Archive for July, 2012


Names are an important key to what a society values.  Anthropologists recognize naming as one of the chief methods for imposing order on perception.‘ David S. Slawson

In a move that has gone largely unnoticed, the NHS Commissioning Board (NHSCB) have reissued, and revised, the guidance, ‘Clinical commissioning groups governing body members: Role outlines, attributes and skills’.  The new guidance can be found here

The notable part of the guidance is the addition of a ‘naming convention’ for CCGs.  CCGs are, of course ‘free to use whatever titles they wish’, but these are the terms that the NHSCB will use (I assume therefore regardless of whatever the CCG has chosen).

The new addition is the concept of a ‘Clinical Leader’.  Each CCG has to have one.  It is the clinician representing the member clinicians, and it has been decreed that this will be the main person that the NHSCB will do business with.  It will be the GP Chair or GP Accountable Officer, and where both are GPs the CCG has to decide who it is.

GPs who are accountable officers are to be called ‘Chief Clinical Officer’.  Managers who are accountable officers are to be called ‘Chief Officer’.  There appears to be a desperate attempt to keep ‘clinical’ in the title for the GPs, presumably to prevent the GPs ‘becoming’ managers, and to demonstrate the newly installed clinical leadership which so differentiates CCGs from PCTs.  This harks back to the days pre-Griffiths of ‘administrators’ rather than managers, and also feels overtly political and designed to help those who talk about CCGs, rather than to help CCGs themselves.

Why might this be an issue for CCGs?  Well for one thing every other NHS organisation uses ‘Chief Executive’ for the accountable officer post.  I am not sure it will be clear to them what a ‘Chief Officer’ is.  Worse, those lead managers that are not accountable officers are to be called ‘Chief Operating Officer’, which in acute trust terms is a Director of Operations.  Not helpful for those lead managers trying to negotiate with acute trust Chief Executives.

Alongside the nomenclature guidance for CCGs, the NHSCB has also added a new role for its Local Area offices.  Originally designed to performance manage CCGs and commission primary care, they are now to ‘develop and secure a strategic overview of the system’.  While in many respects this is a reasonable development, it is a further downgrading of the role of CCGs that has been carried out without conversation or consultation.

Both these developments reinforce the lack of a strong national voice for CCGs.  There has been no response to either of these developments from the NAPC, the NHS Alliance, or NHS Clinical Commissioners (the newly formed joint venture between the two).  The NHS Commissioning Board is to put together an NHS Commissioning Assembly, but only the ‘Clinical Leads’ from CCGs are invited to attend.

CCGs have a big task ahead of them.  To be successful they need to exercise their influence together.  No one is going to create a voice for them.  They need a voice at Local Area Office level to ensure an effective balance of power with the NHSCB.  They need a voice at Commissioning Support Service provider level to ensure the voice of the customer is stronger than the voice of the provider.  And they need to find a way of speaking on equal terms rather than on NHSCB terms at a national level.  CCGs need to take this on for themselves, and the responsibility sits within each CCG.

Maybe CCGs should start with this naming guidance, and choose names that work for them, not names that work for others.

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In the months and weeks leading up to the Olympics, there has been a great deal of hype.  We have watched the stadia be erected and East London be slowly transformed.  We have cheered the torch and watched profiles of our potential champions on the TV.  We have even read the signs telling us to plan our travel journeys carefully.  But ultimately it is just waiting: waiting for the games to begin, and for the sporting drama to unfold. 

This year is similar for Clinical Commissioning Groups (CCGs).  We have decided on the boundaries, are putting people in post, and have listened to those prophesying doom when GPs take charge.  But ultimately this is all preparation, as the games are yet to begin.  Authorisation is simply a part of this preparation.   The most interesting part of authorisation will be watching the role it plays in giving real freedome and accountability for CCGs.

When will CCGs take on real accountability?  The technical answer is 1st April 2013.  The reality is it will be before that. 

The Regional and Local Area Office Directors of the NHS Commissioning Board (NHSCB) have now been appointed, or soon will be.  Many of these are current PCT Cluster Chief Executives.  They will be appointing their teams, many of whom will be current PCT Cluster executives.  In the next few months, as the new personnel shift, the locus of power is going to shift from the SHA and PCT Clusters to the NHSCB regional and local offices. 

PCT Clusters care only about this year: getting the CCGs authorised and ensuring the finance and performance legacy is ok.  The new appointees will care much more about the future, and whether the CCGs upon whom they will rely can take on the delivery challenge next year.  Fast forward to October/November when winter has started to affect performance on the A&E target, and gaps start appearing in QIPP delivery plans.  At some point around that time we are going to see a shift of performance management emphasis that moves from SHA managing PCTs, to the NHSCB managing CCGs. 

What might that mean for authorisation?  Well it seems unlikely that authorisation will remain the innocuous process that is currently portrayed.  The local and regional offices of the NHSCB are going to want make sure it has more teeth.  They are going to want to make sure the system they are responsible for from April 1st is able to meet the challenges ahead.  They are going to want more input and a more hands on approach.

So what might that mean in practice?  Well it might mean more influence over local appointments.  It might mean more influence of the SHA report on the outcomes of authorisation.  It might mean a more local presence on the authorisation assessment panels.  It will almost certainly mean more influence of current local performance on the conditions applied to authorisation. 

Despite the pressure of document submission and Board preparation, and everything else that is required for authorisation, the key focus for CCGs needs to be on delivering today’s performance.  Freedom will be earned and not granted as a right (whatever Mr Lansley might say), and it will come by having control on the finances and the key performance targets.  Authorisation is a distraction, and CCGs that pay too much attention to it today and take their eye of the real agenda will find the freedom they are seeking snatched away.  Like the Olympics, authorisation will come and go, but the need to deliver performance targets is not going anywhere any place soon.



‘I have a very assertive way.  It’s wake up, move your ass, or piss off home.’ Gordon Ramsay. 

Many CCGs are learning to recognise this management style, as it is commonly used by a number of SHAs.  Apparently it is part of ‘keeping grip’ during the transition. 

CCGs that think this is only temporary may be sadly mistaken.  Sir Robert Naylor, Chief Executive of UCL, recognizes the language of promised freedom for CCGS, as it was once promised to Foundation Trusts.  He said, ‘The real challenge for the Health Service is that the Health Service is essentially fully funded by public subscription through taxation, and the politicians find it extremely difficult to let go of the strings and empower organizations like mine’.

David Nicholson is saying the right things.  ‘The NHS chief executive said the management style of the service will have to make a “great leap forward” if it is to survive with little or no investment in the future.  Sir David Nicholson, who is also NHS Commissioning Board chief executive, told a King’s Fund summit on leadership that the NHS had to shift from its “pace-setting” management-style.’ HSJ 30 May.

But the reality is that those appointed as senior officers within the NHS Commissioning Board are not known for exemplifying this new management style.  Leopards do not change their spots.  CCGs that think that the Gordon Ramsay style of performance management is a temporary phenomenon that will end with their new found freedoms post-authorisation are, I fear, going to be disappointed.

But the big challenge for CCG leaders is how they operate performance management within their own organisations.  Do they transfer the behavior exemplified by external organizations internally within the CCG?  Or do they behave differently?  Performance management does not require a Gordon Ramsay style approach to people management.  The choice is not whether a CCG will operate robust performance management or not, it is how they will choose to operate it.  It is this that can differentiate CCGs from their predecessor organisations.

So what is performance management?  At its heart performance management is about people. It’s not about systems or processes or rules or computer systems. It’s about people.   For a new organisation like a CCG what is critical is how it chooses to treat its people.  If we manage people well, we will manage performance well too.

McGregor, in his 1960 classic, ‘The Human Side of Enterprise’, demonstrated that the way individual managers manage (and treat people) depends on assumptions made about human behavior.  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.  Theory Y is that people are inherently trustworthy and have great capacity if the conditions are created to allow them to live up to their potential. 

CCGs can start with a belief in theory Y: that everyone is capable of exceptional effort, productivity, output, and performance.  Understanding this – that everyone is potentially a great performer – is key to being a great manager of people and performance. Recognising and accepting this principle helps focus on helping people to find positive solutions, rather than focusing on blame, criticism and recrimination, the traditional resorts of old-style autocratic or incompetent management and organisations.

CCGs need to be different.  They need to operate in a way that will empower front line GPs to drive change.  GPs can, as David Nicholson is aware, walk away at any time from active engagement in the CCG.  CCGs need to reject the traditional NHS treatment of its staff, and of GP practices, and instead choose to believe in them.  This is not a soft option.  It is the only option that will drive performance in the new world.  It is not the NHS Commissioning Board that will create the new management style for the NHS – it is CCGs.

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‘Change will not come if we wait for some other person, or if we wait for some other time.  We are the ones we’ve been waiting for.  We are the change that we seek.’ Barack Obama

The success of Clinical Commissioning Groups (CCGs) is inextricably linked with the ability of primary care to change itself.  For CCGs to transform care for patients they must start with the transformation of primary care.  So what does a transformed primary care look like? What is the future of primary care?

Let’s start with what it is not.  There is a common misconception that the future is based upon the shift of services from hospitals to primary care.  It is not.  All the evidence to date suggests that all this achieves is higher cost and poorer outcomes.  Dermatology services have been decommissioned from the acute sector to be run by GPSI led clinics in primary care, only to be re-commissioned a year later as the primary care service fails to cope.

Rather the future is a growth of the demand management or ‘gatekeeper’ role of primary care.  Primary care will provide an extended range of in-house services, from routine surgery through to specialist management of long term conditions.  Practices will be larger, with list sizes of 50,000+ becoming the norm.  This will allow each practice to have a GP specialist in each of the common areas, such as orthopaedics, gynaecology, dermatology etc.  Bigger practices, or chains of practices, may even employ their own secondary care specialists directly.  Others will develop strategic partnerships with the acute sector to access this input.  Referral rates for these specialties out of practices will be a fraction of what they are now.

General practice, as it develops alongside CCGs, will move from a fee for service model to a fee for outcomes.  Embracing this fundamental shift will drive much of the change.  There will be a much stronger focus on compliance with agreed pathways, and on training, education and internal quality control.  Risk stratification and active management of high risk patients will become custom and practice for all GPs.

The combination of larger list sizes with payment for outcomes will end the resistance to taking out of hours back in house.  Receiving a poor service from an external provider will no longer be tolerated.  The model of morning surgery followed by visits will change as larger practices start to develop a dedicated 24 hour visiting/response service.  The separation of primary and community care will go, as community nurses, physiotherapists and others are employed directly by primary care.

Primary care as a business model will be transformed.  Small, independent businesses receiving subsidies for capital and estate will be replaced by larger professionally run businesses with independent access to capital.  Traditional partnerships in loose Limited Liability Partnership arrangements (astonishingly more than half of all practices currently do not have a signed partnership agreement in place) will not be able to survive.  More and more GPs will become salaried.  For some this will be through choice, as more and more newly qualified GPs seek part time salaried employment, but for others it will come as part of the acceptance of the new business model for primary care.

How attractive the future sounds probably depends on your view of the present.  The reality is that if primary care does not actively grasp the need to change and the need to change quickly, then it will lose the opportunity to drive the change itself.  Labour are already showing an interest in the need for integrated models across primary, community and secondary care.  Failure to change quickly will not only prevent CCGs delivering to their full potential, but also opens the door for primary care to be ‘integrated with’ (taken over by) secondary care.  With the advent of CCGs comes the opportunity for primary care to drive and be the change in the NHS.  Carpe diem.