Archive for September, 2012


Local Medical Committees (LMCs) were well known for putting in freedom of information requests to PCTs, to find out how much NHS resource had been ‘wasted’ on overpriced management consultancies.  The level of antibodies that exist across large parts of primary care to Mckinsey and their ilk raises an important question for Clinical Commissioning Group (CCG) governing bodies to consider: should CCGs use management consultancies?

There are good reasons for CCGs to take a stance that many LMCs would undoubtedly support and never use management consultants.  CCGs are membership organisations, and if the members do not want management consultants to be used, then they should not be.  CCGs are also striving hard to differentiate themselves from their predecessor PCTs, and this stance is one that visibly enables them to be different.

The real power of CCGs comes from the active engagement and participation of front line clinicians.  Those CCGs that find ways of engaging each and every GP within the group are the ones that give themselves the greatest chance of success.  Part of this is that the engine for change in CCGs shifts from the ‘ivory towers’ that PCT management teams used to drive decision making from, to the interaction of individual GPs with their patients, and the genuine understanding of the changes that are needed that this brings.  CCGs that choose to drive their thinking through management consultants risk doing this at the expense of the engagement of front line clinicians, and for many this is not going to be a risk worth taking.

CCGs also need to find ways of operating with a much reduced management allowance than that which funded PCTs.  One obvious way of doing this is reducing or eliminating the spend on management consultants, which in turn will allow funds to be used for the permanent management capacity that is required to drive sustainable long term change.

There is an argument, however, for using management consultants in very specific sets of circumstances.  One is when there are very new, inexperienced management teams in place, which is currently the case for many CCGs. These teams can benefit greatly from the additional expert support that management consultants can bring in this early stage of their development.  It is notable that many CCGs have actively engaged management consultancies as an ‘organisational development’ partner in the pre-authorisation period.

If you ask the PCT chief executives who regularly employed management consultants, they would say that these companies bring an ability to accelerate and challenge organisational thinking or specific pieces of work, where the ability to do so did not exist within the management team.  For example, where 3-5 year strategies were being developed (something that would by definition be carried out infrequently), they would say it is better to use expert, time limited external capacity, than to try and develop that expertise internally.

Management consultants can also operate as relatively neutral brokers to support and develop multi-organisational working.  So if CCGs are looking to create a system-wide programme on the frail elderly for example, support from management consultancies can create the capacity required to drive it forward quickly, as well as create a requirement for financial commitment from all partners that in turn can lead to greater emotional commitment to the work.  CCGs are also trying to find ways of working with each other, for example so that they can present one voice to their commissioning support provider.  A neutral broker can facilitate this process by bringing an impartial perspective, where leadership by one CCG is often met with mistrust by the others.

So there may be good reasons for CCGs to use management consultants in specific sets of circumstances.  To be clear, these would not include: creating extra capacity (as opposed to expertise) only, as this is far too an expensive a mechanism; looking for external thinking as a substitute for front line clinical engagement; or, worse, because the accountable officer does not trust the judgement of his/her own management team.

Where CCGs do choose to use management consultants, it is critical they have strategies in place for managing the grass root GP antibodies that will exist.  These strategies should consist of some combination of these basic elements:

1. GP leaders not management leaders should lead the procurement process (demonstrating the organisation is still clinically led)

2. GP leaders should be able to clearly articulate the rationale for using management consultants

3. An upfront communication should be in place with the membership about what is happening and why

Management consultants are not evil, and there are occasions when they can add real value. The challenge for CCG leaders is to find ways of accessing this expertise when it is needed, without losing the engagement of the member GPs.  However good the expertise, this is never a price worth paying.



Every week a new layer of complexity seems to be added to the authorisation process.  This week we discover “temporary” restrictions are to be placed on Clinical Commissioning Groups (CCGs).  In previous weeks we have been told there are to be seven types of “conditions” placed on CCGs.  These conditions will be administered by a “conditions panel”.  However, the conditions panel will not actually make decisions about conditions.  It will only recommend them.  The final decisions will be made by a “CCG Authorisation sub-committee” of the NHS Commissioning Board (NHSCB).  And I haven’t mentioned the moderation panel…

What are we to make of this?  The process is outlined in a paper by Barbara Hakin for the NHSCB, which can be found here .  Why create such a process?  The paper states the intention is to,

“Design an approach to moderation, conditions and decisions that is consistent, proportionate, transparent, and legally compliant, supporting the delivery of an efficient and consistent decision-making process. The process design will be accompanied by template documents and conditions to further support efficiency and consistency. This rigorous approach will also protect both the NHS Commissioning Board (NHS CB) and CCGs by ensuring that the risks of CCGs taking on responsibilities before they are ready to do so are minimised, whilst maximising the opportunities for full authorisation.”

Really.  Either someone has been spending too much money with their lawyers, or else the need for control is starting to be expressed by the NHSCB in the way the authorisation process is developing. 

The authorisation process is important not so much because of the outcome, but because of the nature of the relationship it will set between the NHSCB and each CCG.  The Health Service Journal reports,

One reason for the conditions will be that groups are required to demonstrate strong and “credible” operational and service planning for 2013-14, including how they will achieve financial balance.  Few CCGs are in a position to do so and no framework or guidance is yet in place.”  HSJ, 13 September 2012, p6

This is significant because the authorisation process is now not an assessment of the overall capability of the CCG to create a clear and credible plan, but an assessment of the plan itself.  The implication is that all CCGs will potentially be given a condition that they must produce a plan which has to match NHSCB expectations, regardless of the capability of the leadership team.  Producing a plan based on local requirements rather than on those developed nationally or regionally will not, it seems, be allowed.  The NHSCB will not sign off such a plan, and the CCG’s statutory responsibility to produce the plan will not be conferred until a plan is produced that the NHSCB approves of.

Worse, if the noises about authorisation becoming an ongoing and annual, rather than one-off, process are correct, this could easily become the tool by which the NHSCB exercises control over the freedoms given to CCGs in the legislation (i.e. by only releasing those freedoms when the CCG has acted in accordance with the wishes of the NHSCB).

Authorisation, however, should be about enabling freedom, not taking control. 

 “Freedom is actually a bigger game than power.  Power is about what you can control.  Freedom is about what you can unleash.” Harriet Rubin

The system cannot continue to operate through tight central control.  CCGs rightly need to earn their freedom.  The authorisation process should test each CCG’s ability to wield its freedom effectively.  It should not seek to establish control on how CCGs operate. 

Each layer of complexity that is added to the process is another layer of control being developed by the NHSCB.  If CCGs do not find a vocal national advocate soon, and a way of collectively standing up to the NHSCB, they will be sunk before they have even set sail.

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It has become clear that the authorisation process will not create the level of challenge that is going to help Clinical Commissioning Groups (CCGs) set themselves up to be as effective as possible.  It will ensure that CCGs are legal and have all the basics in place.  But it will not bring the expert challenge many CCGs need at this formative stage of their development.

Many CCGs have created large Governing Bodies with a majority of GP members as part of it.  This does not seem to be particularly correlated to the size of the CCG. Large CCGs want to ensure each locality is represented, and smaller CCGs want to ensure that each practice has a voice.  While legal, and even though the argument that representation is needed for practice engagement is understandable, it is a mistake for CCG Governing Bodies to be constructed in this way.

Governing Bodies are essentially governance constructs.  The Cadbury Report defined corporate governance as, “the system by which companies are directed and controlled”.  Strong governance is required not to drive the engagement of the membership, but to ensure that these systems are effective, and that the scandals of Enron, WorldCom and others are not repeated in the NHS.   CCGs must have strong governance.

So when we think about the construction of a CCG Governing Body, it is helpful to consider three key factors: accountability, balance and effectiveness.

1. Accountability.  CCGs hold a three way accountability: to their public and patients; to the NHS Commissioning Board (NHSCB); and to their member practices.  The Governing Body needs to provide the challenge and assurance that the each of these accountabilities is being effectively met.  The risk of having a majority of GPs on the Governing Body is that decisions will be weighted towards the needs of the membership, without sufficient balance to the needs of the public and the statutory requirements that come via the NHSCB.  The composition of the Governing Body needs to give equal weight to each of these three stakeholders.

2. Balance.  The Cadbury Report established that there should be an equal balance of executive and non-executive directors.  Non-executives have a specific role in ensuring effective corporate governance is in place.  The ACCA/DH Report in 2009, “Understanding Governance in the NHS”, and the Audit Commission report “Taking it on Trust” both point to the Cadbury report as the basis for governance in the NHS rather than any internal NHS definition.  Just because there is freedom in the guidance for CCGs in how they set up their Governing Bodies, this does not mean that the principles of good governance are suddenly null and void, or that they should not apply to CCGs. 

GPs (and managers) on the Governing Body are Executive Directors, and their number needs to be balanced with an equivalent number of non-executive directors to ensure good governance.  A majority of GPs on the Governing Body is particularly unhealthy, as it leaves the CCG open to accusations of unfair bias towards primary care, or can create untenable situations where most of the members are required to leave for certain decisions.

3. Effectiveness.  The literature suggests that the ideal number to have on a Governing Body is between 10 and 12, and that the effectiveness of the Board falls as the number rises or falls from this amount.  This is referenced in the “Development Tool to support Emerging CCGs with their Governance Arrangements” published by the National Leadership Council (p47), who carried out a comprehensive literature review (and can be found here–a-ccg-a-development-tool-to-support-emerging-ccgs-with-their-governance-arrangements).  The same research also shows that Governing Bodies that are drawn primarily from the membership may not bring sufficient expertise for it to challenge, set strategy and function effectively.

Many currently composed CCG Governing Bodies have more than 20 members, the majority of whom are GPs.  If the ‘ideal’ Governing Body has 11 members with a balance of executive and non-executive directors, there is a significant risk that these will not be effective, and that sound control over governance will therefore not preside over many CCGs.

It means tough decisions face CCG leaders.  Not every practice or every locality can necessarily be represented on the Governing Body.  A two tier system with an operational or executive board operating below the Governing Body may be required.  Clarity on the roles and relationship between these two groups will be needed. 

Ultimately the choice is not between governance and engagement.  CCGs need to be able to deliver both.  Leaders need to be bold, strong and imaginative in developing solutions that allow both to be achieved.  The bottom line remains, however, that the primary governance task for today is to reduce the number of GPs on the Governing Bodies that are currently proposed.

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“A new world order is taking shape so fast that governments as well as private citizens find it difficult just to absorb the gallop of events” Mikhail Gorbachev, 1990

When in the midst of transition, it is easy to get lost in the detail, and forget the size of the overall change that is taking place.  The introduction of clinical commissioning groups (CCGs) is only one part of the transformation that is taking place in the NHS, but it is of itself a momentous shift.

What was effective in the old world is not necessarily what will be effective in the new world.  CCGs require a different style from that which preceded them.  I want to share a personal example to illustrate this very point.

We recently developed a new 3 year strategy for the CCG.  We had worked intensively with support from management consultants over a number of weeks to develop clear strategic objectives, supported by a series of transformation programmes.  This was all underpinned by a robust set of financial projections outlining a clear bridge analysis between the ‘do nothing’ scenario and long term financial health.

The strategy was presented to two audiences.  The first audience was a mixed group of lay members, patient representatives, senior managers, and lead GPs.  It was extremely well received.  The group liked the ambition of the objectives, the financial robustness of the strategy, and the clear framework provided by the transformation programmes that was neither too vague nor too prescriptive.  The whole strategy was visually summarised in a single slide that all applauded.

So far so good.  The second audience was a group of GP leaders and member practice representatives.  They hated the strategy.  While there was some sympathy for the overall health improvement objectives, they hated the style and layout of the document, they hated the length and prescription of much of the work, and they hated the financial bridge diagrams that the first group had particularly praised.

In discussion the reasons for this became clear.  The document looked and felt too much like the PCT documents that had preceded it.  It was not the quality or otherwise of the content that was the problem.  It was the distillation of the work of the next three years into a slide set.  It was the impression that the world is controllable and that all it needs is the right plan.  It was the lack of resonance between that which was presented and the world in which the member GPs operate on a daily basis.

There is a new world order.  What worked in the past, what set some PCTs apart as ‘world class’, will not work in the future.  CCG leaders need to find new ways of communicating that resonate with member practices.  As we have discussed many times on this site, the critical success factor for all CCGs is active engagement at the level of each member GP.  It is no good a CCG having the greatest strategy in the country if its member practices do not recognise or own it.

We agreed to work with volunteers from the second group to develop a new version of the strategy, one that is fit for the new world.  CCGs will need to find a way of enabling their leaders to be effective in this new world.  For many new CCG leaders it will be a totally alien environment.  CCGs may have gone to great lengths to recruit (for example) the best possible Chief Finance Officer, but without real support from the GP leaders in how to operate in the new world they will struggle to be effective.

The reality is there is no magic formula for operating in the new world.  I have no idea what our strategy will end up looking like.  All I can do is learn from the mistake, keep talking to the member practices, and make sure that as an organisation we prioritise GP engagement over everything else.