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Commissioning support units —what pharmacists do there

Meet the dark horse of the NHS: the commissioning support unit (CSU). Little tends to be said about these organisations, borne out of the NHS reforms in England that went live in April 2013. Initially there were 23 CSUs, but their number has been falling and now sits at 17. In future, there is an expectation that there will be fewer of them, as smaller CSUs merge with larger ones to give them more financial security.

In simple terms, these organisations provide business support services to the newly formed clinical commissioning groups (CCGs), which buy health and care services in England. Individual CSUs can provide services to many CCGs, and this makes them influential players in the new NHS.

So how are they relevant to pharmacy?

Services for sale

It is estimated that around 15% of primary care pharmacists work in CSUs, according to the Primary Care Pharmacists Association. Among the services required by CCGs is advice on medicines management and medicines optimisation. Although many CCGs buy this expertise from CSUs, some use their in-house teams and others may go to private companies.

“One of the key challenges facing pharmacists working in CSUs is the ability to retain — and win — business,” says Andrew White, a pharmacist who is head of medicines management at the Greater Manchester CSU. This is one of the biggest CSUs in the country; it serves a population of 2.8 million people in the Greater Manchester area, which covers all 12 CCGs there, as well as six local authorities.

But CSUs also want to gain business from other commissioners and providers like councils, care homes and hospital trusts. Mr White says: “CCGs are our main customers, but we should not be constrained by that. We are a professional services company now, and pharmacists have the skills to help other parts of the CSU, like business intelligence, and help in developing health and treatment pathways.”

Ami Scott, commissioning pharmacist at Central Southern CSU, agrees that sustainability is an issue and says that her CSU has been training pharmacists on how to pitch for business from CCGs “to cost out what we do on a project-by-project basis”. Her CSU, which employs 10 pharmacists, is the second largest in England, servicing 14 CCGs in areas such as Berkshire, Swindon and Oxfordshire for a population of 3.7 million people.

“So the role of the primary [care] pharmacist has become more financially driven,” says Ian Small, head of medicines management at Anglia CSU. This is one of the smallest CSUs and is looking to be “hosted” by another in future. It has a service level agreement with five CCGs that covers 900,000 people in Norfolk and Waveney.

Mr Small says: “We have a challenge to make sure CCGs understand our role and for them to assure themselves [that our service] is money well spent. Serving five CCGs can be difficult as they may wish to have five different things from our team on the subject of medicines management.”

He adds: “We need to make sure it is business as usual, carrying on doing the roles we were doing before the NHS restructure.”

What are the key roles?

If it is business as usual, what then are the key responsibilities of pharmacists who have found themselves working in CSUs? They are still meeting the challenges of the “quality, innovation, productivity and prevention” (QIPP) agenda and building on the quality of services for patients with the same or smaller budget. They provide strategic clinical advice to CCGs, local authorities and NHS England’s local area teams on medicines optimisation — with a strong focus on cost-effective and quality prescribing. They may be reviewing individual funding requests, assessing the evidence of new drugs before National Institute for Health and Care Excellence guidance comes out, developing joint formularies, assisting CCGs to manage medicines budgets and commissioning services or supporting their redesign.

Mr Small believes that a difference from working in primary care trusts is that CSUs no longer have to deal with community pharmacy issues. “We are very much looking at the cost-effectiveness, quality and safety of prescribing,” he explains. “We are essentially going back to basics to ensure there is value for money. We have at the moment 18 QIPP projects to save money on drug spending and improve quality of prescribing.”

Mr White goes further: “All of this work is done with the patient in mind, ensuring we improve care for individuals, the population as a whole, and do this with best value possible.”

Fragmented or integrated?

In July of this year, the Royal Pharmaceutical Society held a focus group with primary care pharmacists to gain further insight into what was happening following the NHS reforms in England. Its report of the meeting concluded that “there is a level of uncertainty as to how these new organisations will commission [medicines management and medicine optimisation] services and who they will commission them from… . There is also a feeling that everyone is becoming more isolated and fragmented rather than more integrated.”

With primary care pharmacists now employed in CCGs, CSUs and the private sector, are there concerns about professional isolation and poorly connected services?

“There is the potential to fragment,” Mr White suggests, “but the commitment of those people in the system is assisting in preventing it from fragmenting.” He believes communication is key and clinical networks are the best way of ensuring the system is held intact.

His area has the Greater Manchester medicines management group, which pulls together the CCGs, CSU, local professional networks and providers, and has links to NHS England specialist commissioning teams, senates and clinical networks. In the reformed NHS “it is more difficult, but we are trying to make it work”, he adds.

Ms Scott believes that there is a risk that isolation could occur, but they are actively working to maintaining the relationships that existed before April 2013. “For instance, I meet with other commissioning pharmacists (the Southern prescribing group) every two months to share best practice ideas. Pharmacists come from Hampshire, Southampton, Portsmouth, Berkshire (east and west), Buckinghamshire and Oxford.”

Beyond pharmacy, she says that recognition of primary care pharmacist roles is good in her area and that her local health economy understands what medicines optimisation is about. “This is because we have worked hard to build a relationship with our clinicians both in secondary care and within the CCGs.”

Mr Small says: “I am optimistic that we are becoming more integrated but it depends on how you interact with CCGs — you need to be actively involved with [them]. We provide analysis and make prescribing safer, so we take away the burden from CCGs. As long as we are a respected body, medicines management teams will be viable.”

 Future of commissioning support units

Although the number of commissioning support units (CSUs) is falling, the pharmacists interviewed have indicated that their teams have been growing, although slightly. And it appears some of them work closely with the private sector.

Andrew White, of Greater Manchester CSU, says that there is competition between CSUs, but at the moment “we are obliged to collaborate in the interest of patients”.
Anglia CSU’s Ian Small acknowledges that there is also some competition from the private sector but, on the plus side, CCGs like working with CSUs since they have current experience of the issues. “If CCGs purchase services from elsewhere, they may not get the same local knowledge and history,” he points out. His CSU uses various private consultancies, but the medicines management team does not: “We do all the work ourselves.”

He turns to the matter of CSU viability: “I expect smaller CSUs will be hosted by medium- to large-sized CSUs in future. I think there may be five or six fewer CSUs by October 2014, the time our medicines management service level agreement runs out.”

Mr White agrees that not as many CSUs will exist in future “because of economies of scale and likely national policies. Their future depends on politics, but the roles they fulfil will need to be done by someone, regardless of their name, because of the limited resources we will have.”

His CSU is looking to work more closely with the private sector, including large multinational and niche independent consultancies, since they “have skills we don’t have and we have skills they don’t have”. It has made joint bids with one of the big consulting firms.

Elizabeth Sukkar is senior news and feature writer for The Pharmaceutical Journal

Citation: Clinical Pharmacist DOI: 10.1211/CP.2013.11129546

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