Archive for May, 2012


It is mandatory for a Clinical Commissioning Group (CCG) to have a secondary care specialist on its Governing Body.  Following the pause and Future Forum report there was initial outrage expressed by CCGs that this individual had to be from out of area to ensure there was no conflict of interest.  A few CCGs claimed they could make it work and manage conflicts of interest with a local clinician.  They couldn’t.  It quickly became apparent that, for example, the Quality Committee could not be chaired by the local clinician because half the agenda was about his/her Trust.

And now it has all gone quiet.  My suspicion is that there are a whole raft of governance issues waiting to rear their heads through the authorisation process, and this is one of them.  CCGs should not have a secondary care specialist on their Governing Body because they have to.  They should have one because one of the major governance risks they face is so-called ‘groupthink’ from the GPs on the Board.  The secondary care specialist has a critical role in providing the clinically based challenge that the governance and PPI lay members are not going to be able to provide. They can also play a pivotal role in helping the organisation to challenge the behaviour of the local acute trust, but this is secondary to the provision of clinical challenge to the necessarily primary care dominated mindset of the CCG.

So the worst possible individual a CCG could find for this role is a consultant who is friends with one or more of the GPs on the Governing Body, who agree to come as a favour.  A cosy relationship like this will not provide the challenge the CCG needs for it to be effective.  A plea to all CCGs is to ignore the phrase in the publication ‘Clinical Commissioning Group Governing Body Members: Role outlines, attributes and skills’ which states, ‘Whilst the individual may no longer practice medicine, they will need to demonstrate they still have a relevant understanding of care in the secondary setting’.  This implies that CCGs are likely to be targeting local consultants who have retired.  Most CCGs insist that their GP leaders must still practice in order to stay in touch with issues of front line general practice and maintain credibility with the GP membership.  The same has to be true for the secondary care specialist.

So how can CCGs find an effective, credible secondary care specialist for their Governing Body?  One mechanism is for the CCG to form a partnership with one (or potentially more) acute trust that it commissions less than the stated 15% of work from, but that is close enough for regular travel to the CCG to be feasible.  There are three reasons why such a partnership will be attractive to an acute trust:

  1. Development of Medical Leaders.  This provides a fantastic opportunity for an aspiring Medical Director to gain board level experience.  The CCG can offer an extensive induction into the role and a training and development package (it will need to be doing this for its own new GP Governing Body members anyway).
  2. Learn how CCGs work.  If CCGs target trusts where there is a similar CCG configuration locally, e.g. if the CCG is large it will target an acute trust whose local CCG is also large, then the individual can learn how CCGs operate, what their agenda is, what funding is available nationally, how CCGs should be operating with acute trusts, all of which is valuable information for the host acute trust. 
  3. Cross fertilisation of ideas.  Health economies tackle broadly similar issues, such as how to cope with rising demand and an ageing population.  The secondary care specialist on a CCG Governing Body will be able to review plans and their effectiveness, and where they work have ready-made solutions to implement back at base.

There is no reason why the recruitment process cannot be run in a single organisation.  The CCG can identify the trust that it wants to recruit its secondary care specialist from and run a recruitment campaign just in that organisation.  They will need to specify and advertise the role, stress the personal development opportunity, agree the remuneration with the trust (probably better to agree a set number of pa’s per month and for the trust to recharge the CCG), and run both an informal process to provide more information about the role and a formal interview process.  Even better if an agreement can be reached with the local Medical Director that they will encourage suitable candidates to apply.

The Secondary Care Specialist role is not a token role on the Governing Body.  It is a critical role, which requires a specific type of individual who is not afraid to provide challenge, but who can be constructive and strengthen the plans of the organisation.  CCGs need to be creative in how they go about finding the right person, because it is highly unlikely that open recruitment processes run locally are going to unearth the talent that is required.

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As I approached the building in Victoria at 8.30 on a sunny morning it was hard to know what to expect.  I had completed the online assessments, and these had served only to build my apprehension.  Conscious that it was an assessment process I had worked hard at providing examples that I thought demonstrated the high marks I was giving myself.  It was slightly disconcerting to be told on submission of the questionnaire that many marks for myself were unusually high.  ‘Are you sure these marks are correct?  These would only normally be found in an exceptional candidate.  Please review the list to ensure you are happy with the grades you have given yourself’, came the automated comment from the on-line tool.  Self-doubt crept in, ‘Do you really think that you are exceptional?  How do you think the assessors will view that?’.  I marked one of the scores down, from ‘exceptional’ to ‘really, really good’ (or something similar).  The same automated message came up again.  I decided to proceed anyway.

The maths and verbal reasoning tests had been most difficult, purely because they were timed.  It was not so much that the questions were complex, but the pressure of the ticking clock that was hard to bear.  I had set myself up when no one else was in, got my calculator ready, and had done a few times tables in my head to get the right mental juices flowing.  I used to be good at these sorts of things I told myself, but the nagging doubt that my mental capacity had been eroded by years of good living kept chipping away.  I decided to put it off until the next day.  And the next.  Then the emails from Hay Group started coming reminding me that I needed to have my assessments complete.  Eventually I took the plunge and gave it my best.

I had been told that the way it worked was that if you get a question wrong the next one is easier, and that this continues until you get one right.  Also that the reverse is true, so after the first two questions I was dismayed to get a question that an 8 year old could answer.  Why had I decided to do the maths test first?  I should have got used to it with the verbal reasoning and then done the maths.  I started to imagine the ignominy of receiving a development plan with maths lessons as the central part.

My fellow inmates had already arrived and were nervously drinking coffee.  It reminded me of the time I had been in the queue for a bungee jump.  Some were talking to relieve the tension, some were engrossed in their smartphone, and one lady looked genuinely petrified.  This was somehow reassuring, as I had half been expecting everyone else to be fully in control and just irritated by the time out they were having to take.

The message we had received was that we had to arrive by 8.30 for a prompt 9am start, and that we would be finished by 4. At ten to nine a lady who looked about 25 ushered us in to a small room, and instructed us to sit where the paper that said our name was situated.  All it needed was a raffle ticket with a number to be stuck on and it would have been like sitting A-levels again.  Then an equal number of assessors strode into the room, and largely stood around the outside.  Their introduction went along the lines of, ‘my name is Bill and I will be assessing Ted today’ (cue knowing look at Ted, and nervous smile from Ted to Bill).  It was like having your own personal prison guard.  It transpired the day would consist of a two and a half hour interview, a meeting with a Health and Wellbeing Board Chair, a meeting with a GP, and writing a letter to Healthwatch.  Someone had told me over coffee that they had heard they brought actors in, and the 25 year old confirmed this to be true.  ‘Any questions?’ she asked.  A GP, who had clearly had enough of the day already, demanded to know how his maths test was in any way an assessment of his ability to be an Accountable Officer.  Sensing his aggression, the 25 year old played it down and said it was just one part of assessing the overall skill package.  She said if anyone felt they hadn’t been able to do their best in any of the assessments they should let her know.  I sensed a queue forming…

My interrogator was a clearly a wolf in sheep’s clothing.  She was being so nice that I knew it had to be a trap.  The whole conversation was highly enjoyable (we kept talking about me!), to the point where if I talked about what ‘we’ (my team) had done, she insisted I talked about me and what ‘I’ had done.  However, my suspicions remained that the notes she was writing were simply confirmation of the high opinion I had demonstrated I had of myself in the on-line questionnaire.

I was expecting to receive feedback based on the responses from my 360 degree survey.  I had begged colleagues to avoid writing ‘developmental’ comments, and promised to be nicer as a boss/colleague/member of staff in future.  I think they had appreciated my slightly desperate tone and a number had said they had ‘been nice’ to me in the assessment, in a semi-condescending way but I think they meant well.  Worryingly no one mentioned the automated message about ratings that were too high.  Anyway it transpired that no feedback was to be given on the day.  Rather this would all be included in the overall feedback to be received after the event.

The encounters with the actors were disconcerting.  I expected them to make my life difficult and play out a really testing situation.  What happened was that they were much more compliant and prepared to change their minds than in any real life scenario!  The most difficult part was probably at the end when the assessor (who was sat watching and furiously scribbling while the scenario was played out) asked me what I had been trying to do (‘survive’) and the actor what they had been feeling (?).

So the ‘homework’ I had done on my potential responsibilities as accountable officer, reading the NHS Constitution and learning about things such as the Public Sector Equality Duty, all proved largely irrelevant (although I did manage to work parts of this into my interview on principle!).  Apparently we find out on line how we did 4 working days after the assessment, with personal feedback and then separate feedback for us to take to our local assessment.  There is allegedly no pass or fail, but our development plan will make clear whether we are ‘ready now’ or will be ‘ready after some development’.  I can’t help feeling that the former would be preferable.

As I left the building my overriding sense was one of relief: relief that it was over and that I hadn’t made any major mistakes. The 25 year old had insisted that the day was about giving us the opportunity to show the best of ourselves, and while the contrived nature of the experience meant that was impossible, at least it wasn’t designed to catch us out.  I still suspect that the NHS Commissioning Board is ultimately going to want a big say in the appointments of the Accountable Officers, so it will be interesting to see how this plays out through the local processes and into authorisation, and the extent to which they use the ‘development plans’ as sticks to beat proposed candidates with in the future.



The BMA has published new guidance on Clinical Commissioning Group Constitutions. You can find it here

Whilst I am sure the intention of this is for it to be helpful, what it does is call into question the role of the LMC, now that Clinical Commissioning Groups are in place.  On p2 it states, ‘LMCs, as statutory representatives of their profession, should work with their CCGs to ensure that the local profession is consulted in the development of their CCG’.

But CCGs (like LMCs) are membership organisations consisting of member GP practices.  Indeed they are (or soon will be) statutory bodies (unlike LMCs). So what is the role of the LMC?  Historically its primary role has been to negotiate an effective contract for general practice.  But the CCG will not contract with practices, so the need for a statutory representative in the context of the relationship between the practices and the CCG is highly questionable.

The constitution is therefore being used as the contract that LMCs have a role in protecting practices from.  Hence the statement, ‘Before signing up to their CCG constitution or any interpractice agreement issued by the CCG, GP practices should ensure that: (i) The constitution makes a commitment for the CCG to engage with the Local Medical Committee (LMC), as local statutory representatives of the profession;’.  The clear message to general practice is: we are your representatives and CCGs are not.

But CCGs must represent the views of their practices.  It would be fatal for any CCG to let the LMC take this role away from them.  CCGs will harness their commissioning power only through direct, engaged interaction with each of its member practices.  Carrying this out through a third party (e.g. agreeing a constitution with the LMC on behalf of all practices) creates a barrier between the CCG leadership and the member practices, that once established will not only be difficult to dismantle, but will also stifle the ability of the CCG to be ultimately effective.

CCGs are their member practices.  If a gap is created between the CCG and the practices, then it reverts to something very similar to a PCT.  This works for LMCs, because it recreates the very clear role they had as protectors of General Practice against PCTs that did not have GP membership and did contract with primary care.  But it does not work for either CCGs or for general practice.

Indeed if anything it will be harmful for general practice.  CCGs want to invest in general practice, so that services can be redesigned and moved out of hospital.  At present their ability to do this is limited, because primary care as it is currently configured is at full capacity.  Transformation of primary care is required, so that it can operate the new models of care that are required going forward.

So here is the crunch.  Who is going to lead the transformation of primary care? There are only two contenders: CCGs or LMCs.  Ultimately it has the best chance of success if the two are working together.  What it requires is strong leadership.  According to Dwight D. Eisenhower, ‘Leadership is the art of getting someone else to do something you want done because he wants to do it’.  Practices need to want to change.  LMCs cannot take up a role of protecting the status quo.  To do so is to do general practice a disservice.

The push back from the BMA or LMCs will be that CCGs will want to do things that not all member practices are happy with.  This issue lies at the heart of any democracy.  How far should elected GP members of CCGs go along with popular choices?  Is the role of the CCG GP leader to go along with what the majority of GPs want?  Should CCGs have a vote for every GP on every major issue?  The reality is that the role of a leader, even an elected leader, is to do what is right for those they are leading, irrespective of the popularity of those decisions.  Look at Greece.  They are not going to get out of the situation they are in without strong leadership.

In periods where there is no leadership, society stands still.  Progress occurs when courageous, skilful leaders seize the opportunity to change things for the better.’ Harry Truman.

General practice has not had leadership for many years.  As a result is has not progressed.  There is a choice that is real for general practice right now: remain the same and watch things get progressively worse year on year for the next ten years; or change now and seize the opportunity to truly create a primary care led NHS.  If LMCs do have a role then surely it is supporting their CCG leaders to make this change.  If they take on this role they will be a tremendous help to CCGs, but if they follow their lead from the BMA they will prove a hindrance.

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An empowered organisation is one in which individuals have the knowledge, skill, desire and opportunity to personally succeed in a way that leads to collective organisational success.’ Stephen Covey

There are three relationships that lie at the heart of a Clinical Commissioning Group (CCG): those with its employees, those with the member practices, and those with its public and patients.  Chip Conley in his book, ‘Peak:  How Great Companies get their Mojo from Maslow’ describes the practical application of Maslow’s hierarchy of needs to modern businesses.  He argues, based on his own experience as a successful entrepreneur, that businesses must invest in relationships to enable the achievement of ‘peak’ performance (one where individuals derives meaning from their relationship with the business, equivalent to Maslow’s highest level of self-actualisation).

The starting point for a CCG is to determine whether it believes in Theory X or Theory Y.  McGregor, in his 1960 classic, ‘The Human Side of Enterprise’, demonstrated that the way individual managers manage depends on assumptions made about human behaviour.  He grouped these assumptions into Theory X and Theory Y.  Theory X is that people inherently dislike work and will avoid if at all possible.  As a result they must be coerced, controlled and directed to give adequate effort towards the achievement of organisational objectives.  Conley believes in Theory Y, that people are inherently trustworthy and have great capacity if the conditions are created to allow them to live up to their potential.  ‘Great 21st century companies’, he says, ‘are all about unleashing potential as opposed to harnessing experience.  What they (Positive Organisational Scholarship psychology academics) have discovered is that there is an interconnected ecology of relationships found in the most successful organisations: companies that cultivate an environment that allows for peak individual performance are rewarded with peak company performance.  They have been able to show that qualities like creativity, integrity, trust, optimism and teamwork have a profound impact on productivity, customer retention and product quality.

This has profound implications for the ways that CCGs establish themselves.  Most PCTs (and indeed most NHS organisations) are set up as hierarchies.  Hierarchies are predicated on a belief in Theory X.  There are clear structure charts and those at the top are valued much more highly by the organisation than those at the bottom.  The challenge for a CCG is how to establish itself so that it unleashes the potential of its staff and its practices.  It cannot do this through a traditional hierarchy.  CCGs need to find ways of creating organisational coherence that do not concentrate power in the hands of the few and disenfranchise the many.

A current question facing CCGs is whether to adopt Agenda for Change as a framework for staff.  In the absence of any robust accepted alternative and the need to achieve authorisation in the next few months I doubt many will choose against it.  The key is how this framework is used.  The gateways in Agenda for Change could for example be based on 360 degree feedback, or even feedback from member practices.  Conley argues that, ‘great companies give employees a calling, not a job’.  Transforming the lives of individuals is a calling that all CCGs can provide for their staff.

The PCT/practice relationship has always been a contractual one, which in recent years has been characterised by a resentment over the revised GP contract.   CCGs must establish a relationship with practices based on Theory Y, one that is designed to unleash their potential not coerce them into action.

Many CCGs are trying to pick up where PCTs left off in terms of engaging the public.  But Conley believes great companies can create self-actualised customers by meeting unrecognised needs.  Companies that succeed in this inspire true devotion and evangelism.  When a CCG can comprehensively assist patients to reach their highest goals, it will have built a deeply engaged relationship.

Ultimately the challenge for CCGs is one of leadership.  Many PCTs, unintentionally, built organisations around a Theory X mindset towards employees, practices and even the public.  If CCGs are to be great, modern, relevant organisations, they must build relationships that empower their staff, their practices and their public alike, enabling all to achieve their higher goals.

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