition.
Effective collaboration requires commitment: the higher the level of commitment and
scale, the higher the level of potential benefit.
• There are two step-changes in commitment: moving from no involvement to formal
communication; and in moving from participation in projects to agreeing a lead
organisation (joint working and accountability) model.
• In the CCG community it is evident that most have made the first step-change and are
now in communication with others; and that some are on the verge of making the
second step-change to act more coherently in the market.
• This coherence creates scale and increased benefits but requires higher levels of
commitment. We recommend that CCGs take a view of where they are and what could
be achieved through greater levels of collaboration either across an area group or a
sub-group.
Customer Collaboration
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Customer Collaboration
NoInvolvement
CCGs not involved with
collective procurement
Independent CCGs, others informed of
progress and outcome
Consultation
Lead from each CCG,
others consulted at key stages
Bench-marking
?
CCGs compare prices, specs, service levels
etc
Participation
CCGs take part in projects
providing team members
Some CCGs involved, others
informed of progress
CommunicationLead
Organis-ations
CCGs lead on behalf of the whole group
Joint strategy and
governance
Consortium
= step changein commitment
Degrees of Collaboration
No Involvement Involvement
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• Strategic partnerships with suppliers are crucial to high levels of performance in those services core to the CCG’s success as a commissioner. Such partnerships are only strong if both organisations share a willingness to invest in the relationship
• Not all support services need a strategic relationship: an arm’s length relationship can be the most effective way of managing low value services which are peripheral to the CCG’s effectiveness as a commissioner.
• The degrees of customer-provider relationship may be described as:
o Traditional contractual – minimal interaction as long as performance in maintained
o Preferred supplier – where services are ad hoc and alternatives are available
o Contracted supplier – where continuity of supply is required
o Strategic alliance – where there are opportunities for joint service development
o Strategic partnership – a long-term relationship involving cost and benefit sharing, performance improvement activity, and innovation with shared objectives
• The Make Share Buy decision should take customer-provider relationship into account – confirming that the right relationship could be established to enable the success of the decision.
Supplier relationships
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Supplier relationships
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The customer-provider relationship must be attuned to the levels of service and performance required. Whilst the
nature of the service is important in this decision so is the willingness to invest in the relationship. The degree of
willingness indicates the type of relationship achievable.
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Potential advantages and disadvantages of decisions (1)
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Decision type Potential benefits Potential concerns
Independent Buy ▶ Paid-for procurement support available from NHS England when using the LPF
▶ Allows commissioners to focus on a transformational agenda▶ Using the LPF allows opportunity for volume based discounts▶ Provides choice and flexibility of services ▶ Means external objective expertise is used▶ Capacity can be procured as and when needed; can support depth of
talent▶ Can lead to reduced costs and increased competition, supports choice▶ Allows for re-use of supplier knowledge for key areas such as the five
year forward view, new models of care and digital transformation
▶ Dependence on provider▶ Risk of losing knowledge and learning ▶ There may be some risk associated with the
procurement ▶ May need internal contract management skills to
get the most out of CSS suppliers
Shared Buy (Joint
Procurement)
▶ Paid-for procurement support available from NHS England when using the LPF
▶ Allows commissioners to focus on a transformational agenda▶ Economies of scale become more feasible for suppliers offering volume
based discounts. ▶ Using the LPF allows opportunity for volume based discounts▶ Joint investment – creating wider integration and joint working▶ Means external objective expertise is used▶ Common issues and requirements reducing resources requirements▶ Greater ability to influence the supply market▶ Base for broader collaboration▶ Capacity can be procured as and when needed; can support depth of
talent▶ Can lead to reduced costs and increased competition, supports choice▶ Increased opportunity for partnerships and innovation ▶ Allows for re-use of supplier knowledge for key areas such as the five
year forward view, new models of care and digital transformation▶ Contract management skills can be shared between organisations
▶ Dependence on provider▶ Risk of losing knowledge and learning ▶ There may be some risk associated with the
procurement ▶ Some challenges in partnership working, perceived
threat to independence▶ Managing suppliers could become more complex
as a group. ▶ Issues with compliance between CCGs▶ Needs strong relationship management and joint
working
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Potential advantages and disadvantages of decisions (2)
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Decision type Potential benefits Potential concerns
Independent Make ▶ Some commissioners may prefer the level of control that they have internally
▶ Independence from third party suppliers▶ Use of internal capacity and capability, control over talent
management ▶ Ease and responsiveness of internal decision making ▶ Potential for integration with commissioning functions, and ability
to change quickly how the service is delivered.
▶ Responsibility for stranded costs when moving services in house
▶ Supplier volume based discounts not an option▶ The need to focus on service delivery and
breadth of management focus may distract from transformational change
▶ Reduced access to leading expertise▶ Reduced influence on market▶ Potential for becoming outmoded quickly▶ Dependence on key staff members▶ Capacity and flexibility constraints▶ Keeping up with implementation in key areas
such as the five year forward view, new models of care and digital transformation, where supplier can create scale and reuse knowledge
Collaborative
Make (Shared
Service)
▶ Joint investment – creating wider integration and joint working▶ Cost benefits from aggregation▶ Supply and demand smoothing▶ Market making – may also grow through increasing number of
partnerships▶ Provider influencing – can have an impact on providers offers and
VFM
▶ Responsibility for stranded costs when moving services in house
▶ Supplier volume based discounts not an option▶ Perceived threat to independence▶ Cost of set-up or transition and change▶ Keeping up with implementation in key areas
such as the five year forward view, new models of care and digital transformation, where supplier can create scale and reuse knowledge
▶ Capacity and flexibility constraints▶ Needs strong relationship management and
joint working
