We are working through trying to understand exactly how commissioning support (CSS) will work with Clinical Commissioning Groups (CCGs). At a recent time out the lead manager for the CSS presented on the progress being made with Greater East Midlands CSS (GEM). They highlighted the scale of work that is required with the 277 tasks in the development plan. One of the Chief Operating Officers presented the programme of work required to see through the transition from a CCG. As they pointed out, this was a transition plan—for which the work required for authorisation is a component, not the be all and end all. There is as much to do to develop the CCGs as there is to develop the CSS—and they are mutually dependent.

The plans are all available on the software we use for our programme management. It is web based and accessible to those with permission to access it. The software links interdependent projects in the programmes of work. It is a rather neat feature. If a project gets delayed then all the dependent project timelines are automatically updated and extended. The downside is it is rather scary, as it makes very obvious that slippage in implementation is not an option if we are to get everything done by April 2013.

The biggest chicken and egg problem, however, is how much commissioning support will cost and what a CCG will be able to afford. CCGs are small organisations; in some cases they are likely to be able to afford about 20 staff. The rest of their budget will probably have to be invested in the CSS. The CCGs need to be about exploiting local professional and public engagement and leading rapid transformation. They are not PCTs. Yet the prevailing attitude seems to be “how are you going to do everything a PCT has done?” We had a debate about this and concluded that there is a polarity. The real question that needs answering is, in what way do CCGs need not to be PCTs and in what way do they need to be the same?

This generated a further discussion about the critical interdependence that will exist between the CSS and CCGs. A lot, if not all of the subject matter experts will be in the CSS but a CCG, buying their services, will need to be very clear about what it wants as it will be the accountable body—not the CSS. The CSS will need to deliver for its customers. It will want to build a reputation, relationships, and trust. To do that, if it is sensible, it will not want to take on everything and anything. This surfaced the real conundrum which is yet to be resolved.

It is this: if you have a system, like we do at present, that is 80% remunerated and 20% run on goodwill and you then cost it, then it shouldn’t be a shock to discover you can only afford 80% of what you had before. To get the other 20% is going to cost you.

Martin McShane qualified in 1981 from University College Hospital Medical School. He trained in surgery until 1990 then switched to general practice where he spent over a decade working in a semi-rural practice on the edge of Sheffield. In a fulfilling job, with a great lifestyle, he decided to give it all up and take on a fresh challenge. He entered NHS management, full time, in 2004 as a PCT chief executive after experience in fund holding and chairmanship of both a primary care group and subsequent professional executive committee. Since 2006 he has been director of strategic planning for NHS Lincolnshire, where there are 5,600 miles of road but less than 50 miles of dual carriageway.