Archive for November, 2013


I predict that the 5 year visions that each local health economy must produce next year will in fact be far from visionary.  Great visions should be memorable, motivating and measurable, and I predict that the majority of those produced will fail all of these tests.  I am confident in my prediction because we are operating in a system that is not designed to produce great visions.

Seth Godin (in ‘The Icarus Deception’) tells the story that when a world class violinist visited the Juillard School in New York to give a speech and a performance, only 15 of the students attended.  But at the same time every practice room was booked solid.  This is because what got the students into the prestigious school was the ability to play music as it is written, to produce the notes and to follow instructions.

The dilemma these student violinists face is that what got them into the school is not going to help them when they leave.  The world is not short of good violin players.  What the world wants is original art: violin players that play music in ways that no one expects.  And this is what the young students have been culturally encouraged to avoid.

The parallel with leaders in the NHS is clear.  The Hay Group survey of the ‘top leaders’ in the NHS demonstrated that the vast majority have pacesetting as a predominant style.  Leaders in the NHS are good at getting things done.  They have become leaders because in the past when they have been asked to make things happen, they have made them happen.

But once they become a leader, following instructions is no longer sufficient.  The job now is to make the rules, not to follow them.  And we have not been trained for this.  There is no ‘what I should be doing’ because there is no ‘should’.  Now leaders must create a vision, develop the rules and make original art.

But the system of the NHS is not designed for this type of leader.  Is the NHS one organisation or multiple organisations?  Does it require one vision or hundreds?  The reforms were designed to shift the responsibility to the bottom.  To take away even the possibility of another ‘NHS Plan’.  So in the absence of a single grand plan each local health economy is asked to produce their own.

But what this means is that the NHS system as a whole should be supporting local leaders to create great visions.  In the new world, in the absence of a single plan, this has to be the priority.  But of course it isn’t.  The system is trying to find new ways to drive conformity and delivery – urgent care, finance, hospital inspections etc.  Leaders need to be immersed in the here and now.  The NHS does not want its leaders spending their time looking at other industries or other healthcare systems in other countries; what it wants is the crisis of the day to be tackled.

So with a set of leaders with no track record of producing great visions, who are busy playing the violin in the practice rooms, and with no support in place for them to produce one now, I am confident that most of the 5 year visions submitted next year will be neither memorable, motivating nor measurable.



How effective are CCGs?  This is the question that the plentiful reviews of the first six months of CCGs have focussed on.  Reviews have been mixed (CCG reviewers generally more optimistic than non-CCG reviewers, although pretty balanced overall), but very few have focussed on the new context within which CCGs are operating.

What has become clear in the six months since April 1st is that we have entered a new period for the NHS, one that I would characterise as ‘the age of the regulator’.  This year we have seen the system shift from a top down system direct from government, to one where power resides more and more in the hands of the regulators. 

Each month the influence of the TDA grows, as any health economy with a non-foundation trust will testify.  The role of Monitor is expanding (e.g. this month they produced a review of walk-in centres).  The Competition Commission has just blocked plans (which were supported by the local CCG) to merge Royal Bournemouth and Christchurch Hospitals and Poole Hospital Trusts.  Ever since the Francis Report was published the influence of the CQC has risen, and this year they have appointed a Chief Inspector of Hospitals and a Chief Inspector of General Practice with all that that entails.

Even NHS England, with its new post-mandate freedom from political control and directly responsible for expenditure of £25bn, only really seems comfortable in its role as CCG regulator.  Indeed it is with NHS England in this role that all of the talk of CCG authorisation that has dominated many of the 6 month reviews of CCGs has been framed (maybe we could call that section ‘escaping the grasp of the regulators’).

So what does operating within this context mean for CCGs?  Regulation by its very nature (according to Wikipedia, ‘codifying and enforcing rules and regulations and imposing supervision or oversight for the benefit of the public at large’) is not strategic.  Regulators will not create a plan.  There is, it seems, no plan.  And this creates both challenge and opportunity.

It is easy to see the challenges we face: insufficient funding, an aging population and an exponential growth in the demand for health care.  But the frame CCGs must use is that of opportunity: of making the care system sustainable, about integrating around the needs of individuals, and of driving improvements in outcomes.  CCGs have the freedom to create the plan to get there, as there is no national plan that they are expected to implement. 

This means that the most important role for CCGs is that of entrepreneur.  Schumpeter describes an entrepreneur as someone who is, ‘willing and able to convert a new idea or invention into a successful innovation’ (Capitalism, Socialism and Democracy 2012).  The success (or otherwise) of CCGs is likely to be ultimately determined not so much in their ability to evade the grasp of the regulators, but their ability to convert ideas into successful innovations.

So how are CCGs performing in their role as entrepreneurs?  Well if you start with the recently published HSJ list of ‘Health’s top 50 innovators in 2013’ there is not a single CCG entry, so not very well!  But if you look more widely there are promising signs, even within the first six month period.  Bedfordshire CCG has embarked upon an ambitious plan to invest over £120 million over the next 5 years in an integrated MSK system tailored around patient needs.  Cambridgeshire and Peterborough CCG are commissioning a service to provide integrated older people’s services worth up to £800m.  And these are just the high profile examples.  Up and down the country many CCGs are driving the implementation of innovative new models of care.

And while there were no CCG entries in the HSJ list, there were 3 GPs.  Herein lies the opportunity for CCGs, because within the membership of each CCG there are individuals, often clinicians, who are great innovators.  Shortage of ideas is not a problem that many CCGs are facing.  But successful entrepreneurs are not necessarily those with the best ideas.  They are those who can take a good idea and hold the vision clearly in front of them and drive delivery of it, whatever the challenges that emerge along the way.  Effective CCGs will be those that can do the same, who take the best ideas of their members, create a clear vision for the future, and who, in this age of regulation, can navigate a course through to successful implementation.

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The guidance is out.   CCGs and foundation and non-foundation trusts are required to produce a detailed two year plan by March and an agreed 5 year strategy.  Build in to your thinking 4% efficiency targets, a 1.9% tariff deflator and a £3.8bn transfer to social care.  Some challenge.

To be fair the size of this challenge has not gone unrecognised.  The joint letter from NHSE, Monitor, TDA and LGA states that, ‘CCGs, foundation and non-foundation trusts… must develop and implement bold and transformative long-term strategies and plans for their services, otherwise many will become financially unsustainable and the safety and quality of patient care will decline.’ 

A key part of these plans needs to be clear thought and strategic thinking as to the role of hospitals in 5 years’ time.  Somehow CCGs and hospitals have to agree this to create a joined up strategy.  What won’t work is a set of individual plans from hospitals and CCGs that make overly bold savings predictions and lack any vision or strategic thought as to what the future will look like. 

The Nuffield Trust has outlined the consequences of continuing down the road we are currently on.  In their submission to the Health Select Committee earlier this month (here) they warn that the government must think about how to deal with a situation in which hospital trusts start to become unsustainable in larger numbers than the current system is designed to address.  Their research shows no evidence of a step change in productivity which could enable the NHS to be able to do more for less at a rate to stay within the available financial envelope.

But what appears to be lacking is a set of clear options from which local health economies can choose to frame coherent thoughts about the future of hospitals.  There is a real absence of strategic thinking to support the production of these 5 year plans.  And before the writing must come the thinking.

So where do we start?  As good a place as any is an article in the Bulletin of the World Health Organisation (2000) by Martin McKee and Judith Healy, ‘The role of the hospital in a changing environment’ (here).  Despite being written 13 years ago, it still provides a helpful background to the role of the hospital, and highlights the complexities of any efforts to introduce change.  As they put it, ‘Hospitals pose many challenges to those undertaking reform of health care systems. They are, quite literally, immovable structures whose design was set in concrete, usually many years previously. Their configuration often reflects the practice of health care and the patient populations of a bygone era.’

The debate around the future of hospitals tends to centre around the size and configuration of hospitals, as entities in their own right.  To merge or not to merge.  Arguments swirl around improvements in outcomes through increasing specialisation, and greater economies of scale through fewer, bigger hospitals.  Alternatively smaller hospitals produce greater access and reduce inequalities.  The impact of technology is argued both ways.

This debate, however, operates in isolation from reform of the wider system.  And it is not alone in this.  Discussions about the future of general practice equally have an insular focus, without painting any sort of picture of how the system as a whole might operate in the future (as we have previously discussed here).

The most recent discussion on the role of hospitals has come from the Future Hospital Commission of the Royal College of Physicians, when in September it produced, ‘Future Hospital: Caring for Patients’ (here).  Within this there are some interesting recommendations, including:

  • Hospital services to operate across the whole health economy, and for hospitals to be responsible for specialist medical services inside and outside the hospital
  • Care delivered by specialist medical teams in community settings
  • A ‘Clinical Coordination Centre’: an operational command centre operating across the health economy with links to acute, specialist and primary care and community teams

This builds on what was alluded to by Keith Palmer in his 2011 report for the Kings Fund, ‘Reconfiguring Hospital Services: Lessons from South East London’ (here), which states,

Reconfiguration should focus on achieving the best patient outcomes and patient experience for all NHS patients, and on narrowing the quality gap between the best and worst performers. This is best achieved by designing reconfiguration to drive accelerated adoption of best practice models of care in as many services as possible. This in turn is best achieved by designing reconfiguration along patient pathways involving specialist/tertiary hospitals, district general hospitals (DGHs) and primary care providers.’

And if we recall Porter and Lee’s premise in ‘The Strategy that will fix Health care’ (see here) that care needs to be organised into units responsible for the full care pathway of a patient’s condition, then it seems to me that we are left with two real choices in our thinking on the future of hospitals.

The first is that hospitals take the lead on the delivery of pathways across whole systems.  As organisational entities their boundaries are extended as far as primary care, and different hospital  organisations would lead on different pathways (i.e. specialist hospitals would have lead responsibility for more specialist pathways).

The second is that hospital organisations become organisations analogous to shopping centres, whereby they would run the estate and maybe also staff for other organisations that have lead responsibility for pathways, who are able to use the facilities as appropriate.  So just like a shopping centre provides the space and facilities for different retail organisations to use, so hospital organisations could provide theatre and ward space and facilities for care pathway providers.

Clearly this needs thinking through, and I am sure there are other options that I have not thought of.  But what I do think is important is that we make the best possible use of the next 6 months to consider these issues carefully, that we spend some real time collectively thinking in a way that is not constrained by organisational boundaries, and that we produce plans with a vision that we believe is achievable in the tough climate within which we are operating.


Motion: ‘This house believes that promoting choice and competition between CSUs is the best way to secure effective commissioning support for CCGs’.

Opening statement for: The Centre

Based on the experience of PCTs we know that CCGs are too small to be able to provide the whole range of commissioning services in house at sufficient quality.  As a result CCGs should go through a process of deciding which services they will provide directly, which they will share with other CCGs and which they will buy from a CSU.

We (the centre) have spoken to CCGs and they have outlined three issues: concerns about the capability of CSUs; concerns about how the capability of CSUs is going to be raised; and that choice of commissioning support provider is important.  Fundamentally we believe that operational improvement will be accelerated by CCGs’ ability to manage an SLA effectively and to exercise choice.  As a result we are going to put on SLA workshops for CCGs, and create a procurement framework for CCGs to be able to exercise choice as easily as possible.

We want private companies to enter the commissioning support market.  We believe this will improve the quality of offering for CCGs.  So to do this we will ‘externalise’ CSUs from the NHS to create a level playing field and promote effective competition.

Opening statement against: CCGs

We (the CCGs) want capable, effective, responsive commissioning support.  We are frustrated where service delivery from CSUs is not at the level it needs to be.  We are concerned that it is not improving at the rate it needs to.  We want the option to change things if that is what is needed, but only as a last resort.  What we really want is high quality support.

We believe the centre is trying to solve the wrong problem.  We believe the problem is not how do we create an effective choice of CSU, but rather how do we make CSUs capable.  FESC (framework for external support for commissioning) did not work for PCTs, and we don’t think a similar framework for CCGs will work. 

Instead we want to focus on creating strong partnerships between CSUs and CCGs to make each individual service line effective.  We believe procurement frameworks and an over-emphasis on SLAs will make this harder not easier, by creating transactional rather than transformational relationships.  We believe the centre would have more impact by ensuring the leadership of CSUs is clearly focussed on partnering effectively with CCGs.

Closing Statement for: The Centre

We are concerned that CSUs are not developing quickly enough so we will limit the number of slots on the procurement framework to force CSUs to work together.  Whilst this might divert management time it will be worth it because it will ensure that CSUs focus on their strengths and ensure that only the best survive.

We are concerned that in practice CCGs are not exercising choice, but instead choosing to take services in house.  We believe this is a mistake.  We have therefore created guidance to make it more difficult for CCGs to do this, and we will reinforce the need for CCGs to follow a make, buy, share analysis to demonstrate the need for services to be provided by an external provider.

Closing Statement Against: the CCGs

We are concerned about the externalisation of CSUs.  We are worried that staff with whom we are beginning to develop relationships will leave.  We believe that operational stability is what is needed at this stage to enable CSUs to focus on the operational improvements that most are trying to put in place.  We don’t want CSUs distracted by developing mergers and alliances at the expense of making services on the ground effective.

We understand the benefits of delivering services at scale.  We weigh up regularly the potential of these benefits versus the disbenefits of services being provided by others who are not improving them at a rate we are comfortable with.  We want the option to say the risk of leaving it to others is too high and we need to manage these services ourselves.  We need this option because it is the performance of our organisations that is ultimately on the line.


The CCG challenge to the centre is to really listen to what CCGs are saying, rather than simply hearing the parts that fit with existing direction.  CCGs are on the whole committed to commissioning support.  But what CCGs want is a focus on CSU leadership, partnership with CCGs, and attention to operational improvement,  rather than choice, mergers and procurement.