Archive for June, 2012


As the new world gets closer and closer, one fact is becoming abundantly clear: Commissioning Support Services (CSS) will not be very good.  While to some this is simply stating the obvious, there are CCGs persevering with their heads in the sand, glad that the services they have ‘outsourced’ are now someone else’s problem and one less thing to worry about.  But the reality is these problems are becoming bigger and bigger every day that they are ignored.

Don’t get me wrong, I am a big fan of the whole concept of CSS.  Some services, and in particular information, IT, business intelligence, back office finance and contracting, can clearly be provided more effectively at a larger scale.  Clinical Commissioning Groups (CCGs) are right to understand what services need to be delivered in house in order to realise the advantage that clinically led commissioning brings, and then to outsource those that others are better placed to provide.

But this whole concept is starting to collapse as reality bites, because provision at scale does not of itself realise any benefits.  The benefits are not automatic.  It is already clear that the new CSS are not going to be able to deliver these benefits in the near future.  Here is why:

1. The staff they have inherited.  Staff ‘assigned’ to CSS by and large do not want to be there.  They do not want to travel any further than they already do.  They do not want to leave the NHS.  Staff buy in to delivering the benefits of scale is not only absent, it is actively resisted.

2. The leaders are not in place.  It is not only the staff who do not want to be there.  According to this week’s Health Services Journal (28 June 2012 edition) there is a shortage of applicants for the CSS managing director posts.  Dame Barbara Hakin claims this is because ‘people’ have not realised how big the jobs are.  The counter views reported are that they are too risky with the prospect of losing business year on year as alternative providers develop, coupled with the need to pass the next checkpoint and so needing to risk taking up a post that may only exist for a few months.

3. CCGs are taking the best staff for themselves.  How do you think the average CCG decides which PCT staff and functions to take, and which to leave for the CSS?  They take the high performing staff and functions in house and leave the rest.  So even large CSS are left with a number of low performing departments, which through the magic of ‘economies of scale’ they are expected to make high performing overnight.

4. CSS do not know how to share.  The theory that if there is a great IT product in one area that it can be rapidly and effectively deployed in another area is compelling.  The reality is that the NHS is terrible at spreading innovations, and there is no reason to expect CSS to be any better.  Whilst it is true they are now one organisation, very few feel like that and geographic tribalism is alive and kicking across most CSS.

5. PCT staff do not know how to provide a service.  The staff that have been assigned to CSS have in the main never worked in a customer facing environment.  Many have been part of top down command and control structures that outgoing SHAs worked so hard to create.  The requirement for staff in, for example, IT departments, who over many years spent most of their time telling PCT colleagues why they could not help them, to now be able to start being able to help their new ‘customers’ is a much bigger stretch than most recognise.

6. Very few private sector partnerships are in place.  The one way through all of this may have been for these organisations to partner with a company that is customer facing, that is experienced at operating at scale, and that can rapidly disseminate innovations and good practice.  But as CSS remain stuck in NHS mud, not only are these partnerships not in place, the likelihood of them developing in the next few years also seems remote.

So how should CCGs respond?  I think there are two choices.  The first is the wide road, which is to take all of the services in house.  This could be on their own or in partnership with other CCGs, depending on their size.  This will probably deliver the best results in the short term, as it is safe, staff will know what they are doing and results are likely to be solid.  But it limits the delivery of these service to the best of that which has gone before.  Contracting (as an example) will only be as good as it was in PCTs, because it has nothing that can make it any better.

The second choice is the narrow road, which is to partner with the CSS.  It is to acknowledge all of the short term difficulties that the CSS faces, and to create a trusting partnership to create a vision of the future and to commit to working together to deliver it.  It is narrow because results will not be good in the short term.  But what it creates is the potential for results in the future that are significantly beyond those which are deliverable today, even by the best in class.

It is not going to be possible to deliver this partnership through highly specified service level agreements (SLAs).  While CSS need them for checkpoint 3 and CCGs need them for authorisation, the future requires both parties to not allow these documents to shape the relationship between the organisations.  CCGs need to invest time, effort and resources in working with the CSS to support them to get to where they need to be.  There is no point investing effort in beating CSS with SLAs that they are not able to deliver.  Adversarial, contract-based relationships will simply accelerate the demise of CSS.  It is the CCGs who need the CSS to be successful, and so it is CCGs that need to start taking seriously their responsibility to give them the support that they need.

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As the spectre of the 360 degree assessment looms large for all prospective CCGs, it is interesting that it is the returns from member practices that many CCGs are concerned about.  Many GPs are unhappy with CCGs in general, exacerbated by the back door nationalisation of the profession that mandatory membership of a CCG brings.  The worry is that practices will use the survey as an opportunity to vent their frustration.

Engagement of front line, grass roots GPs is the critical success factor for CCGs. The importance of employee engagement as a requirement for organisational success is well recognised.  Jack Welch, former CEO of GE, puts it well, “There are only three measurements that tell you nearly everything you need to know about your organisation’s overall performance: employee engagement, customer satisfaction, and cash flow…It goes without saying that no company, small or large, can win over the long run without energised employees who believe in the mission and understand how to achieve it…”.

GPs are members of CCGs not employees. Fair enough. But the need for real engagement as a member is no less than that required by employees in most businesses.  Ultimately CCGs require a transformation of primary care if they are going to be truly successful. They need a step change in activity taking place in primary care, that stays linked to the ever developing gatekeeper role, which as finances tighten becomes the critical CCG lever.

So what does an engaged GP look like?  A good description comes from ‘Closing the Engagement Gap’ by Don Lowman and Julie Gebauer, “…an engaged (GP) understands what to do to help her company succeed, she feels emotionally connected to the organisation and its leaders, and she is willing to put that knowledge and emotion into action to improve performance, her own and the organisation’s.”

For many CCG leaders right now, this feels many worlds away. Others are on a journey where there are small numbers in this place, but not enough. So how do we get there?  Ultimately this is a function of leadership and relationships, that spread through the organisations.  It starts with the overall GP lead, who works to create an engaged set of GP leaders.  These leaders then work with their group of practices, trying to create an engaged set of leaders, one from each practice.  These practice leaders then go back to their practices to develop engagement from each of the GPs.

So simple in theory, but of course reality is a different matter.  There are, however, steps CCGs can take to make this Utopia more of a reality:

1. The most straightforward step a CCG can take is to ensure that each CCG GP leader is providing leadership to a small number of practices.  Ideally this will be between 5 and 8, and an absolute maximum of 10. Engagement requires real relationships and creating a sense of team, which is very difficult to do when the number of people is too large.

2. If a group of practices are not ‘delivering’ (whatever that means!), the CCG response must focus first on engagement and not on performance management.  No real change is possible without hearts and minds, and so ‘getting tough’ with practices at the first sign of performance issues is potentially the single biggest mistake a CCG can make.  The GP leaders need to be supported to develop effective engagement with their practices, not to deliver performance management.

3. The management textbooks will tell you that the single most important element to engagement is communication.  CCGs must find ways of regular, effective communication with practices.  There is no one right way.  There just needs to be lots of ways, all regularly reviewed, developed and improved.  The biggest complaint GPs had with PCTs is that they never communicated with them, so this needs to be huge priority for CCGs.  Interestingly, GPs tend not to like overly glossy communication.  It needs to be simple, straightforward, honest and jargon-free.

4. The GP Chair/accountable officer must have a regular presence in local meetings.  A telling story came from one CCG where the GP Chair asked the practices what he needed to do to make sure they succeeded where the practices felt the PCT had failed.  ‘Come to our meetings, and speak to us face to face’, was the response.  Practice leaders value very highly the ability to directly interface with the top of the organisation.

5. Delivering some real improvements is of course critical to demonstrating that clinical commissioning can make a real difference.  The lesson we can learn from practice based commissioning is that delivering the change in itself is not enough.  The change needs to be communicated over and over again.  GPs will sometimes even see that a change has taken place, but have no idea that it was down to the efforts of a CCG.  Changes need to be made, and the benefits need to be claimed.  Once there are demonstrable improvements for patients, when good ideas have been actioned instead of ignored, and the benefits are being palpably felt by GPs, that is when there is a platform for engagement.

6. The drive for engagement in commissioning needs to be cogniscent of what life is like for GPs at present.”But I like to think that a lot of managers and executives trying to solve problems miss the forest for the trees by forgetting to look at their people — not at how much more they can get from their people or how they can more effectively manage their people. I think they need to look a little more closely at what it’s like for their people to come to work there every day.”  Gordon Bethune, Continental Airlines.

GP practices are full.  They are not overloaded with spare capacity to attend commissioning meetings, or to introduce the latest scheme.  CCGs  need to acknowledge this openly and regularly if they are to progress real engagement.

7. Use financial incentives.  They have a proven track record in primary care.  They are relatively blunt, and CCGs want to avoid a ‘fee for service’ relationship with practices, but the upside far outweighs the downside, and they are a great way of genuinely acknowledging the pressure GP practices are under.

8. Regularly report on engagement at the Governing Body meetings.  Practice engagement needs to be reviewed alongside all the financial, quality and performance metrics.  It is notoriously hard to measure, but simple proxies are not hard to create.  These can start with attendance at commissioning meetings and move into regular engagement survey scores.  It probably will not be very long before CCGs start using the net promoter scores with their own practice (‘would you recommend your CCG to another practice?’).

Engagement of GPs is elusive and it is slippery.  It is something that Clinical Commissioning Groups (CCGs) work hard to find and then, once they think they have it, they turn round and it is gone again.  The results of the 360 degree survey will be interesting, but they will only ever represent a point in time, and all CCGs will need to continue to prioritise GP engagement in order to be successful.

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It was always going to be a tough job leading a CCG.  Tough because of the financial challenges that exist today and lie in wait for tomorrow.  Tough because of the requirement to operate with three masters: the NHS Commissioning Board, the local population and the member practices.  Tough because of the scale and the complexity of the changes that need to be made.

The NHS, to be fair, has recognised this.  The assessment of the Accountable Officers and GP Chairs includes an assessment of the range of leadership styles that potential leaders are able to adopt.  The highly directive and ‘pacesetting’ styles are shown to have a negative influence on the overall ability of an organisation to deliver effectively, and the ability to provide vision, to coach those around you, and to engage and bring the best out of people are identified as much more effective styles of leadership.  This is particularly true in CCGs, where the PCT levers of command and control are not going to work with the membership.

But talk, as they say, is cheap.  David Nicholson has claimed that the grip will get tighter during the transition.  Those involved in performance management meetings with their SHA will have encountered this notion of tighter grip.  It is displayed by highly aggressive and directive behaviour, which becomes increasingly frequent and pressured as performance falls further and further away from the required standard (whether this is financial, A&E, 18 weeks or infection control).

In these performance meetings the understanding of CCGs as membership organisations seems to slip away.  For example, where ambulances are arriving at the same time at A&E and ambulance turnaround times become longer, SHAs are demanding that CCGs get their practices to change the times of their surgeries so that the calls to ambulances are more spread out through the day, and they want this done straight away.  While there is a coherence to the logic of this request, it displays a total lack of understanding of the influence that CCG leaders have on their membership as providers of primary care.  CCG leaders can scream and shout at their practices all day long, but it will not result in the time of morning surgeries being changed.  The directive management style will not work.  CCG leaders may want to tackle this issue, but it will require the creation of a local vision in partnership with practices and a significant amount of work in changing hearts and minds.  And it will not be quick.

So the behaviour required by the leadership of CCGs is the opposite of that being displayed by those who should be modelling the future behaviour that is being sought.  Many of the CCG leaders are taking up these roles for the first time.  They will learn from the behaviour of those around them.  SHAs should be taking seriously the need to create capability for the future, and not be sacrificing tomorrow for the sake of today.

CCGs, however, are not always making life easy for themselves.  A number of CCGs have created governance structures whereby significant decisions need to be made by a vote of the membership.  The votes need 60, 70 or even 80% support in order to be carried.   How can leaders make difficult decisions for their population if they know that their refusenik colleagues can veto their every move?  How can they sign up to a partnership with other providers in the local health economy when they do not know if they will be able or allowed to fulfil their part of the bargain?  Leadership does require difficult decisions to be made and then carrying people with you.  If this government had to have a referendum every time it had to make a difficult decision we would never get out of the financial crisis we are in.  The requirement for a vote on significant decisions does look like the triumph of idealism over pragmatism.

So many CCG leaders are already in a very tough position.  They are trying to create new clinically led organisations that are able to drive improvements in quality and outcomes for their local populations.  But on the one hand there is the directive performance management regime imposed by the SHAs which is demanding directive action that is neither desirable in the long term nor (in many cases) achievable in the short term.  On the other there is an often increasingly disgruntled membership that has the ability to veto leadership decisions.

After the excitement of the creation of the new organisation, the honeymoon is coming to an end.  No one said it was going to be easy.   What is crucial now is that CCG leaders stay true to their principles, that they pick their role models well, and that they hold the faith that the new style of leadership that values people is the one that will deliver the best results for their population in the new world.

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Clinical Commissioning Groups (CCGs) will take on responsibility for all aspects of performance.  In some areas, in this year of transition, PCT Clusters are keeping a tight hold on performance, not trusting their fledgling CCGs with this level of responsibility.  In other areas, through the scheme of delegation, PCT Clusters have devolved responsibility for performance to the CCGs, and have taken up an SHA-style role of performance managing the CCGs to ensure delivery.

So how are the CCGs with this new responsibility tackling it?  Are the approaches taken by the new clinical commissioners any different from their predecessor PCTs?  A good place to start is first principles: what differences in approach would we expect from CCGs?  Well, we would expect clinician to clinician conversations to be at the heart of any performance conversation.  GPs working with their secondary care colleagues should be able to develop a shared understanding of the vexed issue of demand: how demand is manifesting across all parts of the system; which practice populations it comes from; which care homes it comes from; the timing of demand, particularly in hours and out of hours.  The advent of CCGs represents a fantastic opportunity for systems to move away from anecdote and rumour, to a genuine, shared understanding of what is happening right across the system.

And out of this will come committed joint working to the tackling of demand, with real support from each organisation to initiatives to improve the system.  Acute trusts and community staff will work with GPs and practice staff to identify the patients at highest risk of attendance at A&E and admission to hospital, and will work together to enables these patients’ needs to be met more effectively.  Secondary care consultants will work alongside clinicians in primary care to establish community based multidisciplinary teams to manage long term conditions in radically different ways.  Systems will be put in place that mean patients with an underlying condition can be discharged back to primary care as soon as their acute episode has been addressed.  And this could be just the start.

All well and good.  But what happens when 4 hour performance takes a dive?  What happens when the local trust has more than 50 breaches overnight, and with their backs against the wall are citing ‘unprecedented levels’ of demand, and a lack of confidence in CCG demand management schemes?  What happens when the PCT Cluster and SHA are on the phone demanding contract penalties be applied to the trusts, potentially undoing all the formative work on collaboration that the CCG has been developing?

This is the critical test for CCGs.  For some, it is coming much earlier than they may have wished, but in the end it will only be the extremely fortunate who manage to avoid this position, because if it does not happen with 4 hour performance, it will happen with infection control or some other key target.  Will the CCGs retreat into their bunker and let the trusts retreat into theirs, or will they persevere and continue to try to be different?  Will clinicians continue to work together to understand the genuine issues, and identify the underlying causes of demand that were never uncovered by their predecessor commissioning organisations? 

More importantly, will the leaders who try to enable this to happen, who attempt to enact a new way of working for the system as a whole, be supported in this task?  They will need support from their fellow GP leaders, from the member practices, from the other organisations in the health system.  Because, barring a miraculous change of approach by David Nicholson and the NHS Commissioning Board, the system will damn these leaders as ‘too soft’, and require CCGs to appoint someone ‘with the necessary grip’, thereby recreating the organisations and behaviours of the past, and in so doing tossing the potential of CCGs onto the bonfire of missed opportunities.

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The BMA voted for a day of strike action on the 21st June.  Therefore GPs, as part of the BMA, are going out on strike.  So what does this mean for CCGs?  While at first glance it looks like an issue for GPs as providers and nothing to do with GPs as commissioners, the implications are potentially highly significant.    

The decision to strike is on the face of it an odd one.  The government are confident that they have public support and will not back down.  The press reaction suggests they are right.  The Daily Mail says it is, ‘disreputable, shabby and just plain wrong’.  The Daily Mail has accused the doctors of ‘breathtaking arrogance’.  There are few voices of support from those without a public sector for pension for well paid doctors protecting what is widely perceived to be an over-sized pension. 

So given this highly predictable reaction, why would the BMA allow the profession to strike?  The BMA vote results are interesting.  There was an extremely high turnout (50%) and a two to one majority in favour of strike.  So the strike, it seems, is more to appease the membership than it is to change the government’s mind over the pensions.  The BMA need to be seen to be doing something and acting on their members’ behalf.  Strike action is a visible sign that something is being done.

But where does that leave CCGs?  What happens after the 21st June?  The strike will have taken place, the public backlash and stories of patient suffering at the hands of the ‘greed of fat cat doctors’ will be well documented, and the government will not have shifted its position on doctor pensions.  What does the BMA do then?  The membership will not want any more reputational damage, but equally will not want to go down without a fight.  The whispers are that there is a strong voice coming from particularly the GP membership that the GPs should down tools on commissioning.

This is an interesting prospect.  There are many GPs who are very anti the whole commissioning agenda, and would urge their union to drop it anyway.  GP commissioning is at the very heart of the Health Act, and would seem an easy way to hit the government where it hurts, without impacting on their reputation with the public in the way that strike action does.

So why haven’t the BMA or GPC pursued this line already?  Mainly because their biggest fear is a schism within the profession.  In the days up to the passage of the Health Act we saw letters from group of GPs damning the bill, followed by letters from other groups heralding the benefits of clinical commissioning.  If the BMA urge members to withdraw support for commissioning, they are concerned that many of their membership will resign.  The union cannot afford for the profession to be divided.  But ultimately taking this risk might be preferable to the risk of losing credibility with the general public.

Lack of GP engagement with clinical commissioning is the biggest risk to CCGs.  As we have discussed previously on this site, active GP engagement is the strength that lies at the very heart of CCGs, and is what differentiates them from PCTs.  CCGs are working hard to engage their members, and the national reduction in the rate of GP referrals is a clear sign that success in this area is starting to be achieved.  I suspect it is also fair to say that this engagement is fragile, and that underneath this lies a discontentment amongst many CCG member GPs at the controls that are being introduced to their day to day practice.  A call for the profession to remove their compliance with commissioning is likely to be welcomed by many.  The risk this poses to the success of CCGs has, in risk register terms, both a highly likelihood and a high impact.

So who is helping CCGs mitigate this risk, which lies largely outside of the control of individual CCGs?  No one.  This whole issue highlights again the lack of a national voice for CCGs, as entities in their own right and distinct from primary care.  The doctors’ strike, whichever way you look at it, is important for CCGs.  The NHS Alliance and the NAPC are working to come together with the NHS Confederation to be the single voice for CCGs, which is a positive step and needs to happen.  But in the NHS Alliance Clinical Commissioning Connect newsletter there is no mention of the strike – instead we have a comment from Dr Michael Dixon that it is, ‘slightly disappointing that CCGs are so large’.  Because the leaders are so terrified of upsetting the profession themselves they are not prepared to stand up for the needs of CCGs in their own right.  We do not need a representative organisation for GPs – the GPC does that.  We need a representative organisation for CCGs that puts the needs of CCGs as organisations above everything else, and is not afraid to upset GPs as providers if that is what is required. And we need it now.