Archive for February, 2012


When I talk to managers and staff across the NHS, the question that I am most surprised to be asked is why I am so passionate about clinical leadership, and exactly why I think it is important for GPs to be commissioners.  I am surprised because the literature is unequivocal about the pivotal importance of clinical leadership.  But the reality is that many working in the NHS believe clinical leaders create more problems than they solve.

Taiichi Ohno (1912-1990) is widely regarded to be the father of the Toyota Production System, popularised as Lean Manufacturing.  He believed that managers could not manage if they did not understand the work place.  He was famous for drawing circles in the middle of the shop floor, and instructing managers to stand in them for days on end to observe what was going on and to understand the impact their instructions were having.

The complexity of healthcare makes it difficult for a single ‘workplace’ to be identified where managers can view the impact of their decisions, because patients have their own journeys that cannot be reduced to individual interventions.  Clinicians working within the system can however experience the impact of the decisions they are making.  NHS managers will never be able to truly appreciate the impact of their actions in the way that clinicians can.

Don Berwick, paediatrician and former President of the Institute for Healthcare Improvement and advisor to Barack Obama on health, asserted that the central premise of the health change debate was that only those who provide care (referring to clinical staff) can change it.  In the current financial climate it is even more important that those who understand the system make decisions about it.  The NHS Leadership website states, ‘Effective clinical leadership is critical if we are to achieve an NHS that genuinely has the quality of care at its heart’.  McKinsey have written an article, ‘When Clinicians Lead’, and state that, ‘Leadership must substantially come from doctors and other clinicians.  Clinicians not only make the front line decisions that determine the quality and efficiency of care but also have the technical knowledge to help make sound strategic choices about longer-term patterns of service delivery.’.

GPs were largely uninvolved in PCT led commissioning.  Practice based commissioning did not give GPs real budgets or real accountability.  That all sat with managers at the PCT.  Commissioning decisions are critical.  They determine where precious, limited NHS funding is allocated.  They set the strategy.  They determine which redesign projects are worth investing in and which are not.  GPs are uniquely placed to make these decisions.  They understand the needs of the patients they see on a daily basis.  They are often leaders within their local communities.  They experience through their patients the impact of changes to the health system.  There is no one better placed to lead commissioning.  There is no one more able to put patient needs at the heart of commissioning decisions.  It is not just important that GPs lead commissioning, it is essential.

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Any organisation in the NHS needs an organisation that is prepared to fight their corner nationally.  Doctors have royal colleges and the BMA, NHS managers have the NHS Confederation, and while all are not equally effective, at least they have a voice.  In the midst of the turbulence surrounding the passage and implementation of the Health Bill, it is critical that someone represents CCGs.

But who have we got?  Clare Gerada and the RCGP oppose the bill, and are doing very little to help CCGs with the challenges they face today.  Laurence Buckman and the GPC are committed (understandably) to protecting GP practices, and so regularly come out with guidance for practices similar to the one earlier this year urging practices not to sign any CCG governance agreements.  The NHS Alliance and NAPC coalition should be the organisation providing the voice.  Unfortunately the replacement of the solid Johnny Marshall with the more outspoken Charles Alessi, working alongside the maverick Michael Dixon, means there is not a strong credible clinical leader at the head of the organisation.  They have let CCGs down in their recent 111 paper by not rallying CCGs to resist the proposals collectively until the funding for NHS Direct follows.   The NHS Confederation has done nothing to support CCGs so far, and has its heart with acute hospitals and their managers.

This lack of a national voice comes at the worst possible time.  We are now right at the heart of the move of responsibilities to CCGs, at a time when most are still fledgling, vulnerable organisations.  Examples of where a national voice is required include:

  • Ensuring the recruitment/appointment process of Accountable Officers/Chairs/Chief Finance Officers is not set up in a way that simply moves PCT Cluster executives into these roles, regardless of the wishes of the membership
  • Ensuring the CCG management allowance is protected.  We are still to see clarity on how it will be calculated (e.g. weighted populations), what it will cover (this week CCG buildings have been added to what it needs to pay for).  Many CCGs still have not been given the information as to what their current costs are, and are being prevented from making explicit decisions as to how to use it.
  • Input into the authorisation process, specifically who is doing it and what the consequences of success or otherwise are.  Failure to influence this effectively could result in most CCGs operating within a straitjacket from day one.
  • Establishing the CCG budgets, and influencing what is transferred from historic PCT budgets to CCGs, public health, the NHS Commissioning Board and others.  There is a real risk that CCGs will get what is left rather that what they need.  There is no clarity today at to where historic reserves sit next year, and many PCT Clusters will sit on these reserves, accuse the CCGs of failing and use the reserves to balance the position.

There are many other live current examples.  We need a national voice urgently, and it is not obvious where it is going to come from.  Should CCGs be acting together to set up something new? Should we be lobbying the NHS Alliance/NAPC Coalition to change their leadership team so that they can be effective?  I would love to hear your view – email me at .

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The DH document ‘Baseline Spending Estimates for the new NHS and Public Health Commissioning Architecture’ singlehandedly has the power to derail the progress made by CCGs to date.  The document can be found here:

The key point of this document is that CCG allocations are based on 2010/11 expenditure.  While the rationale for this is clear (i.e. that introducing variation in funding by moving to a capitation based allowance would have a highly destabilising impact on providers), this rationale is now new.  It is no truer today than it was last year, when Barbara Hakin clearly stated that CCG budgets would be based on some form of weighted capitation formula.

So what is the big deal?  The issue is that any CCG worth its salt has been trying to create GP ownership of budgets.  Over the course of this year GP practices, localities and CCGs have been developing a growing understanding of their budgets, and generated plans to bring these under control.  Aspirant CCGs have built on the progress made through practice based commissioning to move to ‘fair share’ budgets.  Using all the indications from the centre, plans for next year have been based on capitation based budgets.  Now, less than 2 months before the start of the financial year, when CCGs should be nearing the completion of their financial plans, this process have been thrown into disarray.  CCGs and localities that thought they have significant gaps find they do not, and those that thought their budget was under control suddenly face a huge challenge.

The heart of the move to GP commissioning, that was always the failure of practice based commissioning, is GP ownership of and accountability for their budget.  It is impossible for CCGs to develop effective systems of accountability for GP management of their budgets, when the goalposts keep shifting.  GPs can rightly ask how they are expected to manage a budget that keeps moving so significantly year on year.  GPs can also rightly ask why they are expected to manage a budget that is not ‘fair’, i.e. one set on the basis of historical patterns of expenditure, rather than based on the needs of the population they serve.

This new DH document makes it twice as hard for CCGs to generate real practice ownership of their budgets, to the point where they genuinely feel accountable for them.  It represents two steps back against the real progress that GP commissioning has made this year.  CCGs need to stand together and fight for fair share budgets, regardless of whether they ‘win’ or ‘lose’ through the allocation process.  Without accountability for budgets  at practice level, the real benefits of CCGs will never be delivered.

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A big issue for CCGs is how to create enough effective challenge on the Governing Body.  GPs are designed into the fabric of the organisation, and it is easy for GP group think to dominate how the decisions are made.  This is not acceptable or desirable for a whole host of reasons, and so the question is where will this challenge come from?

In most NHS statutory bodies this challenge comes from non-executive directors.  There are a majority of non-executive directors over executive Directors.  On a CCG Governing Body this is highly unlikely to be the case.  The Chair does not have to be but is likely to be a GP.  As member organisations each member GP practice has to be represented in some way, and I know of very few CCGs where this representation is not carried out by GPs.  So there will be a significant number of GPs on the Governing Body.  There will be a manager as Accountable Officer or senior manager supporting the accountable officer (often currently referred to as Chief Operating Officer), a Chief Finance Officer, and in larger CCGs other management Executive Directors.

This leaves four key roles that are prescribed that have a critical role in relation to challenge.  These are the lay member with a lead role for governance, the lay member with lead role for championing public and patient involvement, the doctor who is a secondary care specialist, and the registered nurse.  These four individually and collectively have a critical role in relation to ensuring the Governing Body provides effective challenge.  The temptation for the doctor and nurse to sit in a cosy clinically supportive relationship with the GPs is high, but for CCGs to be successful it is critical that they do not design themselves in this way.  These four need to operate as an effective and forceful unit within the Governing Body, purposefully and consistently challenging to drive the overall quality of decision making.

However, the responsibility for challenge cannot sit with these four alone.  Some CCGs are tackling this by increasing the number of either traditional non-executive style directors or patient and public representatives.  Alternatively, GPs representing member practices need to challenge each other, and develop their Governing Body as a forum where this can happen effectively.  To be effective CCGs cannot be GP ‘clubs’ where a favour for one is rewarded by a favour for another.  In addition Executive Directors need to be prepared to challenge both the GPs and each other, in a way that is infrequently seen on many NHS Boards.

CCG Governing Bodies need to be structures that foster and positively encourage real challenge within themselves, so that the decisions made are not only clinically led, but honed through the furnace of proper scrutiny.  Getting this right now is likely to be critical when it comes to authorisation.

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